High Out-of-Pocket Costs Raise Food Insecurity Risk by Up to 90% in Households With Children

High out-of-pocket medical spending is associated with significantly increased odds of food insecurity among US households with children the following year, according to a cohort study published in JAMA Network Open.¹ Out-of-pocket spending has been on the rise.² Nationally, it increased 5.9% to $556.6 billion in 2024, averaging $1632 per capita—up from $1596 the prior year.

Researchers from Nationwide Children's Hospital and The Ohio State University analyzed data from the US Census Bureau's Survey of Income and Program Participation (SIPP) across the 2014, 2018, 2020, 2021, and 2022 panels.¹ The final analytic sample included 6940 households with children who participated in the first 3 years of each 4-year panel.

Out-of-Pocket Medical Costs Raise Food Insecurity Risk by Up to 90%

The study tested 2 commonly used thresholds for out-of-pocket medical financial burden: spending 5% or more of household income on out-of-pocket costs and spending 10% or more. Approximately 21.4% of households in the sample met the 5% burden threshold in year 2, while 10.4% met the 10% threshold.

Households that experienced a 5% out-of-pocket burden in year 2 had 80% greater odds of food insecurity in the following year (OR, 1.80; 95% CI, 1.31-2.48), compared with households without that burden. In concrete terms, those households faced an estimated food insecurity probability of 15.4% vs 10.5% for households without a 5% burden.

The association was even stronger at the 10% threshold: households spending at least 10% of income on out-of-pocket costs had 90% greater odds of food insecurity the following year (OR, 1.90; 95% CI, 1.32-2.75), with an estimated food insecurity probability of 16.6% compared with 10.9% for unexposed households.

Notably, the researchers found no statistically significant associations between out-of-pocket burden and the other health-related social needs (HRSNs) measured—difficulty paying bills (OR, 1.30 and 1.12 for the 5% and 10% thresholds, respectively) or poor housing quality (OR, 1.22 and 1.25). The authors suggest that households may prioritize housing stability—forgoing food to ensure rent and utilities are paid—which could explain why the food insecurity association emerged while bill-paying and housing outcomes did not.

Among the full sample, food insecurity (10.8%), difficulty paying bills (11.6%), and poor housing quality (17.2%) were all prevalent in year 3 of each panel, underscoring the breadth of financial hardship in this population.

Why the 10% Spending Threshold Alone May Miss At-Risk Families

The authors argue that the findings challenge reliance on the 10% threshold alone as the standard measure of medical financial burden. Because risks were similarly elevated at both the 5% and 10% thresholds, households experiencing subthreshold but still substantial out-of-pocket costs may be going undetected and unscreened for food insecurity in clinical settings. The study calls on clinicians to screen for HRSNs following any household experience with high out-of-pocket costs, not just those meeting the higher threshold.

What Are the Limitations of This Study?

The authors acknowledge several important limitations. As an observational study, the research cannot establish causality between out-of-pocket spending and food insecurity. While the use of inverse probability of treatment weights helped account for socioeconomic and health-related confounders, residual confounding cannot be ruled out.

Additionally, households that remained in the SIPP analytic sample for all 3 years tended to have higher incomes and more education than those who dropped out—characteristics associated with lower HRSN risk—meaning the findings may actually underestimate the true association between out-of-pocket burden and food insecurity in the broader population. Finally, the study relied on self-reported income and HRSN data, which may be subject to recall bias or social desirability bias.

Ultimately, households with children that face high out-of-pocket medical costs are at significantly greater odds of experiencing food insecurity in the following year, regardless of whether spending exceeds 5% or 10% of household income, the authors concluded. Future research should examine which factors may help mitigate the association between out-of-pocket medical costs and health-related social needs.

References

1. Caniglia M, Chavez LJ. Out-of-pocket costs and health-related social needs among households with children. JAMA Netw Open. 2026;9(6):e2616485. doi:10.1001/jamanetworkopen.2026.16485

2. Centers for Medicare & Medicaid Services. NHE Fact Sheet. Updated 2025. Accessed June 2, 2026. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet