Cost Barriers to Health Services in U.S. Adults Before and After the Implementation of the Affordable Care Act

Background: The Affordable Care Act (ACA) was passed in 2010 and implemented in 2014 in the United States (U.S.). It was partly intended to reduce the cost burden to health coverage and care. Objective: To determine if ACA implementation reduced the odds of experiencing cost barriers to needed healthcare services for vulnerable groups. Methodology: National Health Interview Survey Data from the Integrated Public Use Microdata Set (2011-2013; 2015-2017) were used to examine cost barriers to primary health, mental health, dental services, and prescription medications particularly for adults living in poverty, those of color, and unmarried individuals before and after implementation of the ACA. The study sample included 112,245 individuals, representing an annual average of 138 million adults (aged 26 to 64 years of age), including 59,367 survey respondents from 2011 to 2013 and 52,878 from 2015 to 2017. Results: Pre/post-ACA, cost barriers to medical care decreased from 9.6% to 7.0% of adults, mental care from 3.0% to 2.4%, dental care 15.0 to 11.7%, and prescriptions from 9.9% to 7.0% (all comparisons p<.001). Survey design-adjusted regression results indicated significant decreases in the odds of experiencing cost barriers to physical, mental, dental health services and prescription medications after the implementation of the ACA for people living under 200% poverty, unmarried adults, and people of color. While the race was not a substantial barrier post-ACA, living in poverty and being unmarried remained the biggest predictors of cost barriers to services. Cost barriers for all services increased post ACA for adults with private coverage, and among older adults for prescription and dental services. Conclusions: While the ACA was largely successful in reducing the number of uninsured adults in the U.S., remaining barriers suggest the need to strengthen the ACA and reduce cost barriers to healthcare services for everyone.