People with depression, substance abuse problems, or other behavioral health issues also often have chronic medical conditions like obesity, hypertension, or diabetes. This “co-occurring” of conditions is far more likely to befall people with low incomes than those with higher incomes. When people have both behavioral and chronic health conditions, those with low incomes spend more on their care than people with higher incomes. This disparity may reflect greater severity of disease as well as poorer access to care.

The Issue

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Simply screening low-income people for behavioral health problems may not be sufficient unless there is greater understanding of the mechanisms that both cause and exacerbate chronic and behavioral health problems in the low-income population.

Research has shown that having both chronic conditions and behavioral health issues is associated with higher health care costs. But prior studies have not explored how an individual’s income plays a role in how much they spend on care and the severity of illness. In a new study, Commonwealth Fund–supported researchers examined whether the link between co-occurring conditions and health care spending differed by income level.

Key Findings

  • Among people with a chronic condition, those with low incomes are much more likely (32%) to have a behavioral health condition than those with moderate incomes (24%) and those with high incomes (21%).
  • Rates of serious psychological stress are much higher among low-income people with chronic and behavioral health problems (29%) compared to higher-income people with similar health conditions (7%).
  • In general, health care spending is higher for individuals with co-occurring chronic and behavioral health conditions compared to people with only chronic or only behavioral health issues. Of those with co-occurring problems, annual spending is significantly higher for low-income people ($9,472) than it is for higher-income people ($7,457).
  • Low-income people with co-occurring conditions spend much more on inpatient or emergency department care than higher-income people do ($363 vs. $101).
  • Among low-income people with co-occurring conditions, 55 percent said they needed urgent medical care in the past year but 22 percent did not receive it. Among higher-income people, 41 percent said they needed urgent care and only 9 percent said they did not receive it.



The Big Picture


Higher health spending by lower-income individuals with co-occurring behavioral and chronic conditions may reflect greater disease severity as well as poorer access to both primary care and urgent care. The researchers note that crisis stabilization units — small inpatient facilities for people in mental health crisis — can prevent the need for inpatient treatment. Making these and other care innovations more widely available, particularly in low-income communities, would help reduce disparities, they say. The authors also call for greater coordination between behavioral health and medical care providers.

About the Study

The researchers based their analysis on data from the 2011–2014 Medical Expenditures Panel Survey – Household Component (MEPS-HC). People were defined as having a chronic condition if they reported that a doctor had ever told them that they had one or more of the following conditions: hypertension, heart disease, high cholesterol, diabetes, asthma, cancer, emphysema, chronic bronchitis, arthritis, or stroke. Behavioral health conditions were based on self-reports by survey respondents.

The Bottom Line

Among people who have behavioral health problems as well as chronic medical conditions, those with low incomes tend to have higher health care spending compared to patients with higher incomes. This discrepancy may reflect the poorer access to care and worse health status of those with low incomes.