RAND, Santa Monica, California.
JAMA Health Forum. 2024 Jun 30;5(6.9):e241932. doi: 10.1001/jamahealthforum.2024.1932.
Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households.
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.
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.
Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation.
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.
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.
重要性：家庭的医疗保健支出负担沉重。采用替代融资方式可以减轻部分家庭的负担。
目的：根据医疗改革政策，估算家庭医疗保健支出在收入中的分布情况。
设计、设置和参与者：使用全国代表性的美国人口 2030 年数据进行横断面研究和微观模拟。将 2022 年当前人口调查中的平民、非机构化人口与 2018 年和 2019 年医疗支出调查以及 2022 年国家卫生支出账户中的支出相关联。
暴露：对医院、医生和其他医疗保健专业人员的支付实行按付款人平均费率定价，与现状持平，支出增长率目标为每年人均 4%，单一付款人医疗保险通过税收融资。
主要结果和措施：家庭医疗保健支出（自付费用、保费和税款）占薪酬的比例。
结果：综合人口包含 154456 条记录，代表 33950 万人，其中 51%为女性，7%为亚洲人，14%为黑人，18%为西班牙裔白人，56%为非西班牙裔白人，5%为其他种族（只有美洲印第安人或阿拉斯加原住民；只有夏威夷原住民或其他太平洋岛民；以及 2 个或更多种族）。在现状下，按收入分组，家庭医疗保健支出占薪酬的比例为 24%至 27%（标准误差[SE]为 0.2%-1.2%）（中位数[IQR]为 22%[4%-52%]低于联邦贫困线[FPL]的 139%；1000%FPL 以上家庭的支出为 21%[4%-34%]）。在费率设定下，1000%FPL 以上家庭的平均（SE）支出增加到 29%（0.6%）（中位数[IQR]为 22%[6%-35%]），而其他收入组的支出则降至 23%至 25%。在支出增长目标下，按收入分组，家庭平均（SE）支出从 23%降至 26%（SE，0.2%-1.2%）。在单一付款人制度下，低于 139%FPL 的家庭的平均（SE）支出下降到 15%（0.7%）（中位数[IQR]为 4%[0%-30%]），而高于 1000%FPL 的家庭的支出增加到 31%（0.6%）（中位数[IQR]为 23%[3%-39%]）。由于医疗补助获得改善，按付款人定价导致无保险人数从 9%降至 6%，而单一付款人制度下则降至零。
结论：基于当前联邦所得税表和工资税的单一付款人融资可以大大提高家庭按收入支付的累进性。费率设定导致高收入家庭的支付略有增加，他们为医疗保险和医疗补助支付更高的费率。支出增长目标使所有家庭的支出略有减少。
