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We studied the effects of health insurance, health care needs, demographic and area characteristics on out-of-pocket health care spending for low and higher income insured populations using the 2002 National Survey of America's Families. Results show that families with non-group insurance have the highest odds of experiencing high out-of-pocket expenses and high financial burden regardless of income, and that public insurance appears to offer the best financial protection from high out-of-pocket expenses and financial burden for low-income families. For higher-income families, having family members in fair or poor health is a risk factor for high out-of-pocket expenses and financial burden. (Medical Care, 44(3), March 2006, pp: 200-209)