Household Health Care Payments Under Rate Setting, Spending Growth Target, and Single-Payer Policies.

Importance: Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households. Objective: To estimate the distribution of household health care payments across income under health care reform policies. Design, Setting, and Participants: Cross-sectional study with microsimulation used nationally representative data of the US population in 2030. Civilian, noninstitutionalized population from the 2022 Current Population Survey linked to expenditures from the 2018 and 2019 Medical Expenditure Panel Survey and 2022 National Health Expenditure Accounts were included. Exposure: Rate regulation of hospital, physician, and other health care professional payments equal to the all-payer mean in the status quo, spending growth target at 4% annual per capita growth, and single-payer health care financed through taxes. Main Outcomes and Measures: Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation. Results: The synthetic population contained 154 456 records representing 339.5 million individuals, with 51% female, 7% Asian, 14% Black, 18% Hispanic White, 56% non-Hispanic White, and 5% other races and ethnicities (American Indian or Alaskan Native only; Native Hawaiian or other Pacific Islander only; and 2 or more races). In the status quo, mean household health care payments as a share of compensation was 24% to 27% (standard error [SE], 0.2%-1.2%) across income groups (median [IQR] 22% [4%-52%] below 139% of the federal poverty level [FPL]; 21% [4%-34%] for households above 1000% FPL [11% of the population]). Under rate setting, mean (SE) payments by households above 1000% FPL increased to 29% (0.6%) (median [IQR], 22% [6%-35%]) and decreased to 23% to 25% for other income groups. Under the spending growth target, mean (SE) payments decreased from 23% to 26% (SE, 0.2%-1.2%) across income groups. Under the single-payer system, mean (SE) payments declined to 15% (0.7%) (median [IQR], 4% [0%-30%]) for those below 139% FPL and increased to 31% (0.6%) (median [IQR], 23% [3%-39%]) for those above 1000% FPL. Uninsurance fell from 9% to 6% under rate setting due to improved Medicaid access, and to zero under the single-payer system. Conclusions and Relevance: Single-payer financing based on the current federal income tax schedule and a payroll tax could substantially increase progressivity of household payments by income. Rate setting led to slight increases in payments by higher-income households, who financed higher payment rates in Medicare and Medicaid. Spending growth targets reduced payments slightly for all households.

Linkages between share pledging, stock price risk and profitability: Evidence from the P.R. China.

Share pledging has become popular as a method of loan collateral among Chinese shareholders. Our research used a sample of Chinese listed firms between 2008-2018 and produced two main findings. Firstly, we found a negative association between stock price risk and firm profitability. Our second finding was that the interaction effect of share pledging and stock price risk is greater on firm profitability than the effect of stock price risk itself. We examined the role of share pledging by modeling pooled OLS and fixed effects using share pledging behavior, controlling shareholders' share pledging and the share pledging ratio to reinforce the robustness of our results. Furthermore, we investigated the Davis Double Play effect of share pledging to analyze how share pledging affects stock price risk. We found that higher EPS and investor expectations cannot mitigate the positive impact of share pledging on stock price risk. That is, the reduction of EPS and the deterioration of investor expectations caused by share pledging risk will not further aggravate the stock price risk, as shareholders may have taken some managerial actions to affect the transmission mechanism.

Out-of-pocket medical expenses compared across five years for patients with one of five common cancers in Australia.

BACKGROUND: Patient medical out-of-pocket expenses are thought to be rising worldwide yet data describing trends over time is scant. We evaluated trends of out-of-pocket expenses for patients in Australia with one of five major cancers in the first-year after diagnosis. METHODS: Participants from the QSKIN Sun and Health prospective cohort Study with a histologically confirmed breast, colorectal, lung, melanoma, or prostate cancer diagnosed between 2011 and 2015 were included (n = 1965). Medicare claims data on out-of-pocket expenses were analysed using a two-part model adjusted for year of diagnosis, health insurance status, age and education level. Fisher price and quantity indexes were also calculated to assess prices and volumes separately. RESULTS: On average, patients with cancer diagnosed in 2015 spent 70% more out-of-pocket on direct medical expenses than those diagnosed in 2011. Out-of-pocket expenses increased significantly for patients with breast cancer (mean AU$2513 in 2011 to AU$6802 in 2015). Out-of-pocket expenses were higher overall for individuals with private health insurance. For prostate cancer, expenses increased for those without private health insurance over time (mean AU$1586 in 2011 to AU$4748 in 2014) and remained stable for those with private health insurance (AU$4397 in 2011 to AU$5623 in 2015). There were progressive increases in prices and quantities of medical services for patients with melanoma, breast and lung cancer. For all cancers, prices increased for medicines and doctor attendances but fluctuated for other medical services. CONCLUSION: Out-of-pocket expenses for patients with cancer have increased substantially over time. Such increases were more pronounced for women with breast cancer and those without private health insurance. Increased out-of-pocket expenses arose from both higher prices and higher volumes of health services but differ by cancer type. Further efforts to monitor patient out-of-pocket costs and prevent health inequities are required.

Determinants of out-of-pocket and catastrophic health expenditure in rural population: A community-based study in a block of Purba Barddhaman, West Bengal.

BACKGROUND: In India, health expenditure accounts for <5% of the Gross domestic product and the level of out-of-pocket (OOP) spending is 69.5% of total health expenditures. OOP expenditure (OOPE) has a negative impact on equity and can increase the risk of vulnerable groups slipping into poverty. OBJECTIVES: The study aimed to estimate the OOPE on health and catastrophic health expenditure (CHE) and their sociodemographic determinants in a rural area of Purba Barddhaman. METHODS: A community-based cross-sectional study was conducted between July 2018 and February 2019 in Bhatar Block of Purba Bardhaman district, West Bengal. Required sample of 235 households, selected randomly were primary study units. One respondent from each household was interviewed with a predesigned, pretested schedule for sociodemographic and health-care expenditure-related variables. Mann-Whitney U test/Kruskal Wallis H test and multivariable logistic regression was applied. RESULTS: The median OOP health expenditure was Rs. 3870 (inter quartile range: 2156-4952). Of 235 families, 38 (16.2%) had CHE over a period of 1 year. The significant correlates for CHE were type of village according to the presence of public health-care facility (adjusted odds ratio [AOR] = 4.748; 95% confidence interval [CI]: 1.886-11.956), presence of health insurance (AOR = 11.124; 95% CI: 3.690-33.535) and gender of the head of the family (AOR = 18.176; 95% CI: 3.353-98.534). Concentration curve suggested a higher concentration of CHE among poor households. CONCLUSION: CHE is substantially high in the area. The efforts are required to make the services available as close to the households as possible and to increase awareness about health facilities.

Government health expenditure, out-of-pocket payment and social inequality: A cross-national analysis of China and OECD countries.

This study aims to assess the association between Chinese out-of-pocket payments and government health spending, investigating their variation ratio in the context of OECD countries. Aggregated time-series data of 37 countries (from China and official OECD members) were collected from the World Bank Open Data source and analyzed using the multiple linear regression models. Benchmarking approach was applied to evaluate the causes of healthcare expenditure rise per capita. The results showed that China's government health expenditure was positively associated with out-of-pocket payment rise, with a higher variation score of 42.70%. The association was statistically significant at 5%. Likewise, the association between government expenditure and out-of-pocket payment in the OECD countries was positively significant at 1%, and their variation score was 2.41%. Health financing in OECD countries showed higher stability and equity than that in China. Policy implications for China is to reduce the distributional disparity of government health funds by tax adjustments in health services, universal health coverage, the removal of social health insurance disparities, and a single health payment method.

Changes In The Equity Of US Health Care Financing In The Period 2005-16.

Spending on health care in the United States amounted to 17.9 percent of gross domestic product in 2017. Households paid for this care through out-of-pocket medical spending and a complex mix of out-of-pocket premiums, employer premium contributions, taxes, and subsidies that combined to finance private employer-sponsored insurance, nongroup insurance, and multiple public insurance programs. Our analysis examined the impact of this complex system of health care financing on households in the period 2005-16, tracking how economic and policy changes affected incidence-that is, the amount paid to finance health care, either directly or indirectly, by households as a share of their pretax income. Health care financing was regressive at the start of our study period, with households in the bottom 20 percent of income paying 26.8 percent of their income compared to about half that amount for those with income in the top 1 percent. By 2016 incidence had become approximately proportional (the same percentage across all income levels). In part, these results reflect increases in coverage through Medicaid and the Affordable Care Act Marketplaces, which are progressively financed through the federal tax system.

Health Benefits In 2019: Premiums Inch Higher, Employers Respond To Federal Policy.

The annual Kaiser Family Foundation Employer Health Benefits Survey found that in 2019 the average annual premium for single coverage rose 4 percent to $7,188, and the average annual premium for family coverage rose 5 percent to $20,576. Covered workers contributed 18 percent of the cost for single coverage and 30 percent of the cost for family coverage, on average, with considerable variation across firms. Fifty-seven percent of firms offered health benefits to at least some of their workers. While some larger firms reported that take-up dropped because of the elimination of the individual mandate penalty, the overall share of workers covered at their own firm (61 percent) was similar to that in recent years. Large employers reported taking a variety of steps to address the opioid epidemic over the past few years. Our findings offer some context for the role of health insurance reform in the 2020 election cycle.

Private health expenditure in Ireland: Assessing the affordability of private financing of health care.

This paper investigates the affordability of private health expenditure among Irish households and the services contributing towards financial hardship. We use data from the Irish Household Budget Survey, a representative survey of household spending in Ireland, covering 2009-10 and 2015-16. Private health expenditure comprises out-of-pocket payments for health and social care services and private health insurance (PHI) premiums. The poverty threshold is 60% of median total equivalised consumption and households with consumption below this level were defined as poor. Households were classified as having unaffordable health expenditure if: 1) they were poor and reported any spending; 2) they were pushed below poverty threshold by health spending; or 3) their spending on health exceeded 40% of capacity to pay. Despite signs of economic recovery, the incidence of unaffordable private health spending increased over the years-from 15% in 2009-10 to 18.8% in 2015-16. People on low incomes were disproportionately affected. The largest component of unaffordable spending for poorer households is PHI and not user charges, which have actually fallen as a cause of hardship. Our findings indicate that reliance on private health expenditure as a funding mechanism undermines the fundamental goals of equity and appropriate access within the health care system.

Assessing progressivity and catastrophic effect of out-of-pocket payments for healthcare in Canada: 2010-2015.

Equity in healthcare is an important policy objective of the Canadian healthcare system. Out-of-pocket payments for healthcare (OPPH) by Canadian households account for a substantial share of total healthcare expenditures. Using data from Statistics Canada's Survey of Household Spending (SHS, n = 33,367), this study examined the progressivity and catastrophic effect of OPPH in Canada over the period 2010 to 2015 inclusive. The Kakwani Progressivity Index (KPI) was used to measure the progressivity of OPPH for each year of the study period. The catastrophic effect of OPPH was calculated using a threshold of 10% of total household consumption. The computed KPI indicated that OPPH are a regressive source of healthcare funding in Canada and the regressivity of OPPH has increased over the study period. This indicates that the distribution of OPPH in Canada is not equitable and the percentage contribution of households from their total consumption to healthcare as OPPH decreases as their consumption increase. The results also suggested that 7% of Canadian households face catastrophic out-of-pocket payments for healthcare (COPPH) over the study period. The proportion of households with COPPH was higher in rural areas compared with urban areas over the study period. Policies to enhance financial risk protection among low-income and rural households are required to improve equity in healthcare financing in Canada.

Impacts on employment, finances, and lifestyle for working age people facing an expected premature death: A systematic review.

ABSTRACTObjective:The working ages (25-65 years) are a period when most people have significant work, financial, and family responsibilities. A small proportion of working age people will face an expected premature death from cancer or other life-limiting illness. Understanding the impact an expected premature death has on this population is important for informing support. The current study set out to summarize research describing the effects that facing an expected premature death has on employment, financial, and lifestyle of working age people and their families. METHOD: A systematic review using narrative synthesis approach. Four electronic databases were searched in July 2016 for peer-reviewed, English language studies focusing on the financial, employment, and lifestyle concerns of working age adults living with an advanced life-limiting illness and/or their carers and/or children. RESULTS: Fifteen quantitative and 12 qualitative studies were included. Two-thirds (n = 18) were focused on cancer. All studies identified adverse effects on workforce participation, finances, and lifestyle. Many patients were forced to work less or give up work/retire early because of symptoms and reduced functioning. In addition to treatment costs, patients and families were also faced with child care, travel, and home/car modification costs. Being younger was associated with greater employment and financial burden, whereas having children was associated with lower functional well-being. Changes in family roles were identified as challenging regardless of diagnosis, whereas maintaining normalcy and creating stability was seen as a priority by parents with advanced cancer. This review is limited by the smaller number of studies focussing on the needs of working age people with nonmalignant disease. SIGNIFICANCE OF RESULTS: Working age people facing an expected premature death and their families have significant unmet financial, employment, and lifestyle needs. Comparing and contrasting their severity, timing, and priority for people with nonmalignant conditions is required to better understand their unique needs.

How the Affordable Care Act Has Improved Americans' Ability to Buy Health Insurance on Their Own: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016.

Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers' experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people's ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch.

Issue: Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law's critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers. Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers' incomes. Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015. Key findings and conclusions: Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia. There has been a similar slowdown in growth in the amounts employees contribute to health plan costs. Yet many families feel pinched by their health care costs: despite a recent surge, income growth has not kept pace in many areas of the U.S. Employee contributions to premiums and deductibles amounted to 10.1 percent of U.S. median income in 2015, compared to 6.5 percent in 2006. These costs are higher relative to income in many southeastern and southern states, where incomes are below the national average.

How the ACA's Health Insurance Expansions Have Affected Out-of-Pocket Cost-Sharing and Spending on Premiums.

One important benefit gained by the millions of Americans with health insurance through the Affordable Care Act (ACA) is protection from high out-of-pocket health spending. While Medicaid unambiguously reduces out-of-pocket premium and medical costs for low-income people, it is less certain that marketplace coverage and other types of insurance purchased to comply with the law's individual mandate also protect from high health spending. Goal: To compare out-of-pocket spending in 2014 to spending in 2013; assess how this spending changed in states where many people enrolled in the marketplaces relative to states where few people enrolled; and project the decline in the percentage of people paying high amounts out-of-pocket. Methods: Linear regression models were used to estimate whether people under age 65 spent above certain thresholds. Key findings and conclusions: The probability of incurring high out-of-pocket costs and premium expenses declined as marketplace enrollment increased. The percentage reductions were greatest among those with incomes between 250 percent and 399 percent of poverty, those who were eligible for premium subsidies, and those who previously were uninsured or had very limited nongroup coverage. These effects appear largely attributable to marketplace enrollment rather than to other ACA provisions or to economic trends.

Individual vs. Employer-Based Health Care: Changing Solutions for Discrete Populations.

The Affordable Care Act has served as a catalyst for the changes currently underway in the U.S. health care system and accelerated change underway over the past two decades. Employers are striving to make sense of an evolving health environment while meeting the needs of an increasingly diverse workforce. The health care landscape has shifted from the "Era of the Health Plan" to the "Era of the Person," where employers must pay heed to the distinct needs of each discrete population. To achieve optimal business performance, employers must adopt differentiated solutions that make health care local, personal and specific.

Financial impact of the GFC: health care spending across the OECD.

Since the onset of the global financial crisis (GFC), health spending has slowed markedly or fallen in many OECD countries after years of continuous growth. However, health spending patterns across the 34 countries of the OECD have been affected to varying degrees. This article examines in more detail the observed downturn in health expenditure growth, analysing which countries and which sectors of health spending have been most affected. In addition, using more recent preliminary data for a subset of countries, this article tries to shed light on the prospects for health spending trends. Given that public sources account for around three-quarters of total spending on health on average across the OECD, and, in an overall context of managing public deficits, the article focuses on the specific areas of public spending that have been most affected. This study also tries to link the observed trends with some of the main policy measures and instruments put in place by countries. The investigation finds that while nearly all OECD countries have seen health spending growth decrease since 2009, there is wide variation as to the extent of the slowdown, with some countries outside of Europe continuing to see significant growth in health spending. While all sectors of spending appear to have been affected, initial analysis appears to show the greatest decreases has been experienced in pharmaceutical spending and in areas of public health and prevention.