In the first 2 years after insurance coverage expanded under the Affordable Care Act (ACA), mean out-of-pocket household spending on healthcare dropped by 11.9%, new data show. The drop was driven largely by spending reductions among people who became eligible for Medicaid and those eligible for cost-sharing and subsidies in exchanges.
However, during the same period, mean spending on premiums increased by 12.1% (95% confidence interval [CI], 1.9% – 23.3%). Most of that increase was driven by a 22.9% increase in premiums among those in a higher-income subgroup (95% CI, 5.5% – 43.1%). Premium spending did not change significantly in other income groups.
When researchers combined out-of-pocket payments, such as copays and deductibles, and premium payments, they found a 16.0% decrease (95% CI, −27.6% to −2.6%) in spending among the lowest-income group, but no significant changes in the full sample or other income groups.
Anna L. Goldman, MD, MPA, from Cambridge Health Alliance in Massachusetts, and colleagues reported the findings from their study in an article published online January 22 in JAMA Internal Medicine.
“Repealing or otherwise dismantling the legislation without a suitable replacement could cause financial harm to many lower-income families,” the authors write.
Table. Decreases in Out-of-Pocket Spending by Income Group
| Income group | Percentage Change (95% CI) | P Value |
| Full sample | −11.9 (−17.1% to −6.4%) | P < .001 |
| Lowest-income (138% of the federal poverty level) | −21.4% (−30.1% to −11.5%) | P < .001 |
| Low income (139% – 250% of the federal poverty level) | −18.5 (−27% to −9%) | P < .001 |
| Middle-income group (251% – 400% of the federal poverty level) | −12.8 (−22.1% to −2.4%) | P = .02 |
The authors cite several reasons the ACA’s effect on out-of-pocket spending was not bigger.
“First, only a small proportion of Americans — 6.5% according to our data — became newly insured after the ACA. Second, about 28 million Americans remain uninsured. Third, many of those with coverage continued to incur high costs,” they write.
They cited individual deductibles under the ACA that are often twice as high as for people in employer-sponsored plans ($3064 in exchange Silver plans vs $1478 in employee-sponsored plans in 2016).
The study population included 83,431 people in the United States in a nationally representative sample of adults aged 18 to 64 years. Researchers used population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after coverage expansions on January 1, 2014.
They compared yearly out-of-pocket and premium payments before the ACA (2012 – 2013) and after (2014 – 2015).
High-Burden Spending
The researchers also looked at people who had high-burden spending, which they defined as those who spent more than 10% of their family income for out-of-pocket costs, more than 9.5% of family income on premium payments, and 19.5% for the combined out-of-pocket and premium payments.
Those in the lowest-income group had a 19.6% drop in adjusted odds of high-burden spending (odds ratio, 0.80; 95% CI, 0.67 – 0.97). No significant changes were found for other income groups.
However, the ACA did not close the gap between higher- and lower-income families in terms of who was most likely to experience high burden in out-of-pocket costs and premium payments, the data show.
“[T]he odds of experiencing high-burden spending were approximately 16 times greater among the poor than among the higher-income group before the ACA and 14 times higher after the ACA,” the authors write.
The study had no direct funding. Dr Goldman’s salary is supported by the National Institutes of Health. A coauthor received salary support for his contributions from internal funds of the Department of Medicine at Cambridge Health Alliance.
JAMA Intern Med. Published online January 22, 2018. Full text
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