Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study

Abstract

Objective To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). Design Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. Setting United States. Participants A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. Main outcomes and measures Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. Results 37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change −28.0% (95% confidence interval −38.4% to −15.8%); adjusted absolute change −$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (−29.0% (−40.5% to −15.3%); −$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change −4.7 (−7.9 to −1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. Conclusion Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act’s implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.

Catastrophic Health Expenditures Across Insurance Types and Incomes Before and After the Patient Protection and Affordable Care Act

“… 1 Premiums are increasingly unaffordable, and underinsurance—incomplete financial protection despite coverage—is increasingly common. 2 Although previous research has shown that the ACA’s Medicaid expansions decreased out-of-pocket spending among low-income adults, 3 broader trends in out-of-pocket spending have not been well characterized. We thus sought to analyze changes in financial risk protection associated with ACA implementation across all income strata and insurance types.…”

Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

“…Among the primary objectives of healthcare systems are to treat sick people and protect them from financial risk [1]. Tax systems and health insurance are major mechanisms that pool financial risk and assure more predictable healthcare finances [2]. However, households with tight financial constraints in low and middle-income countries (LMICs) still pay high levels of direct out-ofpocket (OOP) healthcare payments during illness [3] at the point of seeking healthcare [4].…”

Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act

“…We used a linear probability model to allow for direct interpretation of regression coefficients and to align our methods with those of existing studies. 9,15 MEPS survey weights, strata, and clusters were used to account for the complex survey design, and cluster-robust standard errors were employed to account for correlation within each sampling unit (group of neighboring counties).…”

“…9,10 More directly, analyses of patient expenditures have shown an association between ACA implementation and decreased outof-pocket spending as well as risk of catastrophic health expenditures. [11][12][13][14][15] Veterans have different options for healthcare financing than the broader US population. For example, through the Veterans Health Administration (VHA), veterans with a service-related condition or meeting income eligibility thresholds may qualify for care with minimal to no cost sharing.…”