Impact of out-of-pocket spending caps on financial burden of those with group health insurance

J Gen Intern Med. 2015 May;30(5):683-8. doi: 10.1007/s11606-014-3127-z. Epub 2014 Dec 4.


Background: The Affordable Care Act (ACA) mandates that all private health insurance include out-of-pocket spending caps. Insurance purchased through the ACA's Health Insurance Marketplace may qualify for income-based caps, whereas group insurance will not have income-based caps. Little is known about how out-of-pocket caps impact individuals' health care financial burden.

Objective: We aimed to estimate what proportion of non-elderly individuals with group insurance will benefit from out-of-pocket caps, and the effect that various cap levels would have on their financial burden.

Design: We applied the expected uniform spending caps, hypothetical reduced uniform spending caps (reduced by one-third), and hypothetical income-based spending caps (similar to the caps on Health Insurance Marketplace plans) to nationally representative data from the Medical Expenditure Panel Survey (MEPS).

Participants: Participants were non-elderly individuals (aged < 65 years) with private group health insurance in the 2011 and 2012 MEPS surveys (n =26,666).

Main measures: (1) The percentage of individuals with reduced family out-of-pocket spending as a result of the various caps; and (2) the percentage of individuals experiencing health care services financial burden (family out-of-pocket spending on health care, not including premiums, greater than 10% of total family income) under each scenario.

Key results: With the uniform caps, 1.2% of individuals had lower out-of-pocket spending, compared with 3.8% with reduced uniform caps and 2.1% with income-based caps. Uniform caps led to a small reduction in percentage of individuals experiencing financial burden (from 3.3% to 3.1%), with a modestly larger reduction as a result of reduced uniform caps (2.9%) and income-based caps (2.8%).

Conclusions: Mandated uniform out-of-pocket caps for those with group insurance will benefit very few individuals, and will not result in substantial reductions in financial burden.

Publication types

  • Evaluation Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cost of Illness*
  • Female
  • Financing, Personal / economics
  • Financing, Personal / statistics & numerical data*
  • Health Care Reform / economics*
  • Health Expenditures*
  • Humans
  • Income / statistics & numerical data
  • Insurance Coverage / economics
  • Insurance Coverage / legislation & jurisprudence*
  • Insurance, Health / economics*
  • Insurance, Health / legislation & jurisprudence
  • Male
  • Middle Aged
  • Patient Protection and Affordable Care Act / economics
  • United States