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Under the Massachusetts health reform, low income residents (those with incomes below 150 % of the Federal Poverty Level [FPL]) were eligible for Medicaid and health insurance exchange-based plans with minimal cost-sharing and no premiums. Those with slightly higher incomes (150 %-300 % FPL) were eligible for exchange-based plans that required cost-sharing and premium payments.    Methods  We conducted face to face surveys in four languages with a convenience sample of 976 patients seeking care at three hospital emergency departments five years after Massachusetts reform. We compared perceived affordability of insurance, financial burden, and satisfaction among low cost sharing plan recipients (recipients of Medicaid and insurance exchange-based plans with minimal cost-sharing and no premiums), high cost sharing plan recipients (recipients of exchange-based plans that required cost-sharing and premium payments) and the commercially insured.    Results  We found that despite having higher incomes, higher cost-sharing plan recipients were less satisfied with their insurance plans and perceived more difficulty affording their insurance than those with low cost-sharing plans. Higher cost-sharing plan recipients also reported more difficulty affording medical and non-medical health care as well as insurance premiums than those with commercial insurance. In contrast, patients with low cost-sharing public plans reported higher plan satisfaction and less financial concern than the commercially insured.    Conclusions  Policy makers with responsibility for the benefit design of public insurance available under health care reforms in the U.S. should calibrate cost-sharing to income level so as to minimize difficulty affording care and financial burdens.    Electronic supplementary material  The online version of this article (doi:10.1186/s12939-015-0235-2) contains supplementary material, which is available to authorized users.

Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform