Out-of-Pocket Spending and Premium Contributions After Implementation of the Affordable Care Act

JAMA Intern Med. 2018 Mar 1;178(3):347-355. doi: 10.1001/jamainternmed.2017.8060.


Importance: The Affordable Care Act (ACA) was associated with a reduced number of Americans who reported being unable to afford medical care, but changes in actual health spending by households are not known.

Objectives: To estimate changes in household spending on health care nationwide after implementation of the ACA.

Design, setting, and participants: Population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, and multivariable regression were used to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after the ACA's coverage expansions on January 1, 2014. The study population included a nationally representative sample of US adults aged 18 to 64 years (n = 83 431). In addition, changes were assessed in the likelihood of exceeding affordability thresholds for each outcome and spending changes for income subgroups defined under the ACA to determine program eligibility at 138% or less, 139% to 250%, 251% to 400%, and greater than 400% of the federal poverty level (FPL).

Exposure: Implementation of the ACA's major insurance programs on January 1, 2014.

Main outcomes and measures: Mean individual-level out-of-pocket spending and premium payments and the percentage of persons experiencing high-burden spending, defined as more than 10% of family income for out-of-pocket expenses, more than 9.5% for premium payments, and more than 19.5% for out-of-pocket plus premium payments.

Results: In this nationally representative survey of 83 431 adults (weighted frequency, 49.1% men and 50.9% women; median age, 40.3 years; interquartile range, 28.6-52.4 years), ACA implementation was associated with an 11.9% decrease (95% CI, -17.1% to -6.4%; P < .001) in mean out-of-pocket spending in the full sample, a 21.4% decrease (95% CI, -30.1% to -11.5%; P < .001) in the lowest-income group (≤138% of the FPL), an 18.5% decrease (95% CI, -27.0% to -9.0%; P < .001) in the low-income group (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P = .02) in the middle-income group (251%-400% of the FPL). Mean premium spending increased in the full sample (12.1%; 95% CI, 1.9%-23.3%) and the higher-income group (22.9%; 95% CI, 5.5%-43.1%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%; 95% CI, -27.6% to -2.6%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) and in the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28; 95% CI, 1.03-1.59).

Conclusions and relevance: Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending. Repeal or substantial reversal of the ACA would especially harm poor and low-income Americans.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

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