Risk Of Catastrophic Health Expenditure Research Articles

Household catastrophic health expenditure for COVID-19 during March-August 2021, in South India: a cross-sectional study

BackgroundThe Coronavirus disease 2019 (COVID-19) pandemic increased the utilisation of healthcare services. Such utilization could lead to higher out-of-pocket expenditure (OOPE) and catastrophic health expenditures (CHE). We estimated OOPE and the proportion of households that experienced CHE by conducting a cross-sectional survey of 1200 randomly selected confirmed COVID-19 cases.MethodsA cross-sectional survey was conducted by telephonic interviews of 1200 randomly selected COVID-19 patients who tested positive between 1 March and 31 August 2021. We collected household-level information on demographics, income, expenditure, insurance coverage, direct medical and non-medical costs incurred toward COVID-19 management. We estimated the proportion of CHE with a 95% confidence interval. We examined the association of household characteristics; COVID-19 cases, severity, and hospitalisation status with CHE. A multivariable logistic regression analysis was conducted to ascertain the effects of variables of interest on the likelihood that households face CHE due to COVID-19.ResultsThe mean (95%CI) OOPE per household was INR 122,221 (92,744–1,51,698) [US$1,643 (1,247–2,040)]. Among households, 61.7% faced OOPE, and 25.8% experienced CHE due to COVID-19. The odds of facing CHE were high among the households; with a family member over 65 years [OR = 2.89 (2.03–4.12)], with a comorbid individual [OR = 3.38 (2.41–4.75)], in the lowest income quintile [OR = 1.82 (1.12–2.95)], any member visited private hospital [OR = 11.85 (7.68–18.27)]. The odds of having CHE in a household who have received insurance claims [OR = 5.8 (2.81- 11.97)] were high. Households with one and more than one severe COVID-19 increased the risk of CHE by more than two-times and three-times respectively [AOR = 2.67 (1.27–5.58); AOR = 3.18 (1.49–6.81)].ConclusionCOVID-19 severity increases household OOPE and CHE. Strengthening the public healthcare and health insurance with higher health financing is indispensable for financial risk protection of households with severe COVID-19 from CHE.

Catastrophic Health Expenditure in Patients with Lower-Extremity Orthopaedic Trauma.

Health-care expenditures are a leading contributor to financial hardship in the United States. Traumatic orthopaedic injuries are unpredictable and result in substantial expense. Our objectives were to quantify the catastrophic health expenditure (CHE) risk of patients with orthopaedic trauma and to examine the impact of insurance status, socioeconomic status, sex, and race on CHE. We identified all isolated lower-extremity orthopaedic trauma cases at a safety-net, Level-1 trauma center from 2018 to 2020. We queried an institutional charge database to obtain total hospital charges, insurance status, and ZIP Code to determine out-of-pocket (OOP) expenditures. To evaluate financial hardship, we calculated the CHE risk as defined by the World Health Organization's threshold of OOP expenditures, ≥40% of estimated household post-subsistence income. In our cohort of 2,535 patients, 33% experienced a risk of CHE. A risk of CHE was experienced by 99% of patients who were uninsured, 35% of patients with private insurance, 2% of patients with Medicare, and 0% of patients with Medicaid. Multivariable regression modeling showed that patients who were uninsured were significantly more likely to experience a risk of CHE compared with patients with private insurance (odds ratio, 107.68 [95% confidence interval, 37.20 to 311.68]; p < 0.001). One-third of patients with lower-extremity orthopaedic trauma experience a risk of CHE, with patients who are uninsured facing a disproportionately higher risk of CHE compared with patients who are insured. Our results suggest that the expansion of public insurance options may provide substantial financial protection for those at the greatest risk for CHE. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Low physical activity is associated with adverse health outcome and higher costs in Indonesia: A national panel study.

To assess the association between low physical activity, cardiovascular disease (CVD) and risk factors, health service utilization, risk of catastrophic health expenditure, and work productivity in Indonesia. In this population-based, panel data analysis, we used data from two waves of the Indonesian Family Life Survey (IFLS) for 2007/2008 and 2014/2015. Respondents aged 40-80 years who participated in both waves were included in this study (n = 5,936). Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ-SF). Multinomial logistic regression model was used to examine factors associated with physical activity levels (low, moderate, and high). We applied a series of multilevel mixed-effect panel regression to examine the associations between physical activity and outcome variables. The prevalence of low physical activity increased from 18.2% in 2007 to 39.6% in 2014. Compared with those with high physical activity, respondents with low physical activity were more likely to have a 10-year high CVD risk (AOR: 2.11, 95% CI: 1.51-2.95), use outpatient care (AOR: 1.26, 95% CI: 1.07-1.96) and inpatient care (AOR 1.45, 95% CI: 1.07-1.96), experience catastrophic health expenditure of 10% of total household expenditure (AOR: 1.66, 95% CI: 1.21-2.28), and have lower labor participation (AOR: 0.24, 95% 0.20-0.28). Low physical activity is associated with adverse health outcomes and considerable costs to the health system and wider society. Accelerated implementation of public health policies to reduce physical inactivity is likely to result in substantial population health and economic benefits.

Degree of protection provided by poverty alleviation policies for the middle-aged and older in China: evaluation of effectiveness of medical insurance system tools and vulnerable target recognition

BackgroundChina’s medical insurance schemes and poverty alleviation policy at this stage have achieved population-wide coverage and the system's universal function. At the late stage of the elimination of absolute poverty task, how to further exert the poverty alleviation function of the medical insurance schemes has become an important agenda for targeted poverty alleviation. To analyse the risk of catastrophic health expenditure (CHE) occurrence in middle-aged and older adults with vulnerability characteristics from the perspectives of social, regional, disease, health service utilization and medical insurance schemes.MethodsWe used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database and came up with 9190 samples. The method for calculating the CHE was adopted from WHO. Logistic regression was used to determine the different characteristics of middle-aged and older adults with a high probability of incurring CHE.ResultsThe overall regional poverty rate and incidence of CHE were similar in the east, central and west, but with significant differences among provinces. The population insured by the urban and rural integrated medical insurance (URRMI) had the highest incidence of CHE (21.17%) and health expenditure burden (22.77%) among the insured population. Integration of Medicare as a medical insurance scheme with broader benefit coverage did not have a significant effect on the incidence of CHE in middle-aged and older people with vulnerability characteristics.ConclusionsBased on the perspective of Medicare improvement, we conducted an in-depth exploration of the synergistic effect of medical insurance and the poverty alleviation system in reducing poverty, and we hope that through comprehensive strategic adjustments and multidimensional system cooperation, we can lift the vulnerable middle-aged and older adults out of poverty.

Association of Body Mass Index with Risk of Household Catastrophic Health Expenditure in China: A Population-Based Cohort Study.

Catastrophic health expenditure (CHE) is a major obstacle to achieving universal health coverage, and body mass index (BMI) is linked to both health and economy. We aimed to explore the association of BMI with the risk of CHE to provide advice for reducing CHE. We used national cohort data from the China Family Panel Studies, which comprised 33,598 individuals (14,607 households) from 25 provinces between 2010 to 2018. We used multivariate Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) and 95% confident interval (CI) for CHE in participants at underweight, overweight, and obesity, compared with those at normal weight. Restricted cubic splines were employed to model the association of continuous BMI scale with risk of CHE. We found that families with female household heads at underweight had a 42% higher risk of CHE (aHR = 1.42, 95%CI: 1.16–1.75), and those at overweight had a 26% increased risk of CHE (aHR = 1.26, 95%CI: 1.09–1.47), compared with those at normal weight. A weak U-shaped curve for the association of continuous BMI with risk of CHE in female-headed households (p for non-linear = 0.0008) was observed, which was not significant in male-headed households (p for non-linear = 0.8725). In female-headed households, underweight and overweight BMI are connected with a higher risk of CHE. Concerted efforts should be made to keep a normal BMI to prevent CHE.

The Comparison of Various Types of Health Insurance in the Healthcare Utilization, Costs and Catastrophic Health Expenditures among Middle-Aged and Older Chinese Adults.

Rapid aging in China is increasing the number of older people who tend to require health services for their poor perceived health. Drawing on the China Health and Retirement Longitudinal Study (CHARLS) 2018 data, we used two-part model and binary logistic regression to compare various types of health insurance in the healthcare utilization, costs and catastrophic health expenditures (CHE) among the middle-aged and older adults in China. Compared with uninsured, all types of health insurance promoted hospital utilization rate (ranged from 8.6% to 12.2%) and reduced out-of-pocket (OOP) costs (ranged from 64.9% to 123.6%), but had no significant association with total costs. In contrast, the association of health insurance and outpatient care was less significant. When Urban Employee Medical Insurance (UEMI) as reference, other types of insurance did not show a significant difference. Health insurance could not reduce the risk of CHE. The equity in healthcare utilization improved and healthcare costs had been effectively controlled among the elderly, but health insurance did not protect against CHE risks. Policy efforts should further focus on optimizing healthcare resource allocation and inclining toward the lower socio-economic and poor-health groups.

The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

IntroductionWhile it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.MethodsWe interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05.ResultsOf the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91).ConclusionCosts associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Evaluation of catastrophic health expenditure risk due to measles in Nigeria

ABSTRACT Measles can have a substantial negative impact not only on people’s health but also on their finances, especially in developing countries. This study evaluates the household risk of catastrophic health expenditure (CHE) due to measles, according to regions and wealth quintiles. The CHE risk due to measles was computed based on (1) the likelihood of health service utilization to treat measles, (2) out-of-pocket (OOP) expenditure and indirect costs associated with disease treatment, and (3) household consumption expenditures. I derived the CHE risk associated with measles, conditional on contracting the disease, across regions and wealth quintiles in Nigeria, using secondary data sources for health-care utilization, OOP expenditures, and consumption expenditures. There was a large variation in CHE risk according to regions and wealth quintiles. Among the poorest households, those in the northeast and northwest would have the highest risk of CHE, up to 17%, while those in the southwest would have the lowest risk of 5%. For all regions, as the wealth increases, the CHE risk would decrease. There would be zero or very little CHE risk among the richest households in any regions. Given the proven efficacy of measles vaccines, immunizations can prevent households, especially poorer households in northeast and northwest regions, from facing the CHE risk due to measles.

Sarcopenia and catastrophic health expenditure by socio-economic groups in China: an analysis of household-based panel data.

BackgroundSarcopenia was thought to be associated with adverse outcomes and will cause lots of health expenditure. But the relationship between sarcopenia and catastrophic health expenditure (CHE) had been little explored. Here, we examined the distribution of sarcopenia in relation to medical and payment burdens.MethodsWe used data from three waves of China Health and Retirement Longitudinal Study including 14 130 participants from 9077 households aged over 50 years old. Sarcopenia was operationalized according to the Asian Working Group for Sarcopenia 2019. Medical expenditure was obtained by self‐reported data, and CHE was identified by WHO definitions. We used the negative binomial regression model and logistic mixed‐effects models to examine the associations between sarcopenia and medical and CHE.ResultsA total of 14 130 participants [52.2% female, aged 60.8 (SD 9.3)] from 9077 households were included in this study. The prevalence of sarcopenia was 19.8%, 11.9% for moderate sarcopenia, and 7.9% for severe sarcopenia, respectively. We identified 1416 household CHE events in all three waves. Severe sarcopenia was associated with an increase in the number of inpatient visits [incidence rate ratio 1.31, 95% confidence interval (CI): 1.03–1.66, P = 0.03] and the risk of CHE (odds ratio: 1.04, 95% CI: 1.01–1.07, P < 0.01). We saw similar effects in health service use of sarcopenia in different socio‐economic groups. Moderate sarcopenia increased the risk of CHE in the lowest socio‐economic group (odds ratio 1.03, 95% CI: 1.01–1.06, P = 0.03) and had no statistical significance in other groups. The association between severe sarcopenia and CHE did not attenuate after the adjustment of disease factors.ConclusionsSevere sarcopenia may increase the risk of CHE. Timely and effective intervention on moderate sarcopenia from severe sarcopenia will contribute to reduce the health burden.

How Do Intergenerational Economic Support, Emotional Support and Multimorbidity Affect the Catastrophic Health Expenditures of Middle-Aged and Elderly Families?-Evidence From CHARLS2018.

ObjectivesThe elderly face multiple vulnerabilities such as health, economy and society, and are prone to catastrophic health expenditures. This study aims to analyze the impact of children's intergenerational economic support, emotional support, and illness on the catastrophic health expenditures of middle-aged and elderly families.MethodsUsing China Health and Retirement Longitudinal Study (CHARLS 2018) data to calculate the catastrophic health expenditure of Chinese households as the dependent variable. Taking children's intergenerational economic support, emotional support and multimorbidity as core independent variables, gender, age, marital status, medical insurance and other variables as control variables, and perform logistic regression analysis. According to the heterogeneity analysis of age and gender, the impact of intergenerational economic support, emotional support and multimorbidity on the catastrophic health expenditure of middle-aged and elderly families is explored.ResultsWhen catastrophic health expenditures occur in middle-aged and elderly families, the children's intergenerational economic support will increase significantly, especially in families with members aged 60–74. Children's emotional support can effectively reduce the risk of catastrophic health expenditures for middle-aged and elderly families. Compared with children's intergenerational economic support and emotional support, the impact of multimorbidity on the catastrophic health expenditures of middle-aged and elderly families is the most significant. Suffering from multimorbidity can increase the risk of catastrophic health expenditures for middle-aged and elderly families, especially families with male members suffering from multiple diseases.ConclusionsIt is recommended that we should do a good job in popularizing the knowledge of chronic diseases to minimize the occurrence of multimorbidity. The government should establish group medical insurance related to chronic disease diagnosis. According to the severity of the disease or the special circumstances of the patient, the level of medical insurance reimbursement is divided in detail, especially for chronic disease clinics and drug reimbursement. Children should be encouraged to strengthen the emotional connection and effective care of the elderly, focusing on the elderly 60–74 years old, in order to reduce their care pressure and maintain the physical and mental health of the elderly.

Catastrophic Health Expenditures With Pregnancy and Delivery in the United States.

To describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people). We conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons. We analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation. Pregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.

Assessing Catastrophic Health Expenditures Among Uninsured People Who Seek Care in US Hospital-Based Emergency Departments

Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown. To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits. This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients. Risk of CHE for ED care defined as an ED charge that exceeds 40% of one's estimated annual post-subsistence income. From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit. This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care.

Malnutrition and the Risk of Catastrophic Health Expenditure in Nigeria

BACKGROUND: Malnutrition among children not only affects their health consequences but also does it burden their households&amp;rsquo; finance especially in developing countries. This study evaluates the household risk of catastrophic health expenditure (CHE) due to malnutrition treatments among malnourished children in Nigeria, according to zones and wealth quintiles. We simulate the CHE risk among households with malnourished children who seek treatment.&amp;nbsp; &#x0D; &#x0D; METHODS: The CHE risk due to malnutrition among treated was computed based on 1) the out-of-pocket (OOP) expenditure and indirect costs associated with malnutrition treatment, and 2) household consumption expenditures. I derived the CHE risk associated with malnutrition across zones and wealth quintiles in Nigeria, using secondary data sources for healthcare utilization, OOP expenditures, and consumption expenditures. &#x0D; &#x0D; RESULTS: There was a large variation of CHE risk according to zones and wealth quintiles. Among the poorest households, those in northeast and northwest would have the highest risk of CHE, up to 59 and 47%, while those in southwest would have the lowest risk of 14%. For all zones, as the wealth increases, the CHE risk would decrease. There would be zero or very little CHE risk among the richest households in any zones.&#x0D; &#x0D; INTERPRETATION: Nutrition interventions will help malnourished children improve their health status. However, we should also be wary about the financial consequences of the treatment that households should bear.

Ten-Year Poverty Alleviation Effect of the Medical Insurance System on Families With Members Who Have a Non-communicable Disease: Evidence From Heilongjiang Province in China.

Aims: Non-communicable diseases (NCD) drag the NCD patients' families to the abyss of poverty. Medical insurance due to weak control over medical expenses and low benefits levels, may have actually contributed to a higher burden of out-of-pocket payments. By making a multi-dimensional calculation on catastrophic health expenditure (CHE) in Heilongjiang Province over 10 years, it is significant to find the weak links in the implementation of medical insurance to achieve poverty alleviation.Methods: A logistic regression was undertaken to predict the determinants of catastrophic health expenditure.Results: The average CHE of households dropped from 18.9% in 2003 to 14.9% in 2013. 33.2% of the households with three or more NCD members suffered CHE in 2013, which was 7.2 times higher than the households without it (4.6%). The uninsured households with cardiovascular disease had CHE of 12.0%, which were nearly 10% points lower than insured households (20.4–22.4%). For Medical Insurance for Urban Employees Scheme enrolled households, the increasing number of NCD members raised the risk of impoverishment from 3.4 to 20.0% in 2003, and from 0.3 to 3.1% in 2008. Households with hospital in-patient members were at higher risk of CHE (OR: 3.10–3.56).Conclusions: Healthcare needs and utilization are one of the most significant determinants of CHE. Households with NCD and in-patient members are most vulnerable groups of falling into a poverty trap. The targeting of the NCD groups, the poorest groups, uninsured groups need to be primary considerations in prioritizing services that are contained in medical insurance and poverty alleviation.

Associations of Insurance Churn and Catastrophic Health Expenditures With Implementation of the Affordable Care Act Among Nonelderly Patients With Cancer in the United States

Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. The Patient Protection and Affordable Care Act. Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.

Minimizing the Risk of Catastrophic Health Expenditure in China: A Multi-Dimensional Analysis of Vulnerable Groups.

Background: In moving toward universal health coverage in China, it is crucial to identify which populations should be prioritized for which interventions rather than blindly increasing welfare packages or capital investments. We identify the characteristics of vulnerable groups from multiple perspectives through estimating catastrophic health expenditure (CHE) and recommend intervention priorities.Methods: Data were from National Health Service Survey conducted in 2003, 2008, and 2013. According to the recommendation of WHO, this study adopted 40% as the CHE threshold. A binary regression was used to identify the determinants of CHE occurrence; a probit model was used to obtain CHE standardized incidence under the characteristics of single and two dimensions in 2013.Results: The total incidence of CHE in 2013 was 13.9%, which shows a general trend of growth from 2003 to 2013. Families in western and central regions and rural areas were more at risk. Factors related to social demography show that households with a female or an unmarried head of household or with a low socioeconomic status were more likely to experience CHE. Households with older adults aged 60 and above had 1,524 times higher likelihood of experiencing CHE. Among the health insurance schemes, the participants covered by the New Rural Cooperative Medical Scheme had the highest risk compared with the participants of all basic health insurance schemes. Households with several members seeking outpatient, inpatient care or with non-communicable diseases were more likely to experience CHE. Households with members not seeing a doctor or hospitalized despite the need for it were more likely to experience CHE. Characteristics such as a household head with characteristics related to low socioeconomic status, having more than two hospitalized family members, ranked high. Meanwhile, the combination of having illiterate household heads and with being covered by other health insurance plans or by none ranked the first place. Cancer notably caused a relatively high medical expenditure among households with CHE.Conclusion: In China, considering the vulnerability of the population across different dimensions is conducive to the alleviation of high CHE. Furthermore, people with multiple vulnerabilities should be prioritized for intervention. Identifying and targeting them to offer help and support will be an effective approach.

Churn and catastrophe: insurance loss and high spending among patients with gynecologic cancer in the United States in the era of the Affordable Care Act

<h3>Objectives:</h3> Although often considered a static characteristic in oncology research, insurance coverage is dynamic in reality, potentially changing month-to-month. The Affordable Care Act (ACA) was passed in 2010 with aims of stabilizing and expanding insurance markets, and reducing financial burden, particularly for the poor and sick. We sought to assess insurance churn and catastrophic health expenditures (CHE) among patients with gynecologic cancer in the era of the ACA. <h3>Methods:</h3> Retrospective study of 2006-2017 Medical Expenditure Panel Survey (MEPS) respondents under age 65 reporting care in the given year related to a gynecologic cancer diagnosis. MEPS is an annual survey representative of the civilian, non-institutionalized US population. Weights were applied to estimate national rates of insurance churn (loss/change of coverage) and CHE (family out-of-pocket health spending >10% family income), and differences between subgroups and over time were assessed by the adjusted Wald test. <h3>Results:</h3> A total of 684 MEPS respondents under age 65 reported care related to a gynecologic cancer diagnosis in 2006-2017, representing an estimated average annual population of 533,000 persons (95% CI 462,000-603,000), which was majority White (87.0%) and non-Hispanic (85.5%). Relative to the overall under 65 US population, patients with gynecologic cancer reported higher rates of low-income (family income ≤250% federal poverty level; 45.1% vs 32.2%; <i>p</i><0.001) and employment disruption (15.2% job change/loss, 55.3% part-year unemployment, 38.6% full-year unemployment, vs 10.5%, 44.1%, and 32.4% respectively; <i>p</i><0.05 for all). In the era of the ACA since becoming law in 2010, patients with gynecologic cancer reported high annual rates of insurance churn: 8.8% (95% CI 5.2-12.5) with loss of insurance, 18.7% (95% CI 13.6-23.8) with change in insurance, 21.7% (95% CI 16.5-26.9) uninsured for at least one month, and 8.4% (95% CI 5.7-11.0) uninsured for entire year. The gynecologic cancer population also experienced high rates of catastrophic spending, with 12.8% (95% CI 8.9-16.7) reporting CHE by out-of-pocket expenses alone, and 28.0% (95% CI 21.6-34.4) when including premium spending. Non-white and Hispanic patients collectively reported elevated rates of insurance churn (25.9% insurance change, 30.2% any uninsurance, vs 16.3% and 18.7% respectively for non-Hispanic whites, <i>p</i><0.05 for both), but no difference in rates of CHE. Patients from low-income families faced significantly higher risk of CHE (22.7% vs 3.0% expenses alone, <i>p</i><0.001; 35.3% vs 20.8% including premiums, <i>p</i>=0.01). Full-year Medicaid coverage was more protective from CHE compared with full-year private coverage (overall 15.3% vs 31.3%, <i>p</i>=0.02; low-income 11.5% vs 62.1%, <i>p</i><0.001). In assessment for impact of the ACA comparing full ACA implementation in 2014-17 with pre-ACA years 2006-09, we observed trends towards lower rates of CHE among low-income gynecologic cancer patients after implementation, but no significant differences. <h3>Conclusions:</h3> Gynecologic cancer patients face high rates of insurance churn, with over one in five reporting uninsurance for least one month every year, and catastrophic health spending, with over one in four reporting CHE annually. Low-income patients face the highest risks of CHE, and are better protected with Medicaid coverage as compared to private insurance. There was no significant impact of the ACA, but small sample size limited estimate precision and power to detect small changes.

Age at Primary Cleft Lip Repair: A Potential Bellwether Indicator for Pediatric Surgery.

Background:The bellwether procedures described by the Lancet Commission on Global Surgery represent the ability to deliver adult surgical services after there is a clear and easily made diagnosis. There is a need for pediatric surgery bellwether indicators. A pediatric bellwether indicator would ideally be a routinely performed procedure, for a relatively common condition that, in itself, is rarely lethal at birth, but that should ideally be treated with surgery by a standard age. Additionally, the condition should be easy to diagnose, to minimize the confounding effects of delays or failures in diagnosis. In this study, we propose the age at primary cleft lip (CL) repair as a bellwether indicator for pediatric surgery.Method:We reviewed the surgical records of 71,346 primary cleft surgery patients and ultimately studied age at CL repair in 40,179 patients from 73 countries, treated by Smile Train partners for 2019. Data from Smile Train’s database were correlated with World Bank and WHO indicators.Results:Countries with a higher average age at CL repair (delayed access to surgery) had higher maternal, infant, and child mortality rates as well as a greater risk of catastrophic health expenditure for surgery. There was also a negative correlation between delayed CL repair and specialist surgical workforce numbers, life expectancy, percentage of deliveries by C-section, total health expenditure per capita, and Lancet Commission on Global Surgery procedure rates.Conclusion:These findings suggest that age at CL repair has potential to serve as a bellwether indicator for pediatric surgical capacity in Lower- and Middle-income Countries.

Financial protection in health among the middle-aged and elderly: Evidence from the Greek economic recession

Since the late 2000s, the Greek economy has entered a long period of recession, with reforms and retrenchment in health care being among the main public policy priorities. This study investigates the extent to which financial protection in health has changed among older households during the Greek crisis. We focus on the middle-aged and elderly, the heavy users of health services, who have faced a substantial health and financial burden during the crisis. Our analysis shows that the headcount and overshoot of catastrophic health expenditure (CHE) substantially increased from 2007 to 2015, suggesting that financial protection has eroded to a great extent. Prior to the crisis, CHE was mainly due to inpatient care, followed by outpatient care and medicines. However, the contribution of spending for outpatient medicines to CHE substantially increased during the study period. The headcount of CHE rose across all socioeconomic groups we examined, with low-income households and households with chronic patients being disproportionately affected. In 2007, we do not report signs of socioeconomic inequalities in the risk of CHE. On the contrary, our results show that households of low socioeconomic status are more likely to incur CHE in 2015, revealing substantial inequalities in the risk of CHE. This finding raises significant distributional and equity concerns. Strengthening financial protection among older households is an imperative challenge for the Greek health system, and several policy responses need to be adopted towards this direction.

Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act.

BackgroundDespite 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.ObjectiveTo 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.DesignUsing 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.ParticipantsNationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey.InterventionACA implementation, January 1, 2014.Main MeasuresLikelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income.Key ResultsAmong 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.ConclusionsACA 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.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06807-4.