Prior work has shown that Medicaid coverage offset reductions in employer-sponsored insurance after COVID-19-related job loss in Medicaid expansion states. However, the effect of Medicaid expansion on health care access is not fully understood. To estimate the association of unemployment during COVID-19 with health insurance coverage and health care access in Medicaid expansion versus nonexpansion states. We used restricted, longitudinal National Health Interview Survey (NHIS) data from 2019 to 2020, focusing on working-age adults (N=5156). Using triple-difference models, we estimated changes in outcomes for respondents becoming unemployed between 2019 and 2020 (after COVID-19) relative to continuously employed respondents, in Medicaid expansion versus nonexpansion states. Compared with continuously employed respondents, there was a statistically significant increase in Medicaid coverage among the newly unemployed in expansion states (6.1 percentage points (pp), 95% CI: 1.0 to 11.3, P=0.019) but not in nonexpansion states (3.9 pp, 95% CI: -3.9 to 11.8, P=0.324); however, the triple difference was nonsignificant. Uninsurance increased among the newly unemployed in expansion states by only 4.9 pp (95% CI: 0.9 to 8.9, P=0.016) versus 12.4 pp in nonexpansion states (95% CI: 0.2 to 24.6, P=0.047), but the triple difference was statistically nonsignificant. There was a significant increase in delaying or skipping medical care among newly unemployed respondents in nonexpansion states, but not in expansion states and the triple difference was statistically significant (-15.5 pp, 95% CI: -26.9 to -4.0, P=0.008). Our results suggest that Medicaid expansion prevented disruptions in health care access for the newly unemployed during COVID-19.

Adults with employer-sponsored insurance may remain in employment to retain health coverage for their children-a phenomenon we term dependent-related job lock. Using 2016-23 National Survey of Children's Health data, we estimated the prevalence of dependent-related job lock among families with children covered by employer-sponsored insurance and examined associations with caregivers' health. Nationally, 8.9percent of such families reported dependent-related job lock, with higher rates seen among families with children with special health care needs, particularly those with emotional, behavioral, and developmental problems (23.1percent). Dependent-related job lock was associated with a 4.5-7.1-percentage-point increase in poor or fair caregiver mental health and a 3.7-4.3-percentage-point increase in poor or fair caregiver physical health across groups of children with special health care needs. Sensitivity analyses adjusting for employment suggested some confounding. Findings underscore the need for policy reforms to address insurance-related barriers, reduce disparities in caregivers' health, and promote equitable employment mobility.

Interchangeability, a Food and Drug Administration (FDA) designation allowing pharmacists to substitute a biosimilar for its branded originator at the point of sale, is intended to increase biosimilar adoption. However, little is known about the relationship between interchangeability and biosimilar adoption. We conducted an interrupted time-series analysis to examine this relationship for Semglee, which gained interchangeability in July2021, in Medicaid and the employer-sponsored insurance market in 2021-22. Semglee is a biosimilar for Lantus (insulin glargine), the most-prescribed long-acting insulin in the US. We found that Semglee market share increased by 3.70percentage points in Medicaid and 19.25percentage points in employer-sponsored insurance beginning in the first quarter of 2022, coinciding with improved Semglee coverage, especially in employer-sponsored insurance. State-level variation in pharmacist substitution laws was not associated with Semglee adoption. These results suggest that increased adoption was mediated mainly through improved insurance coverage, with no detectable role for increased prescribing alone and only a secondary role, at most, for pharmacist substitution. Semglee's gains in market share after interchangeability suggest that easing of federal interchangeability requirements may moderately spur biosimilar adoption.

Low health insurance coverage has remained a persistent challenge in Nigeria, restricting access to healthcare despite the coexistence of various insurance schemes. While previous research has primarily focused on the National Health Insurance Scheme (NHIS) or community-based health insurance (CBHI), few studies have collectively examined the factors influencing enrolment across different types of insurance—namely, community-based, employer-sponsored, and private schemes. This study addresses this research gap using household data from the 2018 Nigeria Demographic and Health Survey (DHS). Employing logit and probit regression models, the analysis explores the likelihood of health insurance enrolment. The results reveal that six socioeconomic factors—education attainment, age of the household head, bank account ownership, wealth status, marital status, and employment type—significantly influence enrolment in both overall insurance (all types of insurance) and employer-sponsored insurance. However, these factors vary in importance for community-based and private insurance. For instance, individuals with low education have a higher likelihood of enrolment in CBHI than those with high education. The study also finds that financial constraints may reduce the possibility of enrolment among low-income groups compared to their middle- and high-income counterparts. The findings underscore the need for targeted interventions to enhance enrolment, particularly among individuals with lower educational levels, limited income, and those employed in the informal sector.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12913-025-13422-0.

This study aimed to use claims data to calculate incremental 2022 health care expenditure estimates for children with tic disorders relative to children without tic disorders. Children ages 6-17 years with tic disorders were identified in the Merative MarketScan Multi-State Medicaid (N=6,277) and MarketScan Commercial (employer-sponsored insurance [ESI]; N=6,955) databases via inpatient and outpatient claims and were compared with children without tic disorders, matched at a 1:8 ratio on age, sex, and coverage type. Presence of 12 types of co-occurring disorders was identified. Analyses were stratified by insurance type. Individual-level total expenditures and total inpatient, total outpatient, outpatient psychological services, and filled prescription medication expenditures were calculated and compared by tic disorder status. Two-part regression models for Medicaid and generalized linear regression models for ESI were fit to estimate the difference in expenditures for children with versus without tic disorders, with sex, age, and presence of individual co-occurring disorders as covariates. In 2022, mean per-person expenditures for children with tic disorders were $4,549 in the Medicaid sample and $9,870 in the ESI sample-more than twice as high as totals for children without tic disorders. The adjusted mean difference in expenditures between children with and children without tic disorders was -$15 (nonsignificant) in the Medicaid sample and $1,641 in the ESI sample (p<0.001). This study documents substantial health care utilization and expenditures for children with tic disorders, although higher mean expenditures relative to children without tic disorders largely reflect differences in the prevalence of co-occurring disorders.

26 Background: Employer-sponsored private insurance often provides generous coverage. Mandates of out-of-pocket maximum (OOP max) under the Affordable Care Act (ACA) offers an extra layer of financial protection for adults with private insurance. The OOP max, however, only applies to in-network care. Two trends could erode protections of private insurance: a shift toward high-deductible plans (HDP) and narrowing insurance networks because of provider consolidation. We examined whether the compound effect of HDP and out-of-network care exacerbates financial hardship for privately insured non-elderly adults with colorectal cancer (CRC). Methods: Using MarketScan Commercial Claims and Encounters Data, we applied a claims-based algorithm to identify patients (pts) with incident CRC diagnosed 2015 - 2022, with 12-month continuous enrollment before and after index diagnosis. Total and OOP payments (sum of deductibles, copayments, and coinsurance) were calculated for 12 months post-diagnosis. Pts who received any portion of cancer treatment (surgery, radiation, or systemic therapy) from out-of-network providers were classified as receiving out-of-network care (ONET). We characterized insurance benefit by HDP enrollment (yes/no) and ONET status (yes/no). We used generalized linear models and quantile regressions (at median and 90 th percentile) to compare differences in costs at mean, median, and 90 th percentile, respectively, by benefit characteristics, adjusting for pre-diagnosis comorbidity, region, sex, year, and treatment received. All estimates are reported in 2024 US dollars. Results: Cohort included 10,839 pts with CRC. Overall, 27.3% were &lt; 50 years, 53.6% were male, 23.0% enrolled in HDP, and 20.4% received a portion of cancer treatment from ONET providers. By benefit characteristics, the proportion in noHDP-noONET (Group00), noHDP-ONET (G01), HDP-noONET (G10), and HDP-ONET (G11) was 60.9%, 16.1%, 18.7%, and 4.3%, respectively. Total costs were positively associated with ONET but not with HDP. OOP costs were highest for G11, followed by G10, G01, and G00 (Table). Conclusions: Pts in HDP and received out-of-network care are at highest risk of financial hardship. Although the 2024 ACA OOP max is $9,450, many pts high spenders (top ten percentile) do not benefit from this financial protection. Narrowing network and expanding HDP may exacerbate cancer financial hardship, even among the well-insured. Group Mean P-value (vs. G00) Median P-value (vs. G00) 90 th percentile P-value (vs. G00) Total Costs G00 $111,794 - $90,686 - $190,230 - G01 136,393 &lt;0.001 103,458 &lt;0.001 220,452 &lt;0.001 G10 109,280 0.364 90,261 0.794 192,715 0.671 G11 127,768 0.007 102,542 &lt;0.001 217,326 0.013 OOP Costs G00 $4,087 - $3,491 - $7,856 - G01 5,007 &lt;0.001 4,170 &lt;0.001 9,576 &lt;0.001 G10 5,937 &lt;0.001 5,212 &lt;0.001 10,033 &lt;0.001 G11 6,779 &lt;0.001 6,267 &lt;0.001 12,260 &lt;0.001

Recent research suggests that since the Patient Protection and Affordable Care Act and the US Supreme Court's ruling in Obergefell v Hodges, lesbian, gay, bisexual, and/or transgender (LGBT) individuals are now at or beyond parity in insurance coverage with their non-LGBT counterparts, a reversal of a long-standing health disparity, but shows that gains have not been equitable. To examine health insurance coverage of same-sex and different-sex couples by marital status, sex, insurance provider, state of residence, and income distribution. This cross-sectional study was a secondary data analysis of 2008 to 2022 American Community Survey (ACS) data. The ACS is an annual, nationally representative survey of over 3 million households in the US, and study participants included adults aged 18 to 64 years in a cohabitating relationship. Data were analyzed in October and November of 2024. Cohabitation in a same-sex or different-sex couple. The primary outcome was reporting any health insurance coverage in the 2008 to 2022 ACS results. A series of linear probability models was estimated to assess the association between same-sex couple status and the probability of being covered by any health insurance. The sample included a total of 20 938 414 respondents (mean [SD] age, 45.57 [11.86] years). The majority of respondents in the study sample were women (11 139 506 participants; 53.2% unweighted; 52.6% weighted), were married (13 988 414 participants; 63.2% unweighted; 67.0% weighted), had less than a bachelor's degree (13 408 218 participants; 65.1% unweighted; 64.1% weighted), and were employed (15 921 280 participants; 76.5% unweighted; 76.0% weighted). Participants reported a median (IQR) household income of $88 000 ($84 000). Respondents had a high level of insurance coverage (18 587 258 participants; 88.0% unweighted; 89.0% weighted) with 3 453 491 participants (16.8% unweighted; 16.5% weighted) reporting public and 14 248 083 (65.8% unweighted; 67.4% weighted) reporting private coverage. In further heterogeneity analyses, respondents in same-sex couples were more likely to be insured by employer-sponsored insurance than their counterparts in different-sex couples and less likely to be insured by all other insurance types, including public health insurance. Respondents in same-sex couples in the bottom quintiles of the income distribution were less likely to be insured compared with their counterparts in upper quintiles. Finally, respondents in same-sex couples living in states that had not yet expanded Medicaid (Alabama, Georgia, Kansas, Mississippi, South Carolina, Tennessee, and Wyoming) were less likely to be covered across the sample period. This cross-sectional study examining insurance coverage among same-sex vs different-sex couples documented gains in health insurance status among individuals in same-sex couples in the past decade in the US. These gains, mostly realized by individuals of high socioeconomic status, reversed one of the defining health disparities for sexual minority adults of the late 20th century, but more must be done to ensure that these gains are distributed across the income distribution, especially to those living in states that have not yet expanded access to public health insurance.

IntroductionDespite the profound impact of the COVID-19 pandemic on people living with HIV (PLWH) mental health, large-scale, real-world data on mental healthcare utilisation and associated factors among PLWH remain limited. This study explores mental healthcare utilisation and associated factors among PLWH during the COVID-19 pandemic.MethodsUsing a retrospective cohort design, we identified and included 4575 PLWH through computational phenotyping based on relevant Observational Medical Outcomes Partnership Common Data Model concept sets from the All of Us programme between March 2018 and March 2022. Mental healthcare utilisation was measured using the yearly count of mental healthcare visits and compared between pre-pandemic (2018–2020) and during the pandemic (2020–2022). Incidence rate ratios (IRRs) from the Poisson generalised linear mixed models were used to examine associations between mental healthcare utilisation, history of COVID-19 infection, demographic factors, pre-existing chronic conditions and socioeconomic status.ResultsAnnual number of mental healthcare visits among PLWH decreased significantly during the pandemic compared with pre-pandemic (IRR=0.89, p<0.001). COVID-19 infection (IRR=1.35, p<0.001), pre-existing comorbidities (one comorbidity: IRR=5.49; two or more: IRR=10.4, p<0.001) and Medicaid health insurance (IRR=1.29, p=0.007) were associated with a higher number of visits. Middle-aged group participants (aged 30–39: IRR=2.35, p=0.002; 40–49: IRR=3.49, p<0.001 and 50–64: IRR=2.07, p=0.004) had higher visit numbers compared with the youngest group (18–29 years). Compared with white participants, black or African American (IRR=0.71, p=0.002) and those with employer-sponsored or union-sponsored insurance (IRR=0.54, p<0.001) had fewer visits.ConclusionThis study reveals a decrease in mental healthcare utilisation and diverse experiences of mental healthcare among PLWH during the COVID-19 pandemic. Addressing these disparities is crucial, particularly during public health emergencies.

11107 Background: Financial toxicity (FT), the adverse economic effects resulting from cancer, its treatment, and associated long-term effects, may affect the majority of cancer survivors. FT is associated with multiple factors including employment disruptions; however, the role of workplace policies in mitigating FT is poorly understood. We examined how employer-sponsored health insurance and paid sick leave influence FT among employed U.S. cancer survivors. Methods: We analyzed data from 1,122 employed cancer survivors aged 18-64 with non-missing insurance status and a self-reported history of cancer (diagnosed age 18 or older), representing a weighted total of almost 5 million survivors from the 2021/2022 National Health Interview Survey (NHIS), a nationally representative household survey of the civilian noninstitutionalized U.S. population. Multivariable logistic regression analyses examining associations of employer-sponsored health insurance and paid sick leave (separately) with FT items, controlling for sociodemographic characteristics and cancer type, were conducted using PROC SURVEYLOGISITC in SAS 9.4 adjusting for the complex survey design of the NHIS. Results: Compared with cancer survivors who had employer-sponsored health insurance (n = 842, weighted 76.6%), those without employer-sponsored insurance were significantly (p &lt; 0.05) more likely to experience FT, including worrying about paying medical bills (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.4), skipping/delaying medical care due to costs (OR 2.4, 95% CI 1.5-3.9), and delaying counseling/therapy due to costs (OR 2.5, 95% CI 1.3-4.6). These associations persisted when restricting the sample to survivors with private insurance only. Similarly, compared to survivors with paid sick leave (n = 807, weighted 72.0%), those without paid sick leave were significantly more likely to worry about paying medical bills (OR 1.4, 95% CI 1.1-1.9) and skip/delay medical care due to costs (OR 2.2, 95% CI 1.4-3.4), with consistent findings in the private insurance only subgroup. Having employer-sponsored insurance and paid sick leave were also associated with decreased food insecurity. Conclusions: Workplace policies can mitigate FT and food insecurity among cancer survivors. Employers should consider offering benefits that support health and economic outcomes for employees with cancer and other medical conditions and enhance their ability to contribute to positive workplace environments.

Medical Costs, Health Care Utilization, and Productivity Losses Associated with Hypertension Moderated by COVID-19 Diagnosis Among US Commercial Enrollees.

To determine whether high-deductible health plans (HDHPs) are associated with complicated disease and hospitalization costs for children with appendicitis. Nearly 60% of families with non-governmental employer-sponsored insurance are enrolled in high-deductible health plans (HDHPs). It is unknown how these plans affect children who require surgical care. This retrospective cohort study used the 2016-2020 MarketScan dataset. We included children aged 17 years and younger with non-governmental employer-sponsored insurance who were treated for acute appendicitis. The exposure was a binary variable indicating family enrollment in a HDHP. We assessed the outcomes of complicated appendicitis and hospitalization costs. We used machine learning-based propensity score weights and multivariable regression to assess the association between HDHP enrollment and outcomes. Covariates included age, gender, geographic region, comorbidities, prior healthcare utilization, and month and year treated. Of 18,291 children treated for appendicitis, 40.6% (n=7,434) were enrolled in HDHPs. Groups exhibited covariate balance after propensity score weighting. HDHP enrollment was associated with a 2.6 percentage point (95%CI, 1.2-3.9; P<0.001) increase in the likelihood of presenting with complicated appendicitis (33.2% versus 30.6%); a $2,491 (95%CI, $2,428-$2,555; P<0.001) increase in out-of-pocket costs ($4,341 versus $1,850); and a $703 (95%CI, $185-$1,222; P=0.008) increase in total costs ($24,556 versus $23,852). Children in HDHPs more often present with complicated appendicitis and require more costly hospitalizations. High levels of cost sharing, a dominant component of most private insurance plans, may not serve the needs of children with acute illnesses and can increase costs to patients and society.

The impact of an SCHIP freeze on children and parent's health insurance coverage

Approximately 50% of Americans report having low health insurance literacy, leading to uncertainty when choosing their insurance coverage to best meet their healthcare needs. Therefore, we aimed to evaluate the association between lack of prescription drug benefit knowledge and problems paying medical bills among Medicare beneficiaries. We analysed the 2021 Medicare Current Beneficiary Survey Public Use File of 5586 Medicare beneficiaries aged ≥ 65 years. The binary dependent variable was whether beneficiaries had problems paying medical bills in the past year. The categorical independent variable was how much beneficiaries knew about the Medicare prescription drug benefit. A survey-weighted multivariable logit model, adjusted for covariates (e.g., socio-demographics, comorbidities, private insurance coverage, and satisfaction with out-of-pocket costs), was conducted to examine the association between the independent variable and problems paying medical bills. Approximately 4.3% of study beneficiaries (~2.0 million beneficiaries) reported problems paying medical bills. Of those without and with problems paying medical bills, 27.7% and 39.6%, respectively, reported knowing little/almost nothing about prescription drug benefits. Beneficiaries aged 65-74 years (marginal effect [ME] = 2.1%, p < 0.01), with comorbidities (e.g., ≥ 4 conditions, ME = 3.8%, p < 0.001), dissatisfaction with out-of-pocket costs (ME = 10.1%, p < 0.001), without private insurance (e.g., employer-sponsored insurance, ME = 2.5%, p < 0.01), or with little/almost no knowledge of prescription drug benefits (ME = 1.9%, p < 0.05) were more likely to report problems paying medical bills compared to their counterparts. Tailored programmes aimed at improving beneficiaries' knowledge of prescription drug benefits, reducing out-of-pocket costs and preventing comorbidities may be considered for the at-risk population to address the problem.

Recent data from federal surveys show that more than 70% of adults have either overweight or obesity. Overweight and obesity are associated with several expensive chronic conditions, such as type 2 diabetes, heart disease, hypertension, and hyperlipidemia. The prevalence of chronic disease is a key driver of rising health care spending among employers and the Medicare program. To estimate health care spending among adults with overweight or obesity and have employer-sponsored insurance or Medicare and examine the association of higher and lower body mass index (BMI). This cross-sectional study included privately insured adults and adult Medicare beneficiaries with a BMI of 25 and higher. Data from the Medical Expenditure Panel Survey-Household Component were used to tabulate total annual health care spending. Data were analyzed from April 1 to June 20, 2024. The primary intended measures were total annual health care spending, controlling for patient demographics, income, education, and BMI. The baseline health care spending as a percentage reduction in BMI. An instrumental variable regression model with estimated total spending at various levels of BMI was used. This study included 3774 adults who were insured with Medicare (mean [SD] age, 63.1 [11.1] years; mean [SD] percentage female, 50.4% [49.7%]; mean [SD] percentage non-Hispanic Black adults, 17.4% [37.7%]; mean [SD] percentage non-Hispanic White adults, 61.3% [48.4%]). The study also included 13 435 adults who had employer-sponsored insurance (mean [SD] age, 46.3 [6.9] years; mean [SD] percentage female, 47.6% [48.9%]; mean [SD] percentage non-Hispanic Black adults, 11.1% [30.7%]; mean [SD] percentage non-Hispanic White adults, 73.1% [43.4%]). Overall, adults with employer-sponsored insurance with a weight loss of 5% were estimated to spend a mean of $670 (95% CI, $654-$686) less on health care (8% less), and those with a weight loss of 25% spent an estimated mean of $2849 (95% CI, $2783-$2916) less on health care (34% less). Among adults with Medicare who had 1 or more comorbid conditions, a 5% weight loss was estimated to reduce spending by $1262 (95% CI, $1217-$1306) (7% less) and a 25% weight loss was estimated to reduce health care spending by a mean of $5442 (95% CI, $5254-$5629) (31% less). In this cross-sectional study, projected annual savings from weight loss among US adults with obesity were substantial for both Medicare and employer-based insurance.

For 165million nonelderly Americans, employers provide health insurance either by purchasing a fully insured plan or through self-insurance. By self-insuring, employers bear the financial risk for enrollees' health care spending and are accountable for plan management, either directly or by contracting with a third-party administrator. Using National Association of Insurance Commissioners data, we demonstrate that insurers are deeply entrenched in the provision of administrative services only (ASO) contracts for self-insured employers. In 2022, insurers administered to nearly four times as many ASO enrollees as they covered in fully insured plans, with fifty-six insurer-based ASO contractors providing services for 118million enrollees. The largest ASO contractors-CVS Group, Cigna Health Group, and Elevance Health Inc. Group-collectively served more than seventy million ASO enrollees and demonstrated less variable and stronger profitability relative to other ASO contractors. This study expands understanding of this increasingly important market for employer-sponsored insurance.

This study examines the impact of the Affordable Care Act (ACA) on health insurance coverage among rent-burdened households-those spending more than 30% of their income on rent-and non-rent-burdened households. Using data from American Community Survey, we find that Medicaid take-up rate increased 8.88 percentage points (pp) among rent-burdened households and 7.54 pp among non-rent-burdened households in expansion states. Conditional on household income and demographic characteristics, rent-burdened households exhibit a 1.5 pp higher likelihood of Medicaid enrollment, with an additional decline of 0.7 pp in employer-sponsored insurance and 1.0 pp in directly purchased insurance enrollment. These effects were more pronounced among individuals aged over 26 and those in states without state-run exchanges. The findings show the importance of tailored Medicaid policies to assist households facing housing burdens, especially for those ineligible for housing vouchers.

ABSTRACT The purpose of this research is to examine the impact of different types of healthcare and insurance on the health of Indonesian youth. The study employs logistic regression, a statistical method used to analyze relationships between variables and predict outcomes. Data were collected through an Indonesia’s National Socio-Economic Survey, which gathers information from individuals within a household. The findings reveal that Indonesia’s National Health Insurance (with or without subsidies) reduces the likelihood of children being hospitalized. Families enrolled in the program, often from low- to middle-income backgrounds with limited access to healthcare, benefit significantly from this initiative, which provides affordable and essential health services. This program allows these families to access healthcare that would otherwise be unaffordable. However, private and employer-sponsored insurance did not reduce hospitalization rates, likely because families in these plans already benefit from better overall health, nutrition and access to health-promoting activities. In contrast, children without insurance are more likely to be hospitalized due to their location and economic and financial constraints. Other determinant factors affecting children’s health included age, sex, parent’s education, smoking behavior and house location. The results showed that older children were generally healthier, children of well-educated and non-smoking parents were less likely to be hospitalized and those living in urban areas had a higher likelihood of hospitalization than those in rural areas. This study highlights the importance of expanding access to health insurance and promoting parental education and non-smoking behavior to improve children’s overall health. Failing to address these issues could create challenges for the future, given that the current young generation will eventually become the nation’s leaders.

In anticipation of the end of the COVID-19 public health emergency, Congress ended the Medicaid continuous coverage requirement on March31, 2023, allowing states to terminate coverage for ineligible people and resume eligibility determinations through a process known as unwinding. Although administrative data have documented substantial declines in Medicaid enrollment since April2023, the impact on uninsurance is unknown. Using data from the Census Bureau's Household Pulse Survey, we estimated the early effect of Medicaid unwinding on insurance coverage among people ages19-64. We found that within the first three months of unwinding, the number of people self-reporting Medicaid coverage declined by approximately two million, and there was a much smaller, statistically insignificant decline in overall coverage of approximately 467,000 people. It appears that for many people, the availability of employer-sponsored insurance and other private coverage offset Medicaid coverage loss. These results suggest that the resumption of redeterminations has had less impact on uninsurance than was initially feared. Our findings highlight the importance of tracking coverage transitions during unwinding. By identifying populations at risk for uninsurance after Medicaid loss, these data could enhance the effectiveness of state outreach and enrollment assistance for people eligible for Marketplace coverage and subsidies.

ImportanceApproximately 30% of US families with employer-sponsored health insurance, disproportionately drawn from high-income groups, benefit from flexible spending accounts (FSAs) or health savings accounts (HSAs). The combined association through both out-of-pocket spending and premiums of these tax-favored accounts with health care expenditures and tax expenditures remain uncertain.ObjectiveTo compare the health care and health-related tax expenditures among families holding FSAs, HSAs, or neither type of account.Design, Setting, and ParticipantsThis cross-sectional study used family-level data from the Medical Expenditure Panel Survey from January 1, 2011, to December 31, 2019, and conducted regression models, controlling for demographic and socioeconomic characteristics, chronic conditions, prior health care expenditures, and marginal tax rates to analyze how holding tax-favored accounts is associated with families’ health care spending and tax expenditures. The sample was restricted to families included in the survey for 2 years, with no members 65 years or older, and with at least 1 policyholder covered (only) by full-year employer-sponsored insurance. Data were analyzed from December 1, 2023, to April 30, 2024.ExposuresHolding FSAs or HSAs.Main Outcomes and MeasuresOut-of-pocket and insurance-paid health expenditures overall and by service were measured. Health-related tax expenditures were based on tax-excluded insurance premiums and tax-sheltered out-of-pocket expenses.ResultsOf the 17 038 families included in the study sample, 2628 held FSAs (weighted 17%) and 1845 (weighted 13%) held HSAs. In regression-adjusted models, families with FSAs spent a mean of 20% or $2033 (95% CI, $789-$3276) more on health care annually than non–account holding families, largely due to increased insurer-paid expenses. Families with HSAs spent a mean of 44% or $697 (95% CI, $521-$873) more on out-of-pocket expenditures and had insignificantly higher insurance-paid expenditures than families without accounts, resulting in overall expenditures comparable to those of non–account holders. The additional tax expenditures associated with FSAs were a mean of $1306 (95% CI, $536-$2076) annually per family. Both types of funds were associated with significant increases in tax expenditures from additional office-based visits ($445 [95% CI, $244-$645] for FSAs and $174 [95% CI, $11-$336] for HSAs), outpatient visits ($330 [95% CI, $132-$528] for FSAs and $250 [95% CI, $15-$485] for HSAs), dental visits ($180 [95% CI, $126-$233] for FSAs and $165 [95% CI, $104-$226] for HSAs), and vision care ($36 [95% CI, $28-$45] for FSAs and $52 [95% CI, $40-$64] for HSAs).Conclusions and RelevanceParticipation in FSAs is associated with higher health care expenditures and tax expenditures, while HSAs are not associated with reduced expenditures. Tax policy could be better targeted to enhance insurance coverage and health care accessibility.

How Child Health Financing and Payment Mitigate and Perpetuate Structural Racism