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Children with special health care needs: Impact of health care
expenditures on family financial burden
Lisa C. Lindley and
School of Nursing, University of North Carolina – Chapel Hill, Carrington Hall, CB 7460, Chapel Hill,
NC 27599-7460
Barbara A. Mark
School of Nursing, University of North Carolina – Chapel Hill, Carrington Hall, CB 7460, Chapel Hill,
NC 27599-7460
Lisa C. Lindley: llindley@email.unc.edu
Abstract
We investigated the relationship between health care expenditures for Special Health Care Needs
(SHCN) children and family perception of financial burden. Using 2005/2006 National Survey of
Children with Special Health Care Needs data, a multivariate logistic regression model was used to
estimate the relationship between the SHCN child’s health care expenditure and perceived financial
burden, while controlling for family and child characteristics. Our analysis suggests that health care
expenditures for a SHCN child of $250 and more are associated with family perception of financial
burden. In addition, families with lower socioeconomic status also perceived financial burden at
lower level of expenditures. Members of the health care team who treat children with SHCN have
an important role in understanding and assessing family financial burden as part of the care delivery
to the child and the family. Our study reinforces the need to treat the whole family as the unit of care,
especially when caring for children with special health care needs.
Keywords
children with special health care needs; financial burden; National Survey of Children with Special
Health Care Needs; family centered care; health expenditures
Introduction
Children with special health care needs (SHCN), i.e. those who have or are at increased risk
for a variety of chronic conditions, and who require health services beyond those required by
children generally, typically experience higher health care utilization and expenditures than
the average pediatric population (McPherson et al., 1998). These children often use more
hospital days, emergency room visits, surgical or medical procedures, medical specialist visits,
and home health days than non-SHCN children (Boulet, Boyles, & Schieve, 2009; Newacheck,
Inkelas, & Kim, 2004). This extensive use of services may create a financial burden for many
families (Boulet et al., 2009; Newacheck & Kim, 2005).
Families incur a broad range of expenses associated with a SHCN child’s health care. Families
of children with SHCN conditions such as autism, muscular dystrophy, cystic fibrosis, heart
problems, and emotional problems persistently have annual out-of-pocket medical
Correspondence to: Lisa C. Lindley, llindley@email.unc.edu.
NIH Public Access
Author Manuscript
J Child Fam Stud. Author manuscript; available in PMC 2011 February 1.
Published in final edited form as:
J Child Fam Stud. 2010 February ; 19(1): 79–89. doi:10.1007/s10826-009-9286-6.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
expenditures (excluding insurance premiums) ranging from $2,669 to $69,906 compared to
$676 to $3,181 for families with non-SHCN children (Buescher, Brunnsen, Whitmire, & Klutz-
Hile, 2006; Newacheck et al., 2004; Shenkman, Knapp, Sappington, Vogel, & Schartz,
2007). Health insurance premiums can cost the family of a SHCN child an additional $2,058.00
to $3,593 annually depending on benefit plan type (Davidoff, 2004). There are also costs
incurred by the family from added electricity, heating, and water needs, special clothing,
equipment, food, other drugs, and expenses associated with medical appointments (Miedema,
Easley, Fortin, Hamilton, & Mathews, 2008; Steele & Davies, 2006). For example, children
who are unable to regulate their body temperature may require the heat be kept high or constant
use of air conditioning. Extra laundry may be required for children with incontinence, vomiting,
or constant drooling problems. Special wheelchair lifts and vans to transport children can range
in price from $5,000 to $30,000 (Steele & Davies, 2006). The burden of these costs is magnified
when care for the child means a loss in parental income due to missed work, not being able to
work regular hours, not being able to work additional hours or overtime, having to change
shifts with loss of pay differential, or quitting their jobs (Friedman, Hilden, & Powaski,
2005; Miedema et al., 2008; Montes & Halterman, 2008).
Expenditures such as these have resulted in approximately 40% of families with SHCN children
experiencing financial-related burden due to their child’s health condition (Kuhlthau, Hill,
Yucel, & Perrin, 2005). Family financial burden is defined as the family’s perception of
financial stress and worry caused by inadequate monetary resources to meet the family’s fiscal
demands (McCubbin & Patterson, 1983). Financial burden often emerges as a significant
concern at a time when families are already consumed with the child’s health challenges.
Family members who are preoccupied with financial burden may be distracted and less
attentive to the child’s care needs (Kristjanson, Nikoletti, Porock, Smith, Lobchuk, & Pedler,
1998). In addition, financial burden may have long-term effects on the financial security,
quality of life, and future well-being of the entire family (Miedema et al., 2008).
Few studies have explored family financial burden, particularly for families of SHCN children.
These studies have investigated the relationship of health care expenditures and perceived
family financial burden to child health insurance status (Chen & Newacheck, 2006; Yu, Dick,
& Szilagyi, 2008), location of family residence (Shattuck & Parish, 2008; Skinner & Slifkin,
2007), and child health status (Kuhlthau et al., 2005). Although these studies have contributed
to our knowledge of family and child factors associated with expenditures and financial burden,
there is a lack of knowledge about the relationship of SHCN child health care expenditures to
perceived family financial burden and at what level of health care expenditures families
perceive financial burden. Therefore, the aims of this study were to investigate the relationship
between health care expenditures for SHCN children and family perception of financial burden
and to explore the moderating effect of income.
Figure 1 depicts the conceptual model of financial burden as a function of health care
expenditures, family characteristics, and child characteristics. Health care expenditures require
the family to have adequate monetary resources to meet these fiscal demands. When there are
inadequate financial resources, families may perceive a burden (Davidoff, 2004;Kuhlthau et
al, 2005;Shattuck & Parish, 2008;Skinner & Slifkin, 2007;Yu et al., 2008). In addition as
expenditures increase, requiring greater financial resources, burden may also increase. Family
response to the health care expenditures of the SHCN child depends on the amount of financial
resources, such as income, the family has at its disposal. Those that do not have sufficient
resources may perceive health care expenditures as a burden, whereas those with adequate
resources may not perceive a burden (Kuhlthau et al., 2005).
The model also included selected family and child characteristics that might have a relationship
to family financial burden. For example, Metropolitan statistical area was included because
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rural families may have limited employment opportunities, lower income, limited access to
health, and limited health insurance coverage, which may increase family financial burden.
(Skinner & Slifkin, 2007). Providing home care, stopped work, cut in hours worked, and need
for additional income have all been shown to increase the likelihood of families perceiving or
experiencing financial burden because they reflect the decreasing financial resources of the
family (Heck & Makuc, 2000; Kuhlthau & Perrin, 2001; Kuhlthau et al., 2005; Vicker &
Carlisle, 2000). Family structure was included because single adult families may have fewer
financial resources than family structures with two adults, which may result in a greater
likelihood of perceiving financial burden. Household education and household language were
included because families with less education and those that lack English proficiency may have
lower earning potential and fewer financial resources than those with more education and who
speak English, increasing the likelihood of financial burden (Kuhlthau et al., 2005; Payne,
Devol, & Smith, 2001).
Child characteristics such as age were included because younger children may utilize more
health care services at the onset of their health condition causing the family to experience
greater burden (Himelstein, 2006). Children with more health conditions may require more
financial resources and place a greater financial burden on the family, so number of
conditions was included in the model. Severity of the child’s health condition was included
because a more severe condition may require more health care utilization resulting in greater
financial burden for the family (Emmanuel, Fairclough, Slutsman, & Emmanuel, 2000;
Kuhlthau et al., 2005; Newacheck, Hughes, Hung, Wong, & Stoddard, 2000). Because mothers
are typically the caregivers to SHCN children, they may report more burden than other family
members, so survey respondent was included (Buhse 2008; Knafl & Zoeller, 2000). As the
number of health conditions increases, this may increase the financial burden for the family.
Type of health condition was included because some health conditions such as heart problems
may require more financial resources than others such as headaches/migraines and cause the
family to perceive financial burden. When children have no health insurance or inadequate
coverage, family financial burden may increase, so insurance type was included (Chen &
Newacheck, 2006; Fox, McManus, & Reichman, 2002; Jeffrey & Newacheck, 2006). Sex and
race were included because male and African-American children are more often afflicted with
SHCN conditions, which has the potential to increase the likelihood of financial burden for the
family (Newacheck, Strickland, Shonkoff, Perrin, McPherson, McManus, Lauver, Fox, &
Arango, 1998)
Method
Design and Sample
Data from the 2005/2006 National Survey of Children with Special Health Care Needs (NS-
CSHCN) were used for this analysis. The NS-CSHCN is a national telephone survey conducted
during 2005–2006 of households with one or more children under 18 years old in all 50 states
and the District of Columbia. A total of 364,841 children under 18 years old from 192,083
households were screened to identify those with special health care needs, and 40,723 detailed
CSHCN interviews were collected. If the family had more than one child with SHCN, one
child was randomly selected for completion of the survey.
Sample selection was based on the 40,723 child observations. Child observations were
excluded from the sample if survey data were missing, interviewees refused to answer the
survey question, or interviewees did not know the answer to the survey question. The final
sample size was 18,135 children with special health care needs and their families. This sample
was found to be representative of the original data set based on comparisons of respondents to
non-respondents on several family and child characteristics.
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Data Source
NS-CSHCN provided detailed state- and national-level parent-reported information on the
health status and health care system experiences of children with special health care needs and
their families (Child and Adolescent Health Measurement Initiative, 2005–2006). The NS-
CSHCN is a nationwide telephone survey sponsored by the U.S. Department of Health and
Human Services Administration Maternal and Child Health Bureau (MCHB), and conducted
by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and
Prevention, using State and Local Area Integrated Telephone Survey (SLAITS) technology.
Quality edits on the data included verification of the valid number of cases, assessment of the
range of permissible values, and assessment of missing values.
Measures
Table 1 includes the study variables and definitions. Additional explanation of the variables
of interested is discussed below.
Dependent Variable—Financial burden was measured as a yes/no response to the question
of whether the SHCN child’s health condition caused financial problems for the family.
Independent Variable—Health care expenditures were defined as any out-of-pocket
payments by the family for the medical care of the SHCN child. It included co-payments, dental
or vision care, medications, special foods, adaptive clothing, durable equipment, home
modifications, and any kind of therapy during the past 12 months. This did not include health
insurance premiums or costs that were reimbursed by insurance or another source. This was
measured as an ordered-categorical response from no expenses, less than $250, $250–$500,
$501–$1,000, $1,001–$5,000, to more than $5,000 annually.
Control Variables - Family Characteristic—Home care was measured as a yes/no
response to the question of whether the family provided any care to the child in the home such
as changing bandages, care of feeding or breathing equipment, and giving medications and
therapies. Family structure was defined as the parental structure of the family, and was
measured as the categorical response of two biological/adopted parents, two step parents,
mother only, or other structure. Income was derived from responses to the question of total
combined household income for the previous calendar year. Responses were used to create an
index of income relative to the Department of Health and Human Services Federal Poverty
Guidelines (FPL) by the National Center for Health Statistics. This was measured as an ordered-
categorical response from poor (<100% FPL), low income (100%–199% FPL), moderate
income (200%–399% FPL), and high income (>400% FPL).
Control Variables - Child Characteristics—Severity of health condition was defined as
the severity of the difficulties caused by the SHCN child’s health problems. Respondents were
asked to rate the severity of the health condition from minor, moderate, to severe. If a child
had more than one difficulty, the respondent was asked to rate the most severe difficulty rather
than trying to average severity across all difficulties. Health conditions were measured as
individual yes/no responses to a variety of health conditions that included asthma, attention
deficit disorder/attention deficit hyperactivity disorder, autism/autism spectrum disorder,
Downs syndrome, mental retardation/developmental delays, depression/anxiety/eating
disorders/emotional problems, diabetes, heart problems/congenital heart disease, blood
problems/anemia/sickle cell disease, cystic fibrosis, cerebral palsy, muscular dystrophy,
epilepsy/seizure disorders, migraines, and arthritis/joint problems. The health condition of
allergies was dropped from the model because of multicollinearity.
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Data analysis
The primary question of interest was whether there was an association between SHCN child
health care expenditures and family perception of financial burden. For all analyses, data were
weighted to reflect the population of non-institutionalized CSHCN ages 0–17 years.
Descriptive statistics were obtained on health care expenditures along with other family and
child characteristics. Due to the binary nature of the financial burden variable, a multivariate
logistic (logit) regression model with robust standard errors was used to estimate the
relationship between the SHCN child’s health care expenditure and perceived financial burden,
while controlling for family and child characteristics. Additional logistic regressions were used
to explore how family income levels influenced the relationship between expenditures and
burden controlling for family and child characteristics. Logistic regression analyses are
presented in terms of adjusted odds ratios (ORs) and 95% confidence intervals (CIs). All
analyses are conducted using Stata 10.0 software (Statcorp LP, College Station Texas, 2007).
Results
Table 2 summarizes the characteristics of 18,135 children with SHCN and their families. Over
nineteen percent of the families perceived a financial burden associated the health condition
of their SHCN child. Almost a quarter of the families spent over $1000 annually on their child’s
medical care. Mothers completed the survey more often than fathers. A majority of families
lived in urban areas and were composed of two biological or adopted parents. More than half
the families were 200% of federal poverty level (FPL) or greater. English was the most common
language spoken in the home, and the highest education level in the household was on average
more than high school. Over 50% of the families reported that they did not provide home care,
need additional income, cut work hours, or stop working because of their child’s health
condition. A majority of children were male and almost 11 years old with approximately two
health conditions. Sixty-three percent of the children had private insurance only and 75% were
Caucasian.
Table 3 displays the coefficients and odds ratios (OR) for the estimated logistic regression
model of financial problems. Health care expenditures were positively associated with family
perception of financial burden. The odds ratios on $250–$500 (OR 2.48, p=.001), $501–$1000
(OR 3.21, p=.001), $1001–$5000 (OR 5.59, p=.001) and greater than $5000 (OR 8.84, p=.001)
were significantly and positively associated to family perception of financial burden. The odds
of perceiving financial burden increased from 2 times for expenditures of $250–$500 (OR 2.48,
p=.001) to almost 9 times for expenditures over $5000 (OR 8.84, p=.001) when compared to
$0 expenditures controlling for family and child characteristics. The odds ratio on less than
$250 (OR 1.23, p=.139) was not significant. This suggests that when family expenditures reach
$250 or higher families perceive financial burden.
Families with lower incomes perceived financial burden at lower level of health care
expenditures than families with higher income as displayed on Table 4. For poor and low
income families, the odds ratios on $250–$500, $501–$1000, $1001–$5000 and greater than
$5000 were significantly and positively associated to family perception of financial burden.
For moderate income families, $1001–$5000 and greater than $5000 were significantly and
positively associated to family perception of financial burden. For high income families,
expenditures greater than $5000 were significantly and positively associated to family
perception of financial burden. This suggests that as family income decreases, lower levels of
expenditures are associated with financial burden.
Several family characteristics were significantly associated with increased odds of family
financial burden. These included providing home care (OR 1.42, p=.001), parents stopping
work (OR 3.14, p=.001), cuts in parental working hours (OR 1.91, p=.001), the need for
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additional income (OR 7.74, p=.001), poor (OR 2.92, p=.001), low income FPL (OR 3.190,
p=.001), moderate income (OR 2.36, p=.001). However, when household education level was
less than high school, families had decreased odds of perceiving family financial burden (OR .
60, p=.004).
Child characteristics significantly associated with family financial burden were moderately
severe health conditions (OR 1.71, p=.001), severe health conditions (OR 2.87, p=.001)
emotional problems (OR 1.65, p=.001) heart problems (OR 1.57, p=.012), joint problems (OR
1.57, p=.008), and multi-racial ethnicity (OR 1.36, p=.044). Controlling for other factors, rural,
age, type of health conditions, number of health conditions, sex, insurance type, survey
respondent, family structure, household language, and black/other race had no significant
relationship with financial burden.
Discussion
Our analysis of the 2005/2006 National Survey of Children with Special Health Care Needs
data suggests that health care expenditures for a SHCN child of $250 and more are associated
with family perception of financial burden. Several studies have suggested that spending 10%
of family income on health care equated to financial burden (Emmanuel et al., 2000; Yu et al,
2008); however, our study found a relatively low level of expenditure associated with the onset
of financial burden, especially when compared to other household expenses like cell phones
($756 annually) or groceries ($8513 annually) (Entension, 2008; Fiercewireless, 2007). While
this expenditure amount may be relatively small in comparison to other household expenses,
families with SHCN may in fact be financially stretched because of many years of persistently
costly care resulting in lower expenditures causing the perceptions of problems (Himmelstein,
Warren, Thorne, & Woolhandler, 2005). Couple the amount of these expenditures with 2007
national trends in growing personal debt and decreased financial reserves such as savings, and
these families may lack adequate financial resources to support them in the care of a SHCN
child (Hoover, 2009; Kim, 2009).
We also found that whether or not the family perceived a financial burden depended on the
amount of financial resources the family had at its disposal. Those that did not have sufficient
resources from income perceived health care expenditures as a burden, whereas those with
adequate resources did not perceive a burden. Several studies have suggested that families of
low socioeconomic status have difficulties adjusting to and coping with stressors (Payne et al.,
2001). These low socioeconomic status families have demonstrated decreased adherence to
treatment and increased rates of anxiety and depression (Brownridge & Fielding, 1994;
Fielding & Brownridge, 1999). Our findings suggest that health care expenditures may act as
a family stressor, and that lower socioeconomic families may not have the skills and resources
to adequately cope with the cost of caring for a SHCN child.
There were other interesting findings from our analysis regarding family characteristics.
Families that experienced reduced financial resources because of lost income from either a cut
in work hours or having to stop work perceived greater financial burden, and often responded
that they needed additional income to cover medical expenditures. Meeting the fiscal demands
of health care expenditures with decreased financial resources may result in families selling
assets, taking out loans or mortgages, using savings, or seeking additional employment
(Emanuel, et al., 2000). Those families unable to meet the fiscal demands may find personal
bankruptcy the only remaining option (Himmelstein et al., 2005). Families may also be caught
in a Catch-22. Reestablishing financial well-being may be hindered by decreased employability
and loss of career advancement and mobility caused by being out of the work place for any
extended period to care for the child (Miedema et al., 2008).
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Several of the findings about child characteristics are also worth noting. The severity of the
child’s health condition contributed significantly to the family’s perception of burden. The
more severe the child’s health condition, the higher the odds of the family perceiving financial
problems. This finding was congruent with those of others (Emmanuel et al., 2000; Kuhlthau
et al., 2005), suggesting that children with moderate to severe SHCN may require expensive
medications, medical supplies, and medical equipment (Miedema et al., 2008; Steele & Davies,
2006) which may not be fully covered by insurance and increase the family’s out-of-pocket
expenditures. Child health conditions such as emotional problems, heart problems, and joint
problems also influenced family perception of financial burden. This raises the question of
whether insurance is adequately covering these expenses. For example, in many private benefit
plans, mental health coverage for emotional problems is very limited (Martocchio, 2006).
While studies have investigated the importance of insurance coverage for SCHN children,
future research into specific benefit coverage levels would provide further insight into family
financial burden (Chen & Newacheck, 2006; Davidoff, 2004). We were also surprised that
most of the health conditions were not associated with perceived burden perhaps suggesting
that families do not always perceive their child’s health as a burden (Knafl, Brietmayer, Gallo,
& Zoller, 1996). As an example, families with diabetic children may have a thriving or
accommodating family management style that views the health condition as life-goes-on as
opposed to stressful and serious.
This study had several limitations. First, the cross-sectional nature of the survey does not allow
for causal conclusions to be drawn about the relationships between the variables. Second, the
data were respondent-reported and were estimates based on their recollection over the past 12
months. Therefore, reporting bias may be present. Third, there was no measure of actual family
income in the NS-CSHCN. Measures of income were derived from responses to the question
of total combined household income for the previous calendar year, and were used to create
an index of income relative to the Department of Health and Human Services Federal Poverty
Guidelines (FPL) by the National Center for Health Statistics. Thus, we were not able to
calculate the relative burden or expenditures as a percentage of income, only the absolute
burden (Shattuck & Parish, 2008).
The goal of this study was to improve our understanding of family financial burden by
examining the relationship between health care expenditures for SHCN children and family
financial burden. At a relatively low expenditure level, families perceived financial burden,
which increased as expenditures increased. In addition, families with lower socioeconomic
status also perceived financial burden at lower level of expenditures. We also found that based
on family and child factors, these families may not have adequate financial resources either
through income or insurance coverage to adequately manage the financial burden caused by
caring for their SHCN child. These families may need assistance with coping and adjusting to
the financial consequences of providing health care for their SHCN child (Witt-Sherman,
1998). Members of the care team who treat children with SHCN have an important role in
understanding and assessing family financial burden as part of the care delivery to the child
and the family. Our study reinforces the need to treat the whole family as the unit of care,
especially when caring for children with special health care needs.
Acknowledgments
This publication was made possible by Grant Number T32NR008856 from the National Institute of Nursing Research
(NINR). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of
the National Institute of Nursing Research, National Institutes of Health.
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Figure 1.
Conceptual Model of Family Financial Burden
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Table 1
Variable Definitions
Variable Definition
Health Care Expenditures Any out-of-pocket payments for child’s health-related needs.
Family Characteristics
MSA Families reside in a rural or urban setting. (MSA 500,000 threshold)
Home care Families provided health care at home.
Stopped work Family member stopped working because of child’s health condition.
Cut work hours Family member had to cut down on work hours because of child’shealth condition.
Need additional income Family needed additional income to cover child’s medical expenses.
Family structure Parental composition of family.
Household education The highest level of school that anyone in the household completed or the highest degree anyone in the household
received. (derived)
Income Imputed poverty status of child’s household. (derived)
Household language The primary language spoken in the home.
Child Characteristics
Age Age of child under the age of 18.
# of health conditions Number of health conditions of the child.
Severity A rating of the difficulties caused by child’s health condition.
Survey respondent Relationship of survey respondent to child. (derived)
Health conditions Child’s health conditions.
Insurance type Child’s type of health insurance coverage at interview.
Sex Gender of the child.
Race Ethnicity of the child. (derived).
Financial Burden Whether child’s condition caused financial problems for the family.
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Table 2
Family and child demographic characteristics of study sample
Variable N %
Financial Burden
No 14562 80.3%
Yes 3573 19.7%
Health Care Expenditures
No expenditures 3736 20.6%
<$250 3681 20.3%
$250–$500 4443 24.5%
$501–$1000 2412 13.3%
$1001–$5000 3264 18.0%
>$5000 598 3.3%
MSA
Urban 15016 82.8%
Rural 3119 17.2%
Home Care
No 9485 52.3%
Yes 8650 47.7%
Stopped Work
No 15505 85.5%
Yes 2639 14.6%
Cut Work Hours
No 14925 82.3%
Yes 3210 17.7%
Need Additional Income
No 14907 82.2%
Yes 3228 17.8%
Family Structure
2 biological/adopted parents 9412 51.9%
2 step parents 2031 11.2%
Mother only 5785 31.9%
Other family structure 907 5.0%
Household Education
< High school 1215 6.7%
High school 4262 23.5%
> High school 12658 69.8%
Income
Poor (<100% FPL) 3627 20.0%
Low income (100–199% FPL) 4135 22.8%
Moderate income (200–399% FPL) 5441 30.0%
High income (>400% FPL) 4915 27.1%
Household Language
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Variable N %
English 17373 95.8%
Non-english 762 4.2%
Severity
Minor 9557 52.7%
Moderate 6909 38.1%
Severe 1688 9.2%
Survey respondent
Mother 15179 83.7%
Father 2448 13.5%
Other family member 508 2.8%
Health conditions
Asthma 7943 43.8%
Attention deficit disorder 6003 33.1%
Autism 1016 5.6%
Downs syndrome 199 1.1%
Mental retardation 2231 12.3%
Emotional problems 4280 23.6%
Diabetes 236 1.3%
Heart problems 617 3.4%
Blood problems 472 2.6%
Cystic fibrosis 54 0.3%
Cerebral palsy 363 2.0%
Muscular dystrophy 54 0.3%
Seizures 598 3.3%
Migraines 3210 17.7%
Joint problems 9575 52.8%
Insurance type
Private only 10645 58.7%
Public only 5096 28.1%
Private/public 1433 7.9%
Other insurance 326 1.8%
Sex
Male 10954 60.4%
Female 7181 39.6%
Race
White only 12803 70.6%
Black only 3192 17.6%
Multi-race 725 4.0%
Other race 1415 7.8%
Note: N=18135.
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Table 3
Logistic regression estimating family financial burden
Variable βSE Odds ratio 95% Confidence Interval
Health Care Expenditures
No expenditures 0.00 1.00
<$250 0.21 (.14) 1.23 (0.95–1.61)
$250–$500 0.91** (.14) 2.48** (1.89–3.28)
$501–$1000 1.17** (.15) 3.21** (2.40–4.31)
$1001–$5000 1.72** (.15) 5.59** (4.18–7.46)
>$5000 2.17** (.19) 8.84** (6.08–12.85)
MSA
Urban 0.00 1.00
Rural 0.14 (.08) 1.15 (0.97–1.36)
Home Care
No 0.00 1.00
Yes 0.36** (.08) 1.43** (1.23–1.66)
Stopped Work
No 0.00 1.00
Yes 1.14** (.10) 3.14** (2.61–3.78)
Cut Work Hours
No 0.00 1.00
Yes 0.65** (.09) 1.91** (1.61–2.26)
Need Additional Income
No 0.00 1.00
Yes 2.05** (.08) 7.74** (6.61–9.07)
Family Structure
2 biological/adopted parents 0.00 1.00
2 step parents −0.18 (.12) 0.84 (0.67–1.05)
Mother only 0.16 (.09) 1.17 (0.98–1.40)
Other family structure 0.08 (.19) 1.08 (0.75–1.56)
Household Education
< High school −0.51** (.18) 0.60** (0.42–0.85)
High school −0.17 (.10) 0.85 (0.69–1.03)
> High school 0.00 1.00
Income
Poor (<100% FPL) 1.07** (.16) 2.92** (2.14–3.99)
Low income (100–199% FPL) 1.16** (.12) 3.19** (2.50–4.07)
Moderate income (200–399% FPL) 0.86** (.10) 2.36** (1.95–2.86)
High income (>400% FPL) 0.00 1.00
Household Language
English 0.00 1.00
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Variable βSE Odds ratio 95% Confidence Interval
Non-english 0.08 (.22) 1.08) (0.71–1.65)
Age 0.01 (.01) 1.01 (1.00–1.03)
Number health conditions −0.10 (.08) 0.97 (0.78–1.05)
Severity
Minor 0.00 1.00
Moderate 0.54** (.08) 1.71** (1.46–2.01)
Severe 1.05** (.13) 2.87** (2.21–3.73)
Survey Respondent
Mother 0.00 1.00
Father −0.10 (.11) 0.90 (0.73–1.12)
Other family member −0.38 (.24) 0.69 (0.43–1.11)
Health Conditions
Asthma 0.19 (.13) 1.21 (0.94–1.56)
Attention deficit disorder 0.07 (.11) 1.07 (0.85–1.34)
Autism 0.13 (.16) 1.14 (0.83–1.56)
Downs syndrome 0.17 (.32) 1.89 (0.64–2.21)
Mental retardation −0.02 (.15) 0.98 (0.74–1.31)
Emotional problems 0.50** (.11) 1.65** (1.32–2.09)
Diabetes 0.51 (.28) 1.67 (0.96–3.47)
Heart problems 0.45*(.18) 1.57*(1.10–2.22)
Blood problems 0.33 (.26) 1.38 (0.82–2.32)
Cystic fibrosis 0.30 (.46) 1.35 (0.55–3.33)
Cerebral palsy −0.22 (.25) 0.80 (0.49–1.31)
Muscular dystrophy −0.17 (.46) 0.84 (0.34–2.07)
Seizures 0.32 (.20) 1.37 (0.92–2.03)
Migraines 0.23 (.13) 1.26 (0.99–1.62)
Joint problems 0.45** (.17) 1.57** (1.12–2.20)
Insurance Type
Private only 0.00 1.00
Public only 0.10 (.13) 1.10 (0.85–1.42)
Private/public −0.01 (.15) 1.00 (0.75–1.33)
Other insurance 0.33 (.24) 1.39 (0.87–2.23)
Sex
Male 0.00 1.00
Female −0.11 (.07) 0.89 (0.77–1.04)
Race
White only 0.00 1.00
Black only −0.13 (.12) 0.88 (0.70–1.11)
Multi-race 0.31*(.15) 1.36*(1.01–1.84)
Other race 0.03 (.16) 1.03 (0.76–1.41)
Note: N=18135.
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*p<.05
**p<.01
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Table 4
Logistic regression estimating family financial burden by income status
Variable Overall Model O.R. (95% CI) Poor O.R. (95% CI) Low Income O.R. (95% CI) Moderate Income O.R. (95% CI) High Income O.R. (95% CI)
No expenditures 1.00 1.00 1.00 1.00 1.00
<$250 1.23 (.95–1.61) 1.24 (.82–1.87) 1.41 (.90–2.21) 0.75 (.41–1.38) 0.76 (.28–2.05)
$250–$500 2.48** (1.89–3.28) 4.05** (2.64–6.21) 2.59** (1.64–4.06) 1.41 (.79–2.52) 0.89 (.35–2.23)
$501–$1000 3.21** (2.40–4.31) 5.13** (2.81–9.37) 3.39** (2.03–5.64) 1.97 (1.12–3.44) 1.35 (.56–3.28)
$1001–5000 5.59** (4.18–7.46) 5.78** (3.20–10.47) 5.73** (3.40–9.66) 3.81** (2.22–6.55) 2.12 (.89–5.06)
>$5000 8.84** (6.08–12.85) 4.42* (1.03–19.94) 8.22** (3.21–21.03) 7.18** (3.58–14.42) 3.43** (1.38–8.54)
Note: N=18135.
*p<.05
**p<.01
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