Upstream With A Small Paddle: How ACOs Are Working Against The Current To Meet Patients' Social Needs

Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients' social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently "flying blind," lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs' difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.

How The ACA Dented The Cost Curve

Numerous provisions of the Affordable Care Act (ACA) were designed to make health care more affordable, yet the act's cumulative effects on health care costs are still debated. A key question is whether or not the ACA reduced the annual rate at which total national health care spending increased and brought per capita spending growth rates down. We review the direct and indirect effects of the ACA on spending across segments of the health insurance market. We highlight areas where the ACA has affected spending, but we emphasize that the ACA's long-run impact on spending will depend on sustaining the adjustments made to provider payment systems and expanding the emphasis on value across payers throughout the ACA's second decade and beyond.

A New Approach To Mental Health Care, Imported From Abroad

Can a transformative care strategy, tested and proven in Trieste, Italy, work in Los Angeles, California?

The Power Of Access To Affordable Care

A patient and student with severe asthma chases adequate insurance coverage until the Affordable Care Act provides something more.

Treatment Of Opioid Use Disorder Among Commercially Insured US Adults, 2008-17

There is abundant literature on efforts to reduce opioid prescriptions and misuse, but comparatively little on the treatment provided to people with opioid use disorder (OUD). Using claims data representing 12-15 million nonelderly adults covered through commercial group insurance during the period 2008-17, we explored rates of OUD diagnoses, treatment patterns, and spending. We found three key patterns: The rate of diagnosed OUD nearly doubled during 2008-17, and the distribution has shifted toward older age groups; the likelihood that diagnosed patients will receive any treatment has declined, particularly among those ages forty-five and older, because of a reduction in the use of medication-assisted treatment (MAT) and despite clinical evidence demonstrating its efficacy; and treatment spending is lower for patients who choose MAT. These patterns suggest that policies supporting the use of MAT are critical to addressing the undertreatment of OUD among the commercially insured and that further research to assess the cost-effectiveness of treatment with versus without medication is needed.

Wide State-Level Variation In Commercial Health Care Prices Suggests Uneven Impact Of Price Regulation

Prices charged for health care services in the commercial insurance market are high and vary widely within and between market areas. As a result, prices have been the focus of much policy debate. We extended the literature on commercial prices by examining state-level price variation in the commercial market, relative to Medicare, for a broader set of states and a wider set of services than had been examined. We assessed the potential impact on provider revenue of setting commercial prices at Medicare rates. Consistent with the existing literature, we found that average commercial prices for inpatient and outpatient facility services were about double Medicare fees, while commercial prices for professional services were about 60 percent higher. Finally, average hospital revenue would fall about 35 percent if commercial prices were limited to Medicare rates, but this would vary widely by state. If Medicaid rates were also increased to match Medicare rates, hospital revenue would likely fall by about 30 percent. Given the potentially large impact, policies to address the market failures that lead to high and variable prices in the commercial insurance sector are needed, but they should be structured to avoid the large disruptions that could occur if there were a very rapid transition to Medicare rates in the commercial market.

Innovative Policy Supports For Integrated Health And Social Care Programs In High-Income Countries

As high-income countries face the challenge of providing better and more efficient integrated health and social care to high-needs and high-cost populations, they may require innovative policy supports at both the national and local levels. We categorized policy supports into four areas: governance and partnerships; workforce and staffing; financing and payment; and data sharing and use. Our structured survey of thirty integrated health and social care programs in high-income countries in 2018 found that the majority of programs had policy supports in two or more areas, with supports for governance and partnerships and for workforce and staffing being the most common. Financing and payment and data sharing and use were less common. Local partnerships empowered integration across sectors, and new staff roles that spanned health and social care embedded this integration in care delivery. National policies-including bundled financing and investment in data-enabled integration and cross-sector accountability.

Health Insurance Coverage: What Comes After The ACA?

The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

Copayment Incentive Increased Medication Use And Reduced Spending Among Indigenous Australians After 2010

Australian health policy has prioritized efforts to close the ten-year life expectancy gap between indigenous and nonindigenous Australians, a disparity largely driven by cardiovascular disease and diabetes. Because out-of-pocket spending poses a barrier to accessing medications for chronic conditions, in 2010 the Australian government reduced or eliminated medication copayments for indigenous people with chronic disease or risk factors for chronic disease. In this quasi-experimental study we found that the copayment reductions were associated with a 39 percent relative increase in the use of medications and a 61 percent reduction in out-of-pocket spending. Among indigenous Australians who qualified for the largest copayment reductions, overall use of medications increased by 156 percent-including increases of 26-109 percent in the use of lipid-lowering, hypertension, and diabetes medications. These findings suggest that Australia's novel strategy of targeted copayment reductions improved access to prescription medications among indigenous Australians, a population with a high burden of chronic conditions and marked social disadvantage.

When Should Medicare Mandate Participation In Alternative Payment Models?

The Centers for Medicare and Medicaid Services continues to propose and implement alternative payment models (APMs) to shift Medicare payment away from fee-for-service and toward approaches that emphasize health care value. As APMs expand in scope, one critical question is whether they should engage providers on a voluntary or a mandatory basis. Clinicians and policy makers may view the benefits and drawbacks of these two modes of participation differently. In this Analysis we compare the benefits and drawbacks of mandatory and voluntary participation, based on clinical versus policy perspectives, and we argue that both modes are necessary for APMs to achieve the goal of improving value. Policy makers should match the mode of participation and related financial incentives to each clinical scenario in which an APM is implemented. We propose ways to coordinate mandatory and voluntary APMs based on clinical scenarios.

Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations

Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.

Linking Health And Social Services Through Area Agencies On Aging Is Associated With Lower Health Care Use And Spending

Area Agencies on Aging are increasingly partnering with health care organizations to address the health-related social needs of older adults and contribute to multisector coalitions that promote community health. Using survey data for the period 2008-13, we examined the potential health impacts of establishing such partnerships. Partnerships with hospitals located in an agency's service county were associated with a reduction of $136 in average annual Medicare spending per beneficiary, while partnerships with mental health organizations in an agency's service county saw potentially avoidable nursing home use fall by 0.5 percentage points. When agencies were funded participants in livable community initiatives-multisector coalitions to promote the well-being and health of older adults-potentially avoidable nursing home use fell by nearly 1 percentage point. Our results suggest that investments in health and human services partnerships through Area Agencies on Aging can yield health returns among older adults, in the form of reduced health care use and spending.

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.

Buying Health For North Carolinians: Addressing Nonmedical Drivers Of Health At Scale

Since 2017 the North Carolina Department of Health and Human Services has asked how its resources could be optimized to buy health, not only health care. This has led the department to incorporate whole-person care into all of its priorities, including building a statewide infrastructure and implementing incentives to address nonmedical drivers of health-focusing on food, housing, transportation, employment, and interpersonal safety/toxic stress. This article describes four interconnected initiatives that the department has implemented or is implementing to begin integrating medical and nonmedical drivers of health. This multifaceted effort involves many partners and includes financial incentives for commercial payers, Medicare, and Medicaid that are aligned with whole-person care; a standardized screening process to identify people with unmet social resource needs across all populations; NCCARE360, the first statewide network linking health care and human services providers to one another with a shared technology platform; and a large-scale Medicaid pilot to evaluate the impact of nonmedical health interventions on health outcomes and health care costs. North Carolina's interconnected initiatives can help inform efforts around the US and generate needed evidence on how to implement systems through public-private partnerships to address nonmedical drivers of health at scale.

Differences Between Public And Private Hospital Payment Rates Narrowed, 2012-16

In 2000-12 payments for inpatient hospital stays, emergency department visits, and outpatient hospital care for privately insured patients grew much faster than payments for Medicare and Medicaid patients. This widening of private-public payment gaps slowed or even reversed itself in 2012-16.

Medicaid Expansion Associated With Reductions In Preventable Hospitalizations

Hospitalizations for ambulatory care-sensitive conditions indicate barriers to care outside of inpatient settings. We found that Medicaid expansions under the Affordable Care Act were associated with meaningful reductions in these hospitalizations, which suggests the potential of Medicaid expansions to reduce the need for preventable hospitalizations in vulnerable populations and produce cost savings for the US health care system.

Financial Hardships Of Medicare Beneficiaries With Serious Illness

In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness-despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half reported a serious problem paying medical bills, with prescription drugs proving most onerous.

Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending

Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.

Cost-Effectiveness Of The Sugar-Sweetened Beverage Excise Tax In Mexico

An excise tax of 1 peso per liter on sugar-sweetened beverages was implemented in Mexico in 2014. We estimated the cost-effectiveness of this tax and an alternative tax scenario of 2 pesos per liter. We developed a cohort simulation model calibrated for Mexico to project the impact of the tax over ten years. The current tax is projected to prevent 239,900 cases of obesity, 39 percent of which would be among children. It could also prevent 61,340 cases of diabetes, lead to gains of 55,300 quality-adjusted life-years, and avert 5,840 disability-adjusted life-years. The tax is estimated to save $3.98 per dollar spent on its implementation. Doubling the tax to 2 pesos per liter would nearly double the cost savings and health impact. Countries with comparable conditions could benefit from implementing a similar tax.

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

From Rural Germany, Integrated Care Grows Into A Global Model

Fifteen years after a precursor to the ACO formed in the Black Forest region, a value-based approach to health care gains traction.

Tackling Social Determinants Of Health Around The Globe

A global health equity movement relies on research showing how social factors affect health.

Abandoning List Prices In Medicaid Drug Reimbursement Did Not Affect Spending

State fee-for-service Medicaid programs have traditionally based payments to pharmacies for drugs on a percentage of the drugs' list price. Because list prices have increased more quickly than the prices actually paid by pharmacies, estimating appropriate reimbursements has become challenging. In recent years most states have switched to models where payments were based instead on results from a survey of pharmacy invoices. We examined how this changed fee-for-service Medicaid drug spending. We found that the policy change had minimal, if any, effects on overall Medicaid drug spending. This was at least partially explained by concomitant sharp increases in dispensing fees paid to pharmacies, designed to help cover operating expenses and profit margins. We discuss ways to improve invoice-based pricing approaches and lower costs if desired.

Prices And Cost Sharing For Psychotherapy In Network Versus Out Of Network In The United States

Patients in the US are more likely to receive out-of-network behavioral health care, including treatment for mental health or substance use disorders, than they are to receive other medical and surgical services out of network. To date, out-of-network and in-network trends in the prices and use of ambulatory behavioral health care have been seldom described. Here we compare levels and growth of insurer-negotiated prices (allowed amounts), patient cost sharing, and use of psychotherapy services in network and out of network in a large, commercially insured US population during 2007-17. For both adult and child psychotherapy, prices and cost sharing were substantially higher out of network than they were in network. These gaps widened during the eleven-year period. Prices and cost sharing for in-network psychotherapy decreased during this period, whereas prices and cost sharing for out-of-network psychotherapy increased. Use of adult and child psychotherapy increased during this period, driven by growth of in-network rather than out-of-network use. The increasing gap in prices and cost sharing between out-of-network and in-network psychotherapy, viewed in the context of a shortage of behavioral health providers who accept insurance, may limit access to ambulatory behavioral health care.

Out-Of-Network Spending Mostly Declined In Privately Insured Populations With A Few Notable Exceptions From 2008 To 2016

While out-of-network or potential "surprise" billing has garnered increasing attention, particularly in emergency department and inpatient settings, few national studies have examined out-of-network care overall or in other settings. We examined out-of-network spending and use among two large nationwide populations with employer-sponsored insurance. In a primary sample of 27,883,040 people in data for 2008-16 from the Truven MarketScan Commercial Claims and Encounters Database, we found that the unadjusted share of total spending that occurred out of network decreased from 7.0 percent in 2008-10 to 6.1 percent in 2014-16, an adjusted average decline of 0.10 percentage points per year. Using a secondary sample of 13,093,209 people in the Health Care Cost Institute database provided qualitatively similar results, including when provider charges (upper bound for balance billing) were used in place of observed out-of-network prices. In subgroup analyses of the primary sample, the share of out-of-network spending was stable or declined among all segments of care except hospitalist services, pathologist services, and laboratory tests across the study period. Out-of-network use demonstrated comparable patterns. Prices were higher out of network than in network. Policy makers should focus their efforts on protecting consumers from balance billing or potential surprise billing in clinical scenarios where patients often have little choice over their provider.

The Potential Health Care Costs And Resource Use Associated With COVID-19 In The United States

With the coronavirus disease 2019 (COVID-19) pandemic, one of the major concerns is the direct medical cost and resource use burden imposed on the US health care system. We developed a Monte Carlo simulation model that represented the US population and what could happen to each person who got infected. We estimated resource use and direct medical costs per symptomatic infection and at the national level, with various "attack rates" (infection rates), to understand the potential economic benefits of reducing the burden of the disease. A single symptomatic COVID-19 case could incur a median direct medical cost of $3,045 during the course of the infection alone. If 80 percent of the US population were to get infected, the result could be a median of 44.6 million hospitalizations, 10.7 million intensive care unit (ICU) admissions, 6.5 million patients requiring a ventilator, 249.5 million hospital bed days, and $654.0 billion in direct medical costs over the course of the pandemic. If 20 percent of the US population were to get infected, there could be a median of 11.2 million hospitalizations, 2.7 million ICU admissions, 1.6 million patients requiring a ventilator, 62.3 million hospital bed days, and $163.4 billion in direct medical costs over the course of the pandemic.

Iowa's Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012-17

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.

Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills

"Surprise" out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013-17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.

Integrating Social Services & Health

The health and human services sectors are complementary, but their programmatic separation presents challenges to coordination. A growing body of research offers examples of successful collaborations and models for building them, while confirming that integration of health and human services is driving improved outcomes at the individual and population levels.

Cash Benchmarking For Integrated Health Care And Human Services Interventions: Finding The Value Added

Health-related social needs, which include food insecurity, housing instability, and lack of transportation, are strongly associated with poor health outcomes, more health care use, and higher health care spending. Integrating human services that address health-related social needs into health care may address these issues. In this article we propose an innovative methodological approach (borrowed from developmental economics) called cash benchmarking, which can help determine when health care and human services integration is most useful. This is important because while integrating human services into health care offers potential benefits, it also comes with potential downsides-including the medicalization of social needs; deemphasis of upstream societal causes of health-related social needs, such as tax policy and labor conditions; and opportunity costs within the health care system, as resources are shifted to delivering social care. Ultimately, cash benchmarking can help stakeholders navigate closer to the promise, and away from the pitfalls, of health care and human services integration.

How The ACA Reframed The Prescription Drug Market And Set The Stage For Current Reform Efforts

The Affordable Care Act contained a range of provisions that altered prescription drug access and affordability for patients, payers, and providers. Yet the act stopped short of instituting systemic changes in the pricing of drugs, in part to address concerns that more fundamental changes might disrupt the development of new medicines. Looking back a decade after the Affordable Care Act became law, we found that new drug approvals have accelerated and the therapeutic advances embodied in some novel medicines are substantial-as are the prices that companies are charging for them. The lack of affordability of prescription drugs has become an increasing challenge for American patients and payers, particularly those with limited budgets. In this article we consider how things have changed in the past decade and how missed opportunities in the Affordable Care Act's passage figure prominently in the current drug pricing debate.

Texas Ruling Brings More ACA Uncertainty

Texas ruling and other legal challenges raise questions about the ACA's future even as enrollment holds steady.

Medicare For All: An Analysis Of Key Policy Issues

Medicare for All has emerged as a major topic in the national health reform debate. A clear understanding of the policy issues raised by Medicare for All would benefit both public discussion and policy design. In this article we identify key policy design issues for a Medicare for All system: comprehensiveness of coverage, the private sector's role, the payment approach, and financing. We analyze policy options within these domains and show that the Medicare for All bills under consideration in the 116th Congress propose a comprehensive benefit structure with a limited role for supplementary private insurance. We suggest that Medicare for All could adopt payment rates between existing Medicare rates and the average all-payer rate, or it could implement global payment starting at a level similar to current spending. We propose a financing framework that includes repurposing existing public funds, redirecting private health care spending to public spending, and implementing a mix of progressive taxes to replace the regressive financing of private insurance.

Challenges To Medicare For All Remain Daunting

Medicare for All plans have many advantages over the status quo. Yet the challenges facing such plans are immense, reflecting their ambitions to achieve universal coverage through a single federal plan and their disruption to existing insurance and financing arrangements. Medicare for All will not become viable unless it can meet the daunting political, economic, and administrative realities that govern US health care.

Health Reform On The Campaign Trail

The health reform debate heats up in the Democratic primary while Republicans grapple with developing their own plan.

Changes In The Equity Of US Health Care Financing In The Period 2005-16

Spending on health care in the United States amounted to 17.9 percent of gross domestic product in 2017. Households paid for this care through out-of-pocket medical spending and a complex mix of out-of-pocket premiums, employer premium contributions, taxes, and subsidies that combined to finance private employer-sponsored insurance, nongroup insurance, and multiple public insurance programs. Our analysis examined the impact of this complex system of health care financing on households in the period 2005-16, tracking how economic and policy changes affected incidence-that is, the amount paid to finance health care, either directly or indirectly, by households as a share of their pretax income. Health care financing was regressive at the start of our study period, with households in the bottom 20 percent of income paying 26.8 percent of their income compared to about half that amount for those with income in the top 1 percent. By 2016 incidence had become approximately proportional (the same percentage across all income levels). In part, these results reflect increases in coverage through Medicaid and the Affordable Care Act Marketplaces, which are progressively financed through the federal tax system.