Household Health Care Payments Under Rate Setting, Spending Growth Target, and Single-Payer Policies

Importance Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households. Objective 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. Exposure 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. Main Outcomes and Measures Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation. Results 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. Conclusions and Relevance 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.