Analyzing Financial Risk Protections, Insurance Coverage Under ACA

Since it passed and was implemented 10 years ago, the Patient Protection and Affordable Care Act (ACA) has increased insurance coverage for millions of Americans; however, affordability is still a top concern for consumers and health care professionals.

Charles Liu, MD, MS, department of surgery, Stanford University School of Medicine, Stanford, CA, and colleagues, coauthored a JAMA Network Open letter in which they analyzed changes in financial risk protection associated with ACA implementation across all income strata and insurance types.

Using income, insurance coverage, and spending data from a nationally representative Medical Expenditure Panel Survey, the authors examined a sample of adults aged 20 to 64 years from 2010 through 2017. They focused on catastrophic health expenditures—which the World Health Organization defines as the threshold of calendar-year out-of-pocket plus premium spending exceeding 40% of post-subsistence income.

“We identified 159,941 survey respondents (49.1% men; mean age, 41.8 years [SD, 12.6 years]), representing 186 million individuals annually after survey weighting. The number of uninsured nonelderly adults declined from 42.9 million (23.5%) in 2010 to 27.9 million (14.8%) in 2017, whereas those with Medicaid coverage increased from 11.0 million (6.0%) to 18.3 million (9.7%) (P<.001),” explained the authors.

As for catastrophic expenditures, data show a decrease from 13.6 million (7.4%) in 2010 to 11.2 million (5.9%) in 2017. Individuals with private insurance comprised 46.4% of catastrophic expenditure cases in 2019 vs 53.6% in 2017.

“Financial protection improved for the lowest income quartile, which was one of the ACA’s principal aims,” said the authors. “However, improvements were not observed in higher income quartiles or among the privately insured, who represent an increasing share of those experiencing catastrophic expenditures.”

Under the ACA, millions of Americans gained health insurance but the data shows that 11 million US adults, including 6 million with private insurance still experience catastrophic health expenditures annually.

“These figures are likely to increase as millions lose employment or require unexpected medical care because of coronavirus disease 2019,” concluded the authors. “Health reform should move beyond expanding insurance coverage alone to address persistently high out-of-pocket spending among the insured.” —Edan Stanley