While the Patient Protection and Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services with no consumer cost-sharing, out-of-pocket (OOP) costs for which they should be exempt are still incurred, according to a recent study.
Gaps in enforcing the cost-sharing exemption particularly affect those with chronic conditions, who pay higher OOP costs overall. Those with chronic conditions were more likely to experience cost-sharing for preventive care and had greater expected spending overall. Reasons could include incorrect coding of medical care.
“Patients with diabetes may be more likely to have their wellness visits coded as a maintenance visit for diabetes care, resulting in inadvertent cost-sharing even for purely preventive services,” the researchers wrote. “Standardizing insurer practices regarding cost-sharing exemptions can improve equitable access to high-value preventive care. Incorrectly classifying a preventive visit as an office visit or billing for more complex services than were actually rendered may lead to differences in cost-sharing for patients with chronic conditions compared with those without.”
Researchers analyzed claims and payment data from Symphony Health Solutions’ Integrated DataVerse that were collected from 2017 to 2020 for consumers who presented with insurance through an employer or the ACA Marketplaces. The goal was to determine the incidence, magnitude, and determinants of cost-sharing for preventive care among individuals with and without chronic health conditions.
Those with ambulatory care-sensitive conditions (ACSC) had a 19.20% higher likelihood of cost-sharing for preventive services and 20.69% greater expected OOP spending compared with consumers without any chronic conditions. ACSCs are typically defined as chronic conditions that respond to timely and effective outpatient care.
Chronic conditions represented the leading cause of mortality in 2022, with combined direct and indirect costs in the U.S. estimated at $3.7 trillion annually, the researchers wrote. Preventive care plays a critical role in early detection and improved management of chronic conditions.
“This cost-sharing exemption is one of the most popular provisions of the ACA. The Supreme Court recently upheld its constitutionality, ensuring continued access to free preventive care and reinforcing the policy relevance of our findings,” the researchers wrote.
These findings were reported in Role of Chronic Conditions in Out-of-Pocket Costs for Preventive Care in the US by Allan Tran, MSc; Audrey Laporte, Ph.D.; Eric Nauenberg, Ph.D.; and colleagues.
The full text of Role of Chronic Conditions in Out-of-Pocket Costs for Preventive Care in the U.S. was published on January 8, 2026, by JAMA Network Open. A free copy is available (accessed January 14, 2026).
For more information, contact: Alex Hoagland, Ph.D., Professor, Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Suite 440, Toronto, Ontario Canada; M5T 3M6; Email: alexander.hoagland@utoronto.ca; Website: https://ihpme.utoronto.ca/faculty-profile/alex-hoagland/
March 2026 00US26EUA0004