Another method of presenting the amount of hospital service received by people is by calculating the number of hospital days utilized per person or per 100 persons in a year. Throughout the country during the survey there were 100 hospital days utilized per 100 persons in all families, and 110 days in families with insurance compared with 80 days in families without insurance. (See table 3, appendix.) Again, not until the income group $7,500 is reached do the rates for families with insurance and those without insurance begin to equalize. When the volume of hospital care is broken down by rural and urban areas, other patterns of hospitalization emerge contrary to usual expectations of the behavior of rural populations, since the rural farm insured population has a higher admission rate than the urban insured. In fact, the reverse of the pattern would have been predicted, because it has been assumed that rural people have been less inclined to enter a hospital than those living in urban areas. (See table 4, appendix.) Apparently times have changed when the rural farm population with insurance shows an admission rate of 17 per 100 persons as against 12 in urban areas. It will also be noted that for people in urban and rural farm areas with no insurance the rate is the same, but when insurance enters the picture the impact on rural farm residents is greater than on urban residents. There may be a high selectivity among those insured in rural farm areas, because relatively few people in those areas are insured.

Further corroboration of the rural-urban pattern is found when there is a hospital utilization breakdown by type of locality as measured by size of city in the area. Again, the more rural the area the greater is the hospital admission rate for those who carry hospital insurance, and the shorter is the average length of stay. (See table 5, appendix.)

2. The amount of surgery performed

It has been shown that hospital insurance increased the utilization of hospitals. Likewise, it is found that surgical insurance increased the number of surgical procedures. (See table 6, appendix.) The number of surgical procedures per 100 persons in families with surgical insurance is 7, while in families with no such insurance the rate is 4-a very appreciable difference. The families which have insurance have almost the same amount of surgery, regardless of their incomes. This is also true for families which do not have insurance. Analysis of the two groups reveals, therefore, that the primary factor accounting for the greater amount of surgery is the existence of insurance. (See table 6, appendix.)

What do these rates mean? Again it is necessary to know more of the factors underlying the different rates. Very likely there is a higher proportion of socalled elective surgery in the insured families and a higher proportion of emergency or must surgery in the noninsured families. Is there too little surgery performed in the noninsured group? What is known with certainty is that, given a greater accessibility to surgery, the surgical rate is 7 per 100 persons instead of 4.

3. Dental services

To date dental services have not usually been included in insurance against costs of personal health services except for dental surgery. There is a great difference in the amount of dental service received by income group as measured by visits to dentists, contrary to the pattern shown above in hospitalization and surgery. Among all families 34 percent of the individuals in them sought the services of a dentist during the survey year. In the lowest income group, under $2,000, 17 percent sought service, and in the group $7,500 and over, 56 percent. It can be safely assumed that the lower the income group the higher is the proportion of dental service which is emergency in nature, such as relieving pain and extractions, and the lower is the proportion of preventive care and repair work. (See table 7, appendix.)

TABLE 1.-Hospital admission rates, by family income, during the survey year for persons with and without hospital insurance

1 These are numbers of persons covered or not covered by hospital insurance at end of the survey year Estimates of the number of people enrolled and the number not enrolled in hospital insurance in each group at the end of the survey year were taken as the populations exposed to risk of occurrence in estimating these insurance coverage specific rates. Inasmuch as there was a net increase in hospital insurance enrolment during the survey year and the hospital admissions occurred throughout the survey year, the est mates of the exposed population used in estimating the rates for people enrolled in hospital insurance the time of admission are probably somewhat too large. Similarly, the estimates of exposed populati used in computing the rates for those not enrolled at the time of admission are probably somewhat too small.

Admission rates have not been computed for groups of less than 50.

TABLE 2.—Average number of hospital days per person hospitalized, by family income

1 Average number of hospital days has not been computed for groups of less than 50 persons. TABLE 3.—Number of hospital days per 100 persons in the population, by famús

TABLE 4.-Hospital admission rates and average length of stay per admission during the survey year, by urban, rural, nonfarm, and rural farm

These are persons with hospital insurance and with no hospital insurance at the end of the survey year.

TABLE 5.-Hospital admission rates and average length of stay per admission during the survey year, by place of residence

1 These are persons with hospital insurance and with no hospital insurance at the end of the survey year.

TABLE 6.-Number of surgical procedures per 100 persons, by family income, for persons in families with surgical insurance and persons in families with no surgical insurance 1

This table compares the rates for groups with and without surgical insurance, and gives the rates for persons in families in which one or more persons has surgical insurance, as compared with families in which no one has any form of surgical insurance. Therefore, in the group in which there is some surgical insurance, there are some individuals without such insurance.

*Surgical procedures are defined so as to include the treatment of fractures and dislocations as well as "cutting" procedures. This definition includes deliveries by Caesarean but excludes normal deliveries. See footnote 2 to table 1. The discussion of the estimates of the relative service rates for people covered as against those not covered by hospital insurance is also relevant here.

Number of surgical procedures per 100 was not computed for groups of less than 50 persons.

TABLE 7.-Percentage of persons consulting dentists during the survey year, by family income

1 Percentage of persons consulting a dentist was not computed for groups of less than 50 persons,

4. DEBT AMONG FAMILIES DUE TO COSTS OF PERSONAL HEALTH SERVICES AS OF JULY 1953

PART IV. HIGHLIGHTS

1. Among all families, 15 percent are in debt to hospitals, physicians, dents, and other providers of medical goods and services, and their total debt is $40 million.

2. In absolute terms this means that approximately 7.5 million families have a medical debt and about one million of these families owe $195 or more. 3. The average debt among all families for bills owed to hospitals, physicians, dentists, and other providers of medical goods and services is $121.

4. When debts to financial institutions and individuals are included, the national total is $1.1 billion.

5. A greater proportion, 21 percent, of the families with children have a medical debt than those without children.

6. Four percent of the families reported borrowing from financial institutions and individuals to pay charges for personal health services.'

7. The greater the proportion of family income paid out for personal heath services, the greater is the likelihood that the family seeks a loan.

Being in debt is no novelty for the vast majority of American families since they are accustomed to buying a wide range of goods on credit. In fact, much down and so much a month" is the mainstay of the automobile, refrigerator radio and television, and furniture industries. Presumably, going into debt for automobiles, refrigerators, television sets, and many other items is pleasurab because one can enjoy them while paying for them. There are also the factory of convenience of a payment plan and aggressive salesmanship.

Since being in debt is, so to speak, a normal experience for many Americat families, is there any cause for concern when one learns that 15 percent of families are in debt to hospitals, physicians, dentists, and other providers of medical goods and services, and that 2 percent are in debt for $195 or more! Translated into absolute numbers this means that approximately 7.5 milli families in the United States have some debt and that about one million families owe $195 or more.

If personal health services could be purchased like any other goods or serv ices when desired and in the quantity and of the quality to fit one's purse perhaps the problem of medical debt could be dismissed as of no more concer than the balance owed by a family on its automobile or television set. T cost of these items is known in advance; the costs of personal health services are not so known and when they are needed the consumer usually has no che but to seek the necessary services, regardless of the cost, even if it means into debt. Systematic saving is not a solution since families would not know how much should be saved annually. An effective and accepted mechanism ta is an adequate insurance plan to meet the unpredictable costs of personal ben services; such a plan is, in effect, a savings program of many people pooling their money and their risks.

Hereafter referred to as medical indebtedness.

In a previous part of this report, the distribution of the costs of personal health services by family income was presented showing that some families incurred no costs during the survey year and some incurred costs equaling or exceeding their annual incomes. In the data to follow showing the distribution of outstanding medical indebtedness, it will be noted that such indebtedness is considerably less than the incurred charges presented in a previous report. Apparently, the bills were paid in some way or other-insurance and savingsbut a residue of unpaid bills remains. Considering the magnitudes of some of the incurred charges, it is surprising that the residue of unpaid bills is actually as small as indicated in this survey. Given the definition of medical indebtedness in the study, it would seem that such indebtedness excludes minor costs and includes indebtedness which represents some degree of hardship to the families. Outstanding medical indebtedness includes debts owed to hospitals, physicians, dentists, and other suppliers of medical goods and services at the end of the Surrey rear less any amount which the family planned to pay on such bills during the month following the interview; that is, the informant was asked how much the family owed-including amounts owed on bills not yet received—and was then asked how much the family planned to pay on these bills during the next month. If the informant reported that the family's only outstanding debt was $10 to the doctor and that the bill would be paid during the next month, the family was recorded as having no outstanding indebtedness for personal health services.

This method of getting at outstanding indebtedness was used to determine the number of families who were not current with respect to debts for personal health services, that is, those families who had owed hospitals, physicians, and others for a period longer than normal interim between receiving services of goods and paying for them. The amount of outstanding indebtedness then included all such debts whether incurred prior to the survey year or during the survey year, except that the amount which the family planned to pay in the month following the interview was excluded.

An important point to bear in mind is that medical indebtedness excludes debts to financial institutions and individuals which were incurred to pay for personal health services and goods.

All families in this survey showed 85 percent with no medical indebtedness and 15 percent with some debt. The 15 percent with some debt includes 9 percent under $94, 3 percent $95–$194, 2 percent $195 and over, and 1 percent where the amount was unknown. (See table 1, appendix A.) The average debt per family with medical indebtedness is $121. In national terms, this means that total indebtedness approximates $900 million.

The percent of all families with some medical indebtedness is quite constant until the income groups $5,000 and over are reached. Thereafter, there is a sharp drop. This is not a surprising fact, of course, since upper-income groups lay out a smaller percentage of their income for personal health services although average family costs are higher. It is also of particular interest to note that having or not having insurance had no real appreciable effect on indebtedness. A final observation is that indebtedness in families with incomes under $2,000 undoubtedly represents a greater burden than indebtedness in income groups with higher incomes. Debts are not necessarily distributed evenly in proportion to incomes as are shown in the tables.

The lowest income group has the highest percentage of families with medical debt under $95, namely 13 percent; 4 percent of the highest income group has debts of similar magnitude. It would appear that in three of the income groups, those with insurance are more likely to have debts under $95 than those without insurance. (See table 2, appendix A.)

For families with medical debts ranging from $95 to $194 again, the lower the income group the greater is the hardship experienced. The effect of insurance is negligible. (See table 3, appendix A.)

There is an interesting uniformity of percent of families with medical debts exceeding $195, 2 percent, but the lower the income group the greater is the hardship involved on the part of the families. (See table 4, appendix A.)

The final tables in this report show anticipated patterns and help to buttress the data on medical indebtedness presented in the foregoing data. By and large the greater the percent of family income paid out for personal health services, the larger is the proportion of families who reported outstanding medical indebtedness. This is also true within income groups as well as between income groups. (See table 5, appendix A.)

46293-54-pt. 3-28