Cambridge Health Alliance, Cambridge, Massachusetts.
Department of Medicine, Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2018 Mar 1;178(3):347-355. doi: 10.1001/jamainternmed.2017.8060.
The Affordable Care Act (ACA) was associated with a reduced number of Americans who reported being unable to afford medical care, but changes in actual health spending by households are not known.
To estimate changes in household spending on health care nationwide after implementation of the ACA.
DESIGN, SETTING, AND PARTICIPANTS: Population-based data from the Medical Expenditure Panel Survey from January 1, 2012, through December 31, 2015, and multivariable regression were used to examine changes in out-of-pocket spending, premium contributions, and total health spending (out-of-pocket plus premiums) after the ACA's coverage expansions on January 1, 2014. The study population included a nationally representative sample of US adults aged 18 to 64 years (n = 83 431). In addition, changes were assessed in the likelihood of exceeding affordability thresholds for each outcome and spending changes for income subgroups defined under the ACA to determine program eligibility at 138% or less, 139% to 250%, 251% to 400%, and greater than 400% of the federal poverty level (FPL).
Implementation of the ACA's major insurance programs on January 1, 2014.
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.
In this nationally representative survey of 83 431 adults (weighted frequency, 49.1% men and 50.9% women; median age, 40.3 years; interquartile range, 28.6-52.4 years), ACA implementation was associated with an 11.9% decrease (95% CI, -17.1% to -6.4%; P < .001) in mean out-of-pocket spending in the full sample, a 21.4% decrease (95% CI, -30.1% to -11.5%; P < .001) in the lowest-income group (≤138% of the FPL), an 18.5% decrease (95% CI, -27.0% to -9.0%; P < .001) in the low-income group (139%-250% of the FPL), and a 12.8% decrease (95% CI, -22.1% to -2.4%; P = .02) in the middle-income group (251%-400% of the FPL). Mean premium spending increased in the full sample (12.1%; 95% CI, 1.9%-23.3%) and the higher-income group (22.9%; 95% CI, 5.5%-43.1%). Combined out-of-pocket plus premium spending decreased in the lowest-income group only (-16.0%; 95% CI, -27.6% to -2.6%). The odds of household out-of-pocket spending exceeding 10% of family income decreased in the full sample (odds ratio [OR], 0.80; 95% CI, 0.70-0.90) and in the lowest-income group (OR, 0.80; 95% CI, 0.67-0.97). The odds of high-burden premium spending increased in the middle-income group (OR, 1.28; 95% CI, 1.03-1.59).
Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending. Repeal or substantial reversal of the ACA would especially harm poor and low-income Americans.
重要性：平价医疗法案（ACA）的实施与报告无法负担医疗费用的美国人数量减少有关，但家庭实际医疗支出的变化尚不清楚。
目的：评估 ACA 实施后全国范围内家庭医疗支出的变化。
设计、地点和参与者：利用 2012 年 1 月 1 日至 2015 年 12 月 31 日期间，基于人群的医疗支出面板调查数据，使用多变量回归，研究了在 2014 年 1 月 1 日 ACA 扩大覆盖范围后，自付支出、保费贡献和总医疗支出（自付加保费）的变化。研究人群包括 83431 名年龄在 18 至 64 岁的美国成年人的全国代表性样本。此外，还评估了每个结果的负担能力阈值超过的可能性以及根据 ACA 定义的收入亚组的支出变化，以确定在联邦贫困线（FPL）的 138%或以下、139%至 250%、251%至 400%和超过 400%的计划资格。
暴露：2014 年 1 月 1 日，ACA 主要保险计划的实施。
主要结果和措施：个人层面自付支出和保费支付的平均值，以及高负担支出的比例，定义为自付支出超过家庭收入的 10%、保费支付超过 9.5%以及自付加保费支付超过 19.5%。
结果：在这项针对 83431 名成年人（加权频率，49.1%男性和 50.9%女性；中位数年龄 40.3 岁；四分位距 28.6-52.4 岁）的全国代表性调查中，ACA 的实施与总样本中自付支出平均减少 11.9%（95%CI，-17.1%至-6.4%；P<0.001）、最低收入组（≤138%的 FPL）减少 21.4%（95%CI，-30.1%至-11.5%；P<0.001）、低收入组（139%-250%的 FPL）减少 18.5%（95%CI，-27.0%至-9.0%；P<0.001）和中等收入组（251%-400%的 FPL）减少 12.8%（95%CI，-22.1%至-2.4%；P=0.02）。总样本中平均保费支出增加（12.1%；95%CI，1.9%-23.3%）和高收入组增加（22.9%；95%CI，5.5%-43.1%）。仅在最低收入组中，自付加保费支出减少（-16.0%；95%CI，-27.6%至-2.6%）。家庭自付支出超过家庭收入 10%的可能性在总样本（比值比[OR]，0.80；95%CI，0.70-0.90）和最低收入组（OR，0.80；95%CI，0.67-0.97）中降低。高负担保费支出的可能性在中等收入组中增加（OR，1.28；95%CI，1.03-1.59）。
结论和相关性：ACA 的实施与自付支出减少相关，特别是对低收入人群。然而，许多这些人仍然面临高负担的自付和保费支出。ACA 的废除或大幅逆转将特别伤害贫困和低收入的美国人。
