Background
Study | Countries | Data/Variable | Key Findings | Relevance |
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Baird, 2016 [1] | Australia, France, Israel, Japan, Poland, Russia, Slovenia, Switzerland, United States | Individual survey on OOP spending compared to income from Luxembourg Income Study (2010 for most countries) | • In median country, 13% of people spend more than 10% of income in OOP. • Varies from 3% (France) to 17% (Switzerland). • Poor and elderly at greatest risk of cata-strophic spending. | • Focuses on percentage of population with high OOP spending during a single year. • Emphasizes groups that are most financially vulnerable. • Does not examine countries’ health policies. • Does not examine perceived barriers on access to care. |
Palladino et al., 2016 [2] | Austria, Belgium, Czech Republic, Denmark, France, Germany, Netherlands, Spain, Sweden, Switzerland | Survey of people age 50 and older from Health, Ageing and Retirement in Europe, with data on changes in OOP spending and experiencing catastrophic OOP spending (30% or more of income), from 2006/7 to 2013 (Great Recession) | • Very large range in changes in OOP spending (− 11% in Netherlands to + 101% in Austria). • Increase in catastrophic spending: from 2.3 to 3.9% over study period. • People age 50 and older spent more in 8 of11 countries. • Countries do provide financial protection for poor. | • Focuses on changes in OOP spending during limited time period. • Does not examine countries’ health policies. • Does not examine perceived barriers on access to care. |
Tambor et al., 2011 [3] | 27 countries in the European Union | Review of international data bases, laws and regulations, and reports on changes in patient cost sharing requirements since 1990 | • Cost-sharing requirements vary a great deal between countries, and have increased significantly in many. • Tax-based systems more likely to use co-payments, insurance-based systems more likely to use deductibles and coinsurance. • Almost all countries have policies to protect the poorest and/or sickest. | • Focuses on health policies in countries, but little detail provided. • Includes extremely diverse set of countries. • Does not examine perceived barriers on access to care. |
Zare & Anderson, 2013 [4] | France, Germany, Japan, United Kingdom, United States (Medicare only) | Various data sets from OECD, WHO, European Observatory, and country-specific reports, time period 2000–2010; separately examine cost sharing for pharmaceuticals, inpatient, and ambulatory care | • Inflation-adjusted OOP spending, and spending divided by income, increased in all countries. • Percent of total national health care paid OOP declined in most countries due to protection mechanisms for poor and/or sick. | • Focuses on health policies in 5 countries. • Does not examine perceived barriers on access to care. |
Methods
Choice of countries and time period
Conceptualizing out-of-pocket costs
Definition of terms
Analytic framework
Objective trends and perceived access barriers
Data sources and analysis
Results
Aggregate trends in OOP spending by country
Predicted Mean Percent Change in OOP/Capita 1994–2004 vs. 2004–2014 | p-value | |
---|---|---|
Group 1 - Historically low OOP costs with higher recent growth | 3.63 | reference group |
Group 2 - Historically moderate OOP costs with lower recent growth | −3.00 | < 0.001 |
Group 3 - Historically high OOP costs with low to no recent growth | −3.56 | < 0.001 |
Country-specific OOP policies
Group 1: Historically low OOP costs, higher recent growth (France, Netherlands, UK)
Group 2: Historically moderate OOP costs, lower recent growth (Australia, Canada, Germany, Sweden)
Group 3: Historically high OOP cost, low to no growth in recent years (Norway, Switzerland, United States)
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Medicaid covers a very wide scope of services and this coverage is deep, with minimal cost sharing requirements. As noted, the breadth of program coverage has risen dramatically in recent years, particularly due to expansion under the ACA, doubling from 35 million people in 2000 to 70 million in 2016. One of the main problems is that physician payment rates are so low in some states that it is difficult for program enrolees to find primary care and specialist physicians to treat them.
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The breadth of Medicare coverage is nearly universal in the age 65+ population; the program covers many disabled people as well. Since 2006, with the implementation of prescription drug benefits, nearly all types of services are covered. Depth of coverage is relatively low with coinsurance rates as high as 20% for physician services and no out-of-pocket ceiling. As a result, 86% of Medicare beneficiaries have supplemental coverage [20] to pay for many coverage gaps. Sources include subsidized coverage from former employers, unsubsidized “Medigap” private insurance coverage (which is mainly complementary), and Medicaid for those with low incomes. Cost sharing requirements change only modestly year to year.
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Just over half of insured Americans receive coverage through employers. The scope of services covered tends to be broad. However, cost sharing requirements in such plans have risen steeply in recent years. The most dramatic changes have been for deductibles. On average, annual deductibles for employees who are only covering themselves have gone up almost 2.5-fold, from $602 in 2005 to $1478 in 2016. There have also been substantial increases in the maximum OOP costs beneficiaries can incur each year. In 2005, 33% of employees had a maximum of $3000 or more. But in 2016, this had risen to 66%. Depending on the insurer and type of service, employees are also subject to coinsurance or co-payments, but these requirements have been relatively stable over time except for brand-name drugs that are not on an insurer’s formulary. Most employees do not have coverage for dental care and vision services; for those that do, cost sharing requirements changed little over the past 10 years. There is no major market for complementary coverage. The main supplementary coverage is for dental care.
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Beginning in 2014, individuals have also obtained coverage on the ACA’s insurance exchanges. Deductibles are quite high in the most commonly purchased “Silver” plans, averaging almost $3600 in 2017 [21].