Although the Affordable Care Act’s (ACA) coverage expansions have reduced out-of-pocket spending for low- and middle-income individuals, these patients continue to experience a high burden of premium and out-of-pocket spending, according to study findings published in JAMA Internal Medicine.

Investigators obtained population-based data from the Medical Expenditure Panel Survey (MEPS) to evaluate changes in premium contributions, out-of-pocket spending, premiums, and total healthcare spending during 2012 through 2015. A total of 83,431 adult patients from the United States were included in this analysis, which was considered to be a representation of patients across the nation.


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The implementation of the ACA was found to be associated with an 11.9% decrease in the average out-of-pocket spending across the entire cohort (95% CI, -17.1% to -6.4%; P <.001). Additionally, researchers found that ACA implementation was associated with a 21.4% decrease (95% CI, -30.1% to -11.5%; P <.001) in the lowest-income arm (≤138% of the federal poverty level [FPL]), an 18.5% decrease (95% CI, -27.0% to -9.0%; P <.001) in patients of low-income (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P =.02) among middle-income individuals (251%-400% of the FPL).

Overall, premium spending increased (12.1%; 95% CI, 1.9%-23.3%), with the higher-income group also showing a significant increase in average premiums (22.9%; 95% CI, 5.5%-43.1%). Only the lowest-income group experienced decreased combined out-of-pocket plus premium spending (-16.0%; 95% CI, -27.6% to -2.6%). In addition, the investigators observed a decrease in the odds of out-of-pocket spending of >10% of family income (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) as well as decreased odds of out-of-pocket spending among families of the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). Conversely, high-burden premium spending rose sharply in the middle-income group during the studied period (OR, 1.28; 95% CI, 1.03-1.59).

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The investigators obtained data from a relatively short period, limiting the ability to determine long-term effects of ACA implementation. Additionally, the data on premiums may be subject to error, considering these data were self-reported.

Although the ACA may be associated with only moderate reductions in cost burden for low- to middle-income households, the repeal “or otherwise dismantling the legislation without a suitable replacement could cause financial harm to many lower-income families.”


Goldman AL, Woolhandler S, Himmelstein DU, Bor DH, McCormick D. Out-of-pocket spending and premium contributions after implementation of the Affordable Care Act [published online January 22, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.8060.