Gross D J, Alecxih L, Gibson M J, Corea J, Caplan C, Brangan N
Public Policy Institute, American Association of Retired Persons, Washington, DC 20049, USA.
Health Serv Res. 1999 Apr;34(1 Pt 2):241-54.
To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration.
We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing.
Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare.
While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population.
估算低收入医疗保险受益人的自付医疗费用，并研究接受医疗补助援助者与未接受此类援助者之间的费用差异。数据来源与收集：1993年医疗保险当前受益人调查（MCBS）成本与使用文件，并辅以人口普查局（当前人口调查）、国会预算办公室、医疗保健财务管理局精算办公室（国家卫生账户）以及社会保障管理局的数据。
我们通过医疗保险福利模拟模型分析自付费用，该模型预测了从1993年MCBS到1997年的自付医疗费用。自付医疗费用的定义包括医疗保险免赔额和共保费用；私人保险、医疗保险B部分和医疗保险健康维护组织（HMO）的保费；非承保商品和服务的费用；以及医生的差额计费。它不包括家庭护理和护理机构服务的费用，以及用于医疗保健融资的间接税支付。
1997年，近60%收入低于贫困线的受益人未获得医疗补助援助。我们估计，无论这些受益人是参加医疗保险HMO还是传统的按服务收费计划，他们平均将约一半的收入用于自付医疗费用。75%收入在贫困线100%至125%之间且未参加医疗补助的受益人，如果参加传统计划，估计将其收入的30%用于自付医疗费用；如果参加医疗保险HMO，则约为其收入的23%。按服务收费的受益人中的平均自付费用因受益人是否有医疗差额保险政策、雇主提供的补充保险或无补充保险而有所不同。没有补充保险的人在医疗商品和服务上花费更多，但在医疗保险未涵盖的处方药和牙科护理服务上的花费低于其他群体。
虽然医疗补助为一些低收入医疗保险受益人提供了实质性保护，但自付医疗费用对这一群体中的大多数人来说仍然是一个沉重负担。侧重于将更多成本转嫁给受益人的医疗保险改革讨论应考虑到这一弱势群体已经面临的巨大医疗费用。
