Low-income Americans, older people and women pay a greater share of their incomes toward out-of-pocket health costs than do others, according to a new report issued Tuesday.

The broad analysis of spending by more than 2 million Americans also found that there is a strong correlation between when people tend to pay their out-of-pocket health costs and the months of March and April, when most people get their income tax refunds.

And the report from the JP Morgan Chase Institute found that out-of-pocket health spending was highly concentrated among relatively few families.

“The top 10 percent of health-care spenders contributed 49 percent of total out-of-pocket spending in 2016,” the report said. That top 10 percent on average spent 9 percent of their take-home pay on out-of-pocket health costs.

Out-of-pocket costs are health expenses not covered by a person’s insurance plan, and include charges such as co-payments, deductibles and coinsurance.

“The reality is that many American families don’t have the cash buffer to withstand the volatility created by out-of-pocket health-care payments,” said Diana Farrell, president and CEO of JP Morgan Chase Institute.

“We need to better understand the correlation between financial health and physical health.”

The report comes as Republican leaders in the Senate are pushing a last-ditch bill to repeal and replace much of the Affordable Care Act, also known as Obamacare.

Health experts have predicted that the bill, known as Graham-Cassidy, could greatly weaken, or eliminate in some states, ACA rules that mandate health insurance plans cover a minimum set of so-called essential health benefits, without imposing out-of-pocket charges on patients.

The institute for the report looked at spending from 2013 through 2016 by about 2.3 million Chase checking account customers. That data was “de-identified,” meaning it was not linked to people by name.

The time period examined includes the first three full years of implementation of Obamacare. Critics of that law predicted it would lead to increased health costs.

However, the Chase report found that overall out-of-pocket health spending rose modestly during the time frame, by 4.3 percent on average, and ended up being less of a share of take-home income over time.

In 2013, average annual out-of-pocket health-care spending by a family stood at $629, representing 1.7 percent of take-home pay, the report said.

That grew to $645 per family in 2014 — a 2.6 percent increase — and to $690 per family in 2015, a rise of 6.9 percent.

In 2016, out-of-pocket spending grew to $714 per family, up 3.6 percent from the prior year.

However, from 2014 through 2016, the total spent on out-of-pocket costs on average in each of those years was 1.6 percent of the average family’s household take-home pay — slightly less than the level seen in 2013.

But the burden on certain groups of people was much higher.

Families that earned less than $24,000 annually spent, on average, 2.8 percent of their take-home pay on out-of-pocket costs in 2016. That was up from 2.6 percent of take-home pay in 2015.

The next highest average burden was among families earning between $24,000 and $38,000 annually, which paid 1.6 percent of their take-home pay to out-of-pocket costs. As incomes rose after that, the burden of out-of-pocket costs dropped.

In households where the primary checking account was held by a woman, families paid, on average, 1.8 percent of their take-home pay toward out-of-pocket health costs in 2016, according to the report.

That compares to 1.5 percent among families where men were the primary checking account holders.

The report also found out-of-pocket cost burdens increased in direct correlation to a person’s age.

While people 18 to 25 years old paid just 1.2 percent of their pay toward such costs in 2016, that rose to 1.6 percent for people 35 to 44 years old, and to 1.9 percent for people 55 to 64 years old, the report said.

Farrell, the CEO of the JP Morgan Chase Institute, said that while the overall average burden from out-of-pocket health costs remained stable in the past four years, many people were feeling more pinched from those costs.

“What we hear all the time.. is that these costs are increasing quite significantly, and we note that, too,” Farrell said.

“But why is the burden stable? … By and large people are spending a certain fraction of their income on out-of-pocket health care spend, and then they won’t spend anymore,” she said.

“That means if they get the health care — fine. If that means they won’t pay for something that they’re due to pay, they’re probably not doing it, because we see this tight linkage between ability to pay, and pay,” Farrell said. “It’s almost as though people cap how much they will spend on health care… so when they have more ability to pay, when incomes go up, they pay. When they don’t, they won’t get the health care or they won’t pay for the health care.”

Farrell also said that if the Graham-Cassidy bill that would replace Obamacare becomes law, it will increase the burden on low-income people who already are struggling with out-of-pocket health costs.

“The demographic groups that are really carrying the heavier burden are the ones more likely to feel the impact of the changes,” she said. “Because the last several years have been relatively helpful to those groups, even though the outcome is more burdensome to them.”

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