The Affordable Care Act (ACA) is associated with moderate reductions in the cost burden for the lowest-, low-, and middle-income households, and a repeal or substantial reversal of the ACA would especially harm poor and low-income Americans, according to a study published in JAMA Internal Medicine.

Anna L. Goldman, MD, MPA, from the Cambridge Health Alliance, in Massachusetts, and colleagues analyzed data from the Medical Expenditure Panel Survey (MEPS) from January 1, 2012, through December 31, 2015, to estimate changes in household spending on health care nationwide after implementation of the ACA. The study included adults aged 18 to 64 years. The ACA’s individual mandate and main insurance expansion programs became effective on January 1, 2014.

The sample was divided into 4 income groups. The lowest income group included those with family incomes of 138% or less of the federal poverty level (FPL), the group that was eligible for Medicaid in states that expanded the program as part of the ACA. The low income group included those with family incomes of 139% to 250% of the FPL, most of whom were eligible for subsidized premiums and reduced cost sharing on the ACA’s exchanges. The middle income group included those with family incomes of 251% to 400% of the FPL, who generally qualified for premium subsidies but not for reduced cost sharing. The higher income group included those with family incomes of more than 400% of the FPL, who are not eligible for subsidies. The FPL for a family of 3 was $20,090 in 2015.

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The authors compared annual out-of-pocket and premium payments before (2012-2013) and after (2014-2015) implementation of the ACA using several approaches. The primary  outcome were defined as 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.

The study sample included data from 83.431 nonelderly adults (49.1% men; median age, 40.3 years) and 49,197 households. Sociodemographic and health characteristics changed little from the pre-ACA to post-ACA periods. ACA implementation was associated with an 11.9% decrease in mean out-of-pocket spending in the full sample, a 21.4% decrease in the lowest-income group, an 18.5% decrease in the low-income group, and a 12.8% decrease in the middle-income group.

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Mean premium spending increased in the full sample (12.1%) and the higher-income group (22.9%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80) and in the lowest-income group (OR, 0.80). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28).

“In the first 2 years of implementation, the ACA was associated with a decrease in mean out-of-pocket spending for the overall population, driven by decreases among the lowest- and low-income groups and a reduction in high-burden out-of-pocket spending overall and among the lowest-income group,” the authors said. “Mean premium payments increased moderately, whereas the prevalence of high-burden combined health spending and income-based inequalities in high-burden spending did not change.”


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