Prevalence of Informal Caregiving in States Participating in the US Patient Protection and Affordable Care Act Balancing Incentive Program, 2011-2018.

Importance: The Balancing Incentives Program (BIP), established under the 2010 Patient Protection and Affordable Care Act provided federal funding for states to shift long-term care out of institutional settings and into the home. However, the association of its implementation with informal caregiving is not known.

Objective: To evaluate the association between BIP participation and the prevalence and frequency of informal caregiving and socioeconomic disparities among caregivers.

Design, Setting, and Participants: The cohort study included respondents to the 2011-2018 American Time Use Survey in BIP-adopting states and non-BIP-adopting states.

Exposure: Living in a state that had implemented the BIP after program implementation had begun (April 2012 to April 2018).

Main Outcomes and Measures: Prevalence of caregiving among all respondents, frequency of caregiving, and minutes of daily sleep, a marker of well-being. Differences-in-differences (DID) regression analysis was used to compare these outcomes between BIP-adopting states and non-BIP-adopting states.

Results: The study included 38 343 respondents in BIP-adopting states (median age, 47 years [interquartile range (IQR), 31-61 years]; 51.9% women), of whom 7428 were caregivers (median age, 51 years [IQR, 37-61 years]; 55.6% women), and 26 437 respondents in non-BIP-adopting states (median age, 48 years [IQR, 32-62 years]; 52.7% women), of whom 5527 were caregivers (median age, 52 years [IQR, 38-62 years]; 57.9% women). There was no change in the prevalence of caregiving between BIP-adopting and non-BIP-adopting states after program implementation (DID, 0.00%; 95% CI, -0.01% to 0.01%). Caregivers in BIP-adopting states were more likely to provide daily care after implementation (DID, 3.2%; 95% CI, 0.3%-6.0%; P = .03) and report increased time sleeping (DID, 15.6 minutes; 95% CI, 4.9-26.2 minutes; P = .005) compared with caregivers in non-BIP-adopting states. This association was more pronounced among caregivers with more education (DID, 25.1 minutes; 95% CI, 6.5-43.8 minutes; P = .01) and higher annual family income (DID, 16.9 minutes; 95% CI, 5.9-27.9 minutes; P = .004) compared with caregivers in non-BIP-adopting states who had the same education and income levels, respectively.

Conclusions and Relevance: In this cohort study, the BIP was associated with increased daily caregiving and improved caregiver well-being. However, it may have disproportionately benefited caregivers of higher socioeconomic status, potentially exacerbating disparities in caregiver stress. Future policies should aim to mitigate this unintended consequence.