Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States?☆
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.
References (37)
- et al.
A slow start: use of preventive services among seniors following the Affordable Care Act's enhancement of Medicare benefits in the U.S.
Prev. Med.
(2015) - et al.
Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services
Am. J. Prev. Med.
(2012) - et al.
Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women
Prev. Med.
(2003) - et al.
Cost-sharing and the utilization of clinical preventive services
Am. J. Prev. Med.
(1999) MEPS-HC-155 2012 Full Year Consolidate Data File Documentation Rockville, MD
(2014)Table 1: Usual Source of Health Care and Selected Population Characteristics, United States, 2011
Medical Expenditure Panel Survey Household Component Data. Generated Interactively
(2014)- et al.
Patient cost-sharing and healthcare spending growth
J. Econ. Perspect.
(2011) - et al.
The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults
Ann. Fam. Med.
(2009) - et al.
Estimating model-adjusted risks, risk differences, and risk ratios from complex survey data
Am. J. Epidemiol.
(2010) - et al.
ASPE Issue Brief: Increased Coverage of Preventive Services With Zero Cost Sharing Under the Affordable Care Act
(2014)
Health care worker beliefs about influenza vaccine and reasons for non-vaccination—a cross-sectional survey
J. Clin. Nurs.
Misconceptions About Seasonal Flu and Flu Vaccines
The Center for Consumer Information & Insurance Oversight. Affordable Care Act Implementation FAQs—Set 12
Socio-economic status and prevention of cardiovascular disease in Italy: evidence from a national health survey
Eur. J. Pub. Health
Clinical preventive services coverage and the Affordable Care Act
Am. J. Public Health
Effect of cost-sharing reductions on preventive service use among Medicare fee-for-service beneficiaries
Medicare Medicaid Res. Rev.
Navigating the murky waters of colorectal cancer screening and health reform
Am. J. Public Health
Americans' Attitudes Toward the Affordable Care Act: Would Better Public Understanding Increase or Decrease Favorability?
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2021, Preventive MedicineCitation Excerpt :We do observe that preventive service claims are significantly more likely to occur with an out-of-network provider for those living in rural areas (5.3% in rural areas compared to 2.4% in urban areas; p < 0.001). Adherence to recommended schedules for prevention varies widely by both service category and patient demographics (Vaidya et al., 2012), although there is evidence of improvement following the implementation of the ACA (Agirdas and Holding, 2018; Han et al., 2015). Our estimates suggest that although substantial progress has been made, about 1 in 7 preventive services results in OOP costs, affecting about 1 in 4 patients with ESI a decade after the ACA supposedly made these services free.
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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.