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

## TL;DR

Patients with chronic conditions in the US face higher out-of-pocket costs for preventive care despite ACA exemptions, suggesting a need for better enforcement of cost-sharing rules.

## Contribution

This study is the first to assess how gaps in ACA cost-sharing exemptions affect patients with chronic conditions, revealing significant disparities in preventive care costs.

## Key findings

- Patients with chronic conditions had a 19.20% higher likelihood of cost-sharing for preventive services.
- Expected out-of-pocket spending for preventive care was 20.69% greater for patients with chronic conditions.
- Standardizing insurer practices could reduce financial burdens and disparities in preventive care access.

## Abstract

Are patients with chronic conditions equally protected from out-of-pocket (OOP) costs for preventive care under the cost-sharing exemptions mandated by the Patient Protection and Affordable Care Act’s (ACA)?

In this propensity score–matched cohort study of more than 1 million privately insured US patients, those with ambulatory care–sensitive conditions had a 19.20% higher likelihood of cost-sharing for preventive services and 20.69% greater expected OOP spending compared with patients without any chronic conditions.

Patients with chronic conditions faced increased preventive care costs, implying that improved compliance with ACA cost-sharing exemptions may reduce financial burdens and disparities in preventive care access.

This cohort study examines the relative incidence, magnitude, and determinants of cost-sharing for preventive care among individuals with chronic conditions compared with individuals without such conditions.

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.

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.

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.

Presence of ambulatory care–sensitive conditions (ACSCs) compared with no chronic conditions.

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.

A total of 1 262 414 patients (800 693 female patients [63.42%]; mean [SD] age at the time of visit, 54.46 [12.40] years) received 5 236 253 preventive services over 1 984 354 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 < .001). Propensity score–matched models found that individuals with ACSCs had a 19.20% increase (95% CI, 18.87%-19.18%; P < .001) in the probability of facing OOP costs for preventive care, and a 20.69% (95% CI, 19.19%-20.91%; P < .001) increase in expected preventive OOP costs overall.

These findings suggest that patients with chronic conditions were more likely to experience cost-sharing for preventive care and had greater expected spending overall. Standardizing insurer practices regarding cost-sharing exemptions can improve equitable access to high-value preventive care.