How Has the ACA Affected Populations at Risk for High Health Spending?

An analysis of prescription drug spending among stable prescription drug users, including a subsample with major chronic conditions, before and after implementation of the Affordable Care Act (ACA), showed there was a 30% reduction in the proportion of the population that was uninsured in 2014 compared with 2013.

That change allowed previously uninsured people who gained private coverage to fill, on average, 28% more prescriptions with 29% less out-of-pocket spending per prescription in 2014 compared with 2013. The individuals who gained Medicaid coverage had larger increases in fill rates (79%) and reductions in out-of-pocket spending per prescriptions (58%), and those who gained coverage who had at least 1 chronic condition followed in the study had larger decreases in out-of-pocket spending compared with those who did not have at least 1 condition. The study, by Andrew W. Mulcahy, of the RAND Corporation, and colleagues, was published in Health Affairs.

The researchers studied prescription drug transaction data, tracking changes in coverage and prescription drug use and spending, in a sample of 6.7 million people with at least some prescription use prior to ACA coverage expansion. Of the 6.7 million users, nearly two-thirds (4.2 million) had significant chronic conditions including diabetes, depression, asthma, or chronic obstructive pulmonary disease, breast cancer, and hyperlipidemia.

The study compared changes in coverage, usage, and spending before and after the January 1, 2014, coverage expansion implementation date of the ACA. The data came from IMS Health’s Integrated Data Warehouse, which are aggregated from a large sample of primarily retail pharmacies and claims processors. It is estimated that the data tracked by IMS Health captures 53% of prescription transactions in the United States annually, with geographic coverage ranging from 35% to 89% across states.

The investigators recorded the specific drugs filled by the patients from January 2012 through December 2014; dates of service; and whether all, some, or none of the cost was paid by health insurance. The data offers a useful window into changes in coverage, use, and spending for an important population of people who take prescription drugs, including patients with chronic conditions, who are likely to regularly fill prescriptions, they said.

The drop in the uninsurance rate (net 30.4% from 2013 to 2014) among prescription drug users was similar across age and sex categories. The uninsurance rate dropped by 29.5% for people with prescriptions for at least 1 of the 5 study chronic conditions. People without one of these conditions saw a similar relative decline in the uninsurance rate (31.0%) but from a higher level of uninsurance. States that opted to expand Medicaid by early 2014 had significantly larger declines in uninsurance rates (39.1%) compared with states that did not (22.6%).

The authors say their results corroborate previous survey-based analyses suggesting that millions of Americans gained health insurance as a result of ACA coverage expansion.

“By reducing financial barriers to care, the ACA has increased treatment rates while reducing out-of-pocket spending, particularly for people with chronic conditions,” they concluded.