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Out of pocket health care expenditures represent a rapidly growing burden for consumers, both in terms of their increasing size and the lack of financing options to available to address them. While finance companies have rushed to provide credit for discretionary medical expenses, few funding sources are available to consumers needing money to pay for medically necessary procedures. These consumers often must rely on regular credit cards, then turn to other sources such as home equity, retirement savings and friends and family when they reach their credit limit. To a limited extent, health savings accounts and flexible spending accounts have helped consumers save money to meet their medical expenses, but the need for additional solutions far outweighs these programs' capacity. Retail clinics, which offer basic medical services at affordable prices in a retail setting, have also helped somewhat, but cannot address expenses related to high cost medical treatments.

This report analyzes out-of-pocket health care spending by U.S. consumers and the resulting U.S. market for health care financing services.

• Cash/check
• Credit card
• Loans and lines of credit
• Medical financing programs
• Health savings accounts (HSAs)
• Flexible spending accounts (FSAs)

• Kaiser Commission on Medicaid and the Uninsured
• Kaiser Family Foundation
• Centers for Medicare and Medicaid Services (CMS)
• U.S. Department of Labor, Labor Statistics
• Demos and The Access Project, “Borrowing to Stay Healthy,” January 2007
• Center on Budget and Policy Priorities, Medicaid Expenditure Panel surveys
• Center for Studying Health System Change
• Hewitt Associates
• Corporate reports and other corporate publications
• Miscellaneous trade journals, publications, websites

Table of Contents

• Scope and Methodology
• The U.S. Healthcare Market
• The Need for Alternatives
• High Cost of Care
• Inconsistent Quality of Care
• Inaccessible Care
• Vulnerable Populations
• Medicaid Recipients
• Disabled Persons
• Senior Citizens
• The Mentally Ill
• Obese Persons
• Persons with Chronic Medical Conditions
• Healthcare Reform
• Out-of-Pocket Expenditures in 2006
  • Payment Types
  • Figure 1-1: Distribution of Out-of-Pocket Healthcare Expenditures by
  • Payment Type, 2006
  • Insurance Co-Payments
  • Direct Payments
  • Premiums and Plan Fees
  • Payment Methods
  • Cash or Check
  • Credit Cards
  • Flexible Spending Accounts
  • Loans and Lines of Credit
  • Health Savings Accounts
  • Healthcare Financing
  • Amount Financed
  • Elective Procedures
  • Non-Elective Procedures and Prescription Drugs
  • Consumers Who Pay Out of Pocket

• Out-of-Pocket Expenditures in 2007-2011
  • Healthcare Inflation
  • Managed Care Cost Shifting
  • Retail Clinics
  • Disease Management Programs
  • Medicare Prescription Drug Benefit
  • Generic Drugs
  • Rx-to-OTC Switches
  • Medical Tourism
  • Healthcare Advisers
  • Forecasts

• Medical Procedure Financing in 2006
  • Types of Procedures Financed
  • Elective Procedures
  • Non-Elective Procedures
  • Financing Products
  • Key Players

• Medical Procedure Financing in 2007-2011
  • Consumer Debt
  • Payday Loans
  • Weak Housing Market
  • Widening Wage Gap
  • Financial Awareness
  • Security Concerns
  • New Credit Card Products and Customers
  • Forecasts

• Overview
• Public Healthcare
• Private Healthcare
• State-Licensed Health Insuring Organizations
• Commercial Health Insurers
• Blue Cross and Blue Shield Plans
• Health Maintenance Organizations
• Self-Funded Employee Health Benefit Plans
• Participation
• Cost Issues
• Figure 2-1: National Health Expenditures (NHE) and NHE as a Percentage of GDP, 1980-2011
• Figure 2-2: Premium Increases vs. Increases in Workers' Earnings and Inflation, 1989-2005
• The Uninsured and Underinsured
• The Uninsured
• The Underinsured
• Regulation
• Table 2-1: Selected U.S. Federal and State Healthcare Oversight Bodies, 2007
• Healthcare Reform
• Universal Federal Healthcare Coverage
• State Healthcare Coverage
• Current State Healthcare Initiatives
• Table 2-2: U.S. Healthcare Coverage by State, 2007
• Federal Support of State Healthcare Reform

• Overall Out-of-Pocket Spending
• Figure 3-1: Average Share Paid Out-of-Pocket by U.S. Consumers, by Percentile of Total Healthcare Expenses, 2003
• Figure 3-2: Average Amount Paid Out-of-Pocket by U.S. Consumers, by Percentile of Total Healthcare Expenses, 2003
• Payments Types
• Figure 3-3: U.S. Consumer Out-of-Pocket Healthcare Expenditures by Payment Type, 2006
• Insurance Co-Payments
• Direct Payments
• Premiums and Plan Fees
• Payment Methods
• Figure 3-4: U.S. Consumer Out-of-Pocket Healthcare Expenditures by Payment Type, 2006
• Cash or Check
• Credit Cards
• Table 3-1: Credit Card Debt of Consumers with Medical Debt by Health Insurance Status, 2007
• Table 3-2: Credit Card Debt of Consumers with Medical Debt by Demographic Group, 2007
• Flexible Spending Accounts
• Loans and Lines of Credit
• Health Savings Accounts
• Healthcare Financing
• Amount Financed
• Elective Procedures
• Figure 3-5: Methods of Payment for Elective Procedures, 2006
• Figure 3-6: U.S. Consumer Out-of-Pocket Spending for Elective Procedures, Amount Financed vs. Paid with Cash or Check, 2003
• Non-Elective Procedures and Prescription Drugs
• Figure 3-7: Average Share of U.S. Healthcare Expenses Paid Out of Pocket, by Type of Service, 2003
• Figure 3-8: Average Share Paid Out of Pocket by U.S. Consumers, by Percentile of Total Healthcare Spending and Type of Service, 2003
• Figure 3-9: Distribution of Out-of-Pocket Spending on Non-Elective Procedures for the Average Person, 2003
• Figure 3-10: Distribution of Out-of-Pocket Spending for the Average Person, by Spending Level and Type of Service, 2003
• Figure 3-11: Drug Cost Coverage by Payor Type (Public, Private, Cash), 1965, 1986, 2000, 2004
• Consumers Who Pay Out Of Pocket
  • Medicaid Recipients
  • Figure 3-12: Change in Out-of-Pocket Healthcare Expenses for Medicaid Recipients, 1997 to 2002
  • The Disabled
  • Figure 3-13: Out-of-Pocket Healthcare Expenses for Disabled and Non-Disabled Medicaid Recipients, 1997 vs. 2002
  • Senior Citizens
  • The Mentally Ill
  • Obese Persons
  • Table 3-3: Obesity in the U.S., 1980-2011
  • Persons with Chronic Conditions
  • Figure 3-14: Adults Under Age 65 with Chronic Conditions by Type of Insurance, 2003

• Trends
• Out-of-Pocket Expenditure Growth Drivers Healthcare Inflation
• Managed Care Cost-Shifting
• Figure 4-1: Extent to Which Consumers Believe Cost-Shifting Will Result in Beneficial Outcomes, 2003
• Retail Clinics
• Services
• Pricing
• Consumer Response
• Expansion
• Figure 4-2: Growth of U.S. Retail Clinics, 2001-2011
• Out-of-Pocket Expenditure Growth Constraints
• Disease Management Programs
• Medicare Prescription Drug Benefit
• Generic Drugs
• Private-Label OTC Medications
• Rx-to-OTC Switches
• Table 4-1: Selected Rx-to-OTC Switches in the United States, 1982-2007
• Table 4-2: Rx-to-OTC Switch Candidates in the U.S., 2007-2012
• Medical Tourism
• Table 4-3: Cost Savings From Medical Tourism for Various Procedures, 2007
• Healthcare Advisers
• Forecasts
• Table 4-4: U.S. Consumer Out-of-Pocket Expenditures per Worker, 2001-2011 (in billion $)
• Payment Type
• Table 4-5: U.S. Consumer Out-of-Pocket Expenditures by Payment Type, 2001-2011 (in billion $)
• Figure 4-3: Distribution of U.S. Consumer Out-of-Pocket Spending by Payment Type, 2001, 2006, 2011
• Payment Methods
• Table 4-6: U.S. Consumer Out-of-Pocket Expenditures by Payment Method, 2001-2011 (in billion $)
• Figure 4-4: Distribution of U.S. Consumer Out-of-Pocket Spending by Payment Method, 2001, 2006, 2011
• Amount Financed
• Elective Procedures
• Table 4-7: Amount of U.S. Consumer Out-of-Pocket Expenditures for Elective Procedures That Are Financed, 2001-2011 (in billion $)
• Figure 4-5: Share of U.S. Consumer Out-of-Pocket Spending for Elective Procedures Paid for Through Financing, 2006-2011
• Non-Elective Procedures
• Table 4-8: Amount of U.S. Consumer Out-of-Pocket Expenditures for Non-Elective Procedures That Are Financed, 2001-2011 (in billion $)
• Figure 4-6: Distribution of Out-of-Pocket Spending on Non-Elective Procedures for the Average Person, 2006 vs. 2011
• Figure 4-7: Share of U.S. Consumer Out-of-Pocket Spending for Non-Elective Procedures Paid for Through Financing, 2006-2011
• Consumers Who Pay Out of Pocket
• Table 4-9: Size of High-Risk Groups for High Out-of-Pocket Healthcare Expenditures,2001-2011 (in millions)

• Types of Procedures Financed
• Elective Procedures
• Figure 5-1: Distribution of Medical Procedure Financing Market, 2006
• Chiropractic Services
• Cosmetic Surgery
• Table 5-1: Cosmetic Surgical Procedures Offered in the U.S., 2007
• Cosmetic Dentistry
• Elective Eye Procedures
• PRK Procedures
• LASIK Procedures
• LASEK Procedures
• Forecast
• Hair Restoration
• Fertility Treatments
• Table 5-2: Fertility Treatments Offered in the U.S., 2007
• Weight Loss Surgery
• Table 5-3: Leading Weight Reduction Surgeries Offered in the U.S., 2007
• Non-Elective Procedures

• Financing Programs
  • Costs to Consumers
  • Table 5-4: Comparison of Selected Medical Financing Program Costs to Consumers, 2006
  • Costs to Providers
  • Usage and Acceptance
  • Key Players
  • Elective Procedures
  • Table 5-5: Selected Elective Procedures Covered by Leading Medical Financing Companies, 2007
  • Figure 5-2: Leading Players' Share of U.S. Elective Procedure Financing Market, 2006
  • Non-Elective Procedures
  • Table 5-6: Selected Non-Elective Procedures Covered by Leading Medical Financing Companies, 2007
  • Figure 5-3: Leading Players' Share of U.S. Elective Procedure Financing Market, 2006

• Trends
• Consumers
• Consumer Debt
• Payday Loans
• Weak Housing Market
• Widening Wage Gap
• Financial Awareness
• Security Concerns
• Financial Institutions
• Increasing Share of Wallet
• New Credit Card Products
• New Credit Card Customer Segments
• Forecasts
• Table 6-1: Consumer Out-of-Pocket Expenditures for Elective Procedures Paid Through Patient Financing Programs, 2001-2011 (in billion $)
• Table 6-2: Consumer Out-of-Pocket Expenditures for Non-Elective Procedures Paid Through Patient Financing Programs, 2001-2011 (in billion $)
• Figure 6-1: Consumer Out-of-Pocket Expenditures for Elective and Non-Elective Procedures Paid Through Patient Financing Programs, 2001-2011 (in billion $)
• Figure 6-2: Proportion of Consumer Out-of-Pocket Spending for Elective Procedures Paid Through Patient Financing Programs, 2006-2011

• Table 7-1: Main Business Activities of Selected Medical Financing Companies, 2007
• APFUSA
• History and Lines of Business
• Financial Information
• Patient Financing
• AURORA QUICK CARE
• History and Lines of Business
• Financial Information
• Convenience Clinics
• CAPITAL ONE HEALTHCARE FINANCE
• History and Lines of Business
• Financial Information
• Patient Financing
• CARECREDIT
• History and Lines of Business
• Financial Information
• Patient Financing
• CHECKUPS
• History and Lines of Business
• Financial Information
• Convenience Clinics
• CREDIT MEDICAL
• History and Lines of Business
• Financial Information
• Patient Financing
• CSI FINANCIAL SERVICES
• History and Lines of Business
• Financial Information
• Patient Financing
• E-FINANCING SOLUTIONS
• History and Lines of Business
• Financial Information
• Patient Financing
• HEALTH READY
• History and Lines of Business
• Financial Information
• Patient Financing
• MEDCHOICE FINANCIAL
• History and Lines of Business
• Financial Information
• Patient Financing
• MEDDIRECT
• History and Lines of Business
• Financial Information
• Patient Financing
• MEDPROVA
• History and Lines of Business
• Financial Information
• Patient Financing
• MINUTECLINIC
• History and Lines of Business
• Financial Information
• Convenience Clinics
• PFS
• History and Lines of Business
• Financial Information
• Patient Financing
• REDICLINIC
• History and Lines of Business
• Financial Information
• Convenience Clinics
• RELIANCE MEDICAL FINANCE
• History and Lines of Business
• Financial Information
• Patient Financing
• SOLANTIC
• History and Lines of Business
• Financial Information
• Convenience Clinics
• SPRINGSTONE PATIENT FINANCING
• History and Lines of Business
• Financial Information
• Patient Financing
• TAKE CARE HEALTH SYSTEMS
• History and Lines of Business
• Financial Information
• Convenience Clinics
• TARGET CLINIC MEDICAL ASSOCIATES
• History and Lines of Business
• Financial Information