Role of Chronic Conditions in Out-of-Pocket Costs for Preventive Care in the US

Abstract

Importance: The Patient Protection and Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services with no patient cost-sharing, but patients covered by these provisions still incur out-of-pocket (OOP) costs for which they should be exempt. To date, no work has assessed how gaps in enforcing the ACA's cost-sharing exemption affect patients with chronic conditions, who have higher OOP costs overall, which increases the financial burden from their health care. Objective: To determine the relative incidence, magnitude, and determinants of cost-sharing for preventive care among individuals with chronic conditions compared with individuals without such conditions. Design, Setting, and Participants: This cohort study used propensity score matching of patients insured through their employers or the ACA Marketplaces, using claims and remittance data from Symphony Health Solutions' Integrated DataVerse from 2017 to 2020. Analysis was completed between November 2024 and November 2025. Exposure: Presence of ambulatory care-sensitive conditions (ACSCs) compared with no chronic conditions. Main Outcomes and Measures: Primary outcomes included the incidence and amount of costs levied for preventive care. Secondary outcomes included the incidence of cost-sharing for preventive care specifically due to service code misclassification and visit complexity. Results: A total of 1262414 patients (800693 female patients [63.42%]; mean [SD] age at the time of visit, 54.46 [12.40] years) received 5236253 preventive services over 1984354 unique visits. The likelihood of a preventive service resulting in cost-sharing was significantly greater among patients with ACSCs compared with those without ACSCs (17.91% [95% CI, 17.69%-17.95%] vs 15.64% [95% CI, 15.69%-15.95%]; P