Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA.
J Gen Intern Med. 2022 Feb;37(3):573-581. doi: 10.1007/s11606-021-06807-4. Epub 2021 May 6.
Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored.
To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA.
Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending.
Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey.
ACA implementation, January 1, 2014.
Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income.
Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care.
ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.
尽管公众看法如此，但在退伍军人事务部 (VHA) 之外，近 2000 万美国退伍军人中的大多数人都有健康保险，而且退伍军人的 VHA 资格和使用情况因退伍军人而异。因此，自付医疗费用仍然是退伍军人面临经济困难的一个潜在来源。平价医疗法案 (ACA) 的目的是扩大医疗保险的覆盖范围，但它对退伍军人的财务风险保护的影响尚未得到探索。
评估 ACA 的实施是否与退伍军人发生灾难性医疗支出的风险变化有关，并描述 ACA 实施后退伍军人灾难性医疗支出的驱动因素。
使用多变量线性概率回归，我们研究了 ACA 实施后发生灾难性医疗支出的可能性的变化，按年龄（18-64 岁与 65 岁及以上）、家庭收入三分位数和支付方（VHA 与非 VHA）进行分层。在 ACA 实施后发生灾难性支出的退伍军人中，我们评估了自付费用的来源。
来自 2010 年至 2017 年医疗支出面板调查的年龄在 18 岁及以上的 13030 名具有代表性的退伍军人。
ACA 实施，2014 年 1 月 1 日。
灾难性医疗支出的可能性，定义为家庭自付支出超过家庭收入的 10%。
在 18-64 岁的退伍军人中，ACA 的实施与灾难性医疗支出可能性降低 26%（绝对变化，-1.4 个百分点[pp]；95%CI，-2.6 至-0.2；p=0.03）相关，从 ACA 实施前的 5.4%降至实施后的 3.9%。这是由于非 VHA 覆盖范围内的退伍军人灾难性支出减少了 38%（绝对变化，-1.8pp；95%CI，-3.0 至-0.6；p=0.003）。相比之下，65 岁及以上退伍军人的灾难性支出率仍然很高，ACA 实施前为 13.0%，实施后为 12.5%。退伍军人 ACA 实施后支出的主要驱动因素包括牙科护理、处方药和家庭护理。
ACA 的实施与年轻退伍军人而非老年退伍军人的家庭灾难性医疗支出减少有关。这些发现突显了退伍军人财务保护方面的差距和政策干预的领域。
