How the Affordable Care Act impacted families’ health care costs


The Affordable Care Act was meant to reduce the financial burden of receiving health care. A report examines whether the legislation helped families mitigate their health care costs.

One of the intents of the Affordable Care Act legislation was to help alleviate the financial burden placed on families because of health care. A report in JAMA Pediatrics offers some insight into whether the legislation had the intended effect.1

Researchers ran a cohort study that used data from the Medical Expenditure Panel Survey, which is a nationally representative, population-based survey. The changes in family financial burden were examined using multivariable regression with a difference-in-differences estimator. The income groups were (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The main outcomes were family annual out-of-pocket health care and premium cost relative to the familial income. Burdensome premiums were considered to be those that exceeded 9.5% of income and extreme out-of-pocket burden was classified as costs that were more than 10% of income.

When compared with high-income families who saw a lesser change following the implementation of the Affordable Care Act (high out-of-pocket burden, 1.1% pre-Affordable Care Act vs 0.9% post-Affordable Care Act), families with the lowest income had the greatest reduction in high out-of-pocket burden (35.6% before implementation vs 23.7% after implementation difference-in-differences: −11.4%; 95% CI, −13.2% to −9.5%). Low-income families saw a reduction (24.6% pre-implementation vs 17.3% post-implementation, difference-in-differences: −6.8%; 95% CI, −8.7% to −4.9%) and even middle-income families saw a reduction (6.1% before implementation vs 4.6% following implementation, difference-in-differences: −1.2%; 95% CI, −2.3% to −0.01%). Premiums rose for all groups, but the affordability was not as exacerbated among the lowest, low, and middle-income families when compared to the high-income families.

The investigators concluded that the findings indicated that low and middle-income families with children who were eligible for Medicaid because of an expansion or received Marketplace subsidies saw greater reductions in the financial burden linked with health care. However, a number of families still have to deal with expensive premiums and high out-of-pocket costs.


1. Wisk L, Peltz A, Galbraith A. Changes in health care–related financial burden for US families with children associated with the affordable care act. JAMA Pediatr. September 28, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.3973

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