Changes in Health Care-Related Financial Burden for US Families With Children Associated With the Affordable Care Act

JAMA Pediatr. 2020 Nov 1;174(11):1032-1040. doi: 10.1001/jamapediatrics.2020.3973.


Importance: The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear.

Objective: To examine changes in health care-related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies.

Design, setting, and participants: Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians.

Exposures: Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013).

Main outcomes and measures: Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index.

Results: Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: -11.4%; 95% CI, -13.2% to -9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: -6.8%; 95% CI, -8.7% to -4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: -1.2%; 95% CI, -2.3% to -0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families.

Conclusions and relevance: The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care-related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.

MeSH terms

  • Adolescent
  • Boston
  • Child
  • Financial Stress*
  • Health Care Costs / standards*
  • Health Care Costs / trends
  • Humans
  • Patient Protection and Affordable Care Act / standards
  • Patient Protection and Affordable Care Act / trends*
  • United States