Out-of-Pocket Spending Under the Affordable Care Act for Patients With Cancer

Abstract

The Patient Protection and Affordable Care Act (ACA) included several key provisions aimed at lowering the out-of-pocket cost burden for patients. In this review, we summarize the effect of 3 provisions under Medicaid, Medicare, and commercial insurance, respectively: expansion of Medicaid eligibility, closing the doughnut hole for Medicare Part D beneficiaries, and requiring an annual limit on out-of-pocket spending for commercially insured patients. Through this review, we find early evidence that these 3 ACA provisions have reduced the out-of-pocket burden or increased access to health insurance for many patients. Proposals to repeal and replace the ACA should consider retaining some of these important features that limit financial exposure for patients. At the same time, we have highlighted some important gaps left by the ACA that could be targeted by replacement plans. Addressing these issues may help to increase access to care and affordability for patients with cancer and without.

FIGURE 1.

Comparison of Medicaid coverage in expansion and nonexpansion states using the median Medicaid eligibility limits for nonexpansion states in 2016.

FIGURE 2.

Medicare Part D standard benefit design, 2010 and 2020. *Plan pays 75% of generic drug price.

FIGURE 3.

Patient out-of-pocket drug costs required to reach catastrophic coverage phase, 2010–2017. *Out-of-pocket costs in the initial coverage phase assume a 25% coinsurance.

FIGURE 4.

Cost sharing for branded and generic products in the Medicare Part D coverage gap, 2010–2020.