Elsevier

Preventive Medicine

Volume 78, September 2015, Pages 85-91
Preventive Medicine

Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States?

https://doi.org/10.1016/j.ypmed.2015.07.012Get rights and content

Highlights

  • Changes were observed following elimination of cost-sharing as part of the ACA.

  • Receipt of blood pressure checks, cholesterol checks and flu vaccination increased

  • The changes were primarily among privately insured non-elderly population.

  • Few changes were observed for cancer screening services.

Abstract

Background

An early provision of the Affordable Care Act (ACA) eliminated cost-sharing for a range of recommended preventive services. This provision took effect in September 2010, but little is known about its effect on preventive service use.

Methods

We evaluated changes in the use of recommended preventive services from 2009 (before the implementation of ACA cost-sharing provision) to 2011/2012 (after the implementation) in the Medical Expenditure Panel Survey, a nationally representative household interview survey in the US. Specifically, we examined: blood pressure check, cholesterol check, flu vaccination, and cervical, breast, and colorectal cancer screening, controlling for demographic characteristics and stratifying by insurance type.

Results

There were 64,280 (21,310 before and 42,970 after the implementation of ACA cost-sharing provision) adults included in the analyses. Receipt of recent blood pressure check, cholesterol check and flu vaccination increased significantly from 2009 to 2011/2012, primarily in the privately insured population aged 18–64 years, with adjusted prevalence ratios (95% confidence intervals) 1.03 (1.01–1.05) for blood pressure check, 1.13 (1.09–1.18) for cholesterol check and 1.04 (1.00–1.08) for flu vaccination (all p-values < 0.05). However, few changes were observed for cancer screening. We observed little change in the uninsured population.

Conclusions

These early observations suggest positive benefits from the ACA policy of eliminating cost-sharing for some preventive services. Future research is warranted to monitor and evaluate longer term effects of the ACA on access to care and health outcomes.

Introduction

Out-of-pocket payments can be a barrier to the use of recommended preventive services (Rezayatmand et al., 2013, Trivedi et al., 2008). Previous studies have shown that reductions in cost-sharing were associated with increased use of preventive services (Goodwin and Anderson, 2012, Guy, 2010, Meeker et al., 2011, Sabatino et al., 2012, Solanki and Schauffler, 1999, Solanki et al., 2000), although these studies were limited by older data or selected study participants with certain insurance types or employers. Few studies evaluated the effects of cost-sharing on use of preventive services in national population-based samples (Rezayatmand et al., 2013). Further, many of these studies only evaluated a few types of preventive services, mostly cancer screening (Rezayatmand et al., 2013).

With a strong emphasis on disease prevention, the Affordable Care Act (ACA) requires non-grandfathered private health plans (i.e. plans effective after the ACA was signed on March 23, 2010 or plans that existed before the ACA but lost its grandfathered status at renewal (Washington State Office of the Insurance Commissioner, 2014)) to provide coverage without cost-sharing for preventive services rated as ‘A’ (strongly recommended) or ‘B’ (recommended) by the US Preventive Services Task Force (USPSTF), for vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP), and services for infants, women, and children recognized by the Health Resources and Services Administration (Fox and Shaw, 2015). This provision took effect for non-grandfathered private health plans starting with plan years beginning after September 23, 2010. Medicare was also required to eliminate cost-sharing starting January 1, 2011 for preventive services recommended by the USPSTF (Fox and Shaw, 2015). By definition, elimination of cost-sharing for recommended preventive services did not affect the uninsured. Thus, the implementation of this ACA provision provides an opportunity to evaluate the association between cost-sharing elimination and utilization of recommended preventive services by type of health insurance, at a national population-based level.

To fill research gaps on the relationship between cost-sharing and preventive service use and to evaluate the early impact of ACA elimination of cost-sharing provision, we analyzed nationally representative survey data and examined changes in use of multiple preventive services and cancer screening services before and after the implementation of the ACA provision. Furthermore, we also examined the heterogeneity in the effects of cost-sharing: if the low income and the sickest population were more likely to adjust health care utilization in response to changes in cost-sharing, as suggested by previous studies (Baicker and Goldman, 2011).

Section snippets

Study sample

The study sample included adults aged ≥ 18 years in the pooled data from 2009 (before the implementation of ACA elimination of cost-sharing for recommended preventive services) and from 2011/12 (after the implementation) Medical Expenditure Panel Survey (MEPS) Household Component. The MEPS is a nationally representative survey of the US civilian non-institutionalized population sponsored by the Agency for Healthcare Research and Quality. The MEPS collects data on health insurance, access to care,

Results

We identified 64,280 (21,310 before and 42,970 after the implementation of ACA cost-sharing provision) adults eligible in the study. The majority of the participants were younger than 65 years old, non-Hispanic white, living in an MSA and privately insured (Table 1). Participants were similar before and after the ACA implementation, except that those from 2009 were slightly younger (56.5% vs. 54.5% less than 50 years old) and had a lower educational level (45.9% vs. 41% did not go to college) (

Discussion

Our findings suggest that the rate of uptake increased for some, but not all, recommended preventive services in which cost-sharing had been eliminated for many health plans during the first 2 years after implementation of the ACA provision. Specifically, we found that after the elimination of cost-sharing requirements began in 2010, the receipt of blood pressure checks, cholesterol checks and flu vaccination significantly increased from 2009 to 2011/2012, primarily among privately insured

Conflict of interest statement

The authors declare that there are no conflicts of interests.

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    Note: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institutes of Health or the Centers for Disease Control and Prevention.

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