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

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.