The effect of pharmaceutical co-payment increase on the use of social assistance—A natural experiment study

Abstract

Health care out-of-pocket payments can create barriers to access or lead to financial distress. Out-of-pocket expenditure is often driven by outpatient pharmaceuticals. In this nationwide register study, we study the causal relationship between an increase in patients’ pharmaceutical expenses and financial difficulties by exploiting a natural experiment design arising from a 2017 reform, which introduced higher co-payments for type 2 diabetes medicines in Finland. With difference-in-differences estimation, we analyze whether the reform increased the use of social assistance, a last-resort financial aid. We found that after the reform the share of social assistance recipients increased more among type 2 diabetes patients than among a patient group not affected by the co-payment increase, suggesting the reform increased the use of social assistance among those subject to it. The results indicate that increases in patients’ pharmaceutical expenses can lead to serious financial difficulties even in countries with a comprehensive social security system.

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013–2020

“…Medication copayments increased notably, and these increases mainly affected individuals with chronic illnesses. Previous studies revealed coinciding decrease in medication consumption and increase in economic problems 15–18. I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship.…”

“…Previous studies revealed coinciding decrease in medication consumption and increase in economic problems. [15][16][17][18] I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship. I ask whether austerity coincided with exacerbation of inequalities, and whether hardship related to medications developed differently than other economic problems.…”

“…21 The incidence of catastrophic health spending, driven by prescription medicines and outpatient care, is higher than that in other Nordic countries, and unmet needs are more prevalent than in many other Western European countries. 19 During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill. [16][17][18][19] Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018. 19 In terms of tax benefit policies, the three governments that operated during the period differed in their approaches.…”

“…During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill 16–19. Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018 19…”

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013–2020

“…Medication copayments increased notably, and these increases mainly affected individuals with chronic illnesses. Previous studies revealed coinciding decrease in medication consumption and increase in economic problems 15–18. I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship.…”

“…Previous studies revealed coinciding decrease in medication consumption and increase in economic problems. [15][16][17][18] I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship. I ask whether austerity coincided with exacerbation of inequalities, and whether hardship related to medications developed differently than other economic problems.…”

“…21 The incidence of catastrophic health spending, driven by prescription medicines and outpatient care, is higher than that in other Nordic countries, and unmet needs are more prevalent than in many other Western European countries. 19 During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill. [16][17][18][19] Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018. 19 In terms of tax benefit policies, the three governments that operated during the period differed in their approaches.…”

“…During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill 16–19. Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018 19…”

Socioeconomic inequalities in insulin initiation among individuals with type 2 diabetes – A quasi-experimental nationwide register study

“…Previous studies have suggested an increase in economic difficulties ( Aaltonen, Niemelä, & Prix, 2022 ; Rättö & Aaltonen, 2021 ; Lavikainen, Aarnio, Jalkanen, et al, 2020 ), negative developments in satisfaction of care ( Lavikainen, Aarnio, Niskanen, Mäntyselkä, & Martikainen, 2020 ), and impacts related to the consumption of type 2 antidiabetics ( Lavikainen, Aarnio, Jalkanen, et al, 2020 ; Lavikainen, Aarnio, Niskanen, et al, 2020 ) among individuals with type 2 diabetes after the reform. Regarding insulin consumption, a survey study found responders reporting increased insulin use due to cost ( Lavikainen, Aarnio, Niskanen, et al, 2020 ).…”

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013–2020

“…Medication copayments increased notably, and these increases mainly affected individuals with chronic illnesses. Previous studies revealed coinciding decrease in medication consumption and increase in economic problems 15–18. I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship.…”

“…Previous studies revealed coinciding decrease in medication consumption and increase in economic problems. [15][16][17][18] I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship. I ask whether austerity coincided with exacerbation of inequalities, and whether hardship related to medications developed differently than other economic problems.…”

“…21 The incidence of catastrophic health spending, driven by prescription medicines and outpatient care, is higher than that in other Nordic countries, and unmet needs are more prevalent than in many other Western European countries. 19 During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill. [16][17][18][19] Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018. 19 In terms of tax benefit policies, the three governments that operated during the period differed in their approaches.…”

“…During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill 16–19. Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018 19…”

Socioeconomic inequalities in insulin initiation among individuals with type 2 diabetes – A quasi-experimental nationwide register study

“…Previous studies have suggested an increase in economic difficulties ( Aaltonen, Niemelä, & Prix, 2022 ; Rättö & Aaltonen, 2021 ; Lavikainen, Aarnio, Jalkanen, et al, 2020 ), negative developments in satisfaction of care ( Lavikainen, Aarnio, Niskanen, Mäntyselkä, & Martikainen, 2020 ), and impacts related to the consumption of type 2 antidiabetics ( Lavikainen, Aarnio, Jalkanen, et al, 2020 ; Lavikainen, Aarnio, Niskanen, et al, 2020 ) among individuals with type 2 diabetes after the reform. Regarding insulin consumption, a survey study found responders reporting increased insulin use due to cost ( Lavikainen, Aarnio, Niskanen, et al, 2020 ).…”

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013–2020

“…Medication copayments increased notably, and these increases mainly affected individuals with chronic illnesses. Previous studies revealed coinciding decrease in medication consumption and increase in economic problems 15–18. I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship.…”

“…Previous studies revealed coinciding decrease in medication consumption and increase in economic problems. [15][16][17][18] I complement previous evidence by examining financial access to medicines as part of more general patterns of economic hardship. I ask whether austerity coincided with exacerbation of inequalities, and whether hardship related to medications developed differently than other economic problems.…”

“…21 The incidence of catastrophic health spending, driven by prescription medicines and outpatient care, is higher than that in other Nordic countries, and unmet needs are more prevalent than in many other Western European countries. 19 During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill. [16][17][18][19] Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018. 19 In terms of tax benefit policies, the three governments that operated during the period differed in their approaches.…”

“…During the study period, the following health payment increases were implemented: public healthcare user charges were increased in 2015 and 2016, and copayment increase was targeted to prescription medications in 2013, 2016 and 2017, with the latter two leading to increase particularly among the chronically ill 16–19. Cuts on reimbursements for private healthcare and private dental care were implemented in 2015 and 2016, and reimbursements for travel costs to healthcare were reduced in 2013, 2015, 2016 and 2018 19…”

Socioeconomic inequalities in insulin initiation among individuals with type 2 diabetes – A quasi-experimental nationwide register study

“…Previous studies have suggested an increase in economic difficulties ( Aaltonen, Niemelä, & Prix, 2022 ; Rättö & Aaltonen, 2021 ; Lavikainen, Aarnio, Jalkanen, et al, 2020 ), negative developments in satisfaction of care ( Lavikainen, Aarnio, Niskanen, Mäntyselkä, & Martikainen, 2020 ), and impacts related to the consumption of type 2 antidiabetics ( Lavikainen, Aarnio, Jalkanen, et al, 2020 ; Lavikainen, Aarnio, Niskanen, et al, 2020 ) among individuals with type 2 diabetes after the reform. Regarding insulin consumption, a survey study found responders reporting increased insulin use due to cost ( Lavikainen, Aarnio, Niskanen, et al, 2020 ).…”