Insulin Out‐of‐Pocket Spending Caps and Employer‐Sponsored Insurance: Changes in Out‐of‐Pocket and Total Costs for Insulin and Healthcare
ABSTRACT Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance. Study Setting and Design We evaluated changes in costs using a quasi‐experimental (triple dif...
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| Vydáno v: | Health services research Ročník 60; číslo 6; s. e14656 - n/a |
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| Hlavní autoři: | , , , , |
| Médium: | Journal Article |
| Jazyk: | angličtina |
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Oxford, UK
Blackwell Publishing Ltd
01.12.2025
Health Research and Educational Trust |
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| ISSN: | 0017-9124, 1475-6773, 1475-6773 |
| On-line přístup: | Získat plný text |
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| Abstract | ABSTRACT
Objective
To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance.
Study Setting and Design
We evaluated changes in costs using a quasi‐experimental (triple difference‐in‐differences; “DDD”) design to analyze multi‐carrier claims from insulin users enrolled in fully insured (state‐regulated) and self‐funded (generally exempt) employer‐sponsored plans in 10 states with caps by January 2021 compared to no‐cap states pre‐/post‐cap implementation. Primary outcomes were changes in insulin out‐of‐pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out‐of‐pocket and total costs.
Data Sources and Analytic Sample
In the policy year (no‐cap states: 2021), we identified 218,441 insulin‐users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self‐funded plans; no‐cap states: 97,239 in fully insured and 71,237 in self‐funded plans) and 215,635 in the year prior.
Principal Findings
We found evidence of modest decreases in 30‐day standardized (DDD: −$5 [95% CI: −$6 to −$4]; p < 0.001) and annual (DDD: −$67 [95% CI: −$82 to −$51]; p < 0.001) insulin out‐of‐pocket spending. Savings increased by spending quantile (e.g., 95th‐percentile change:−$347 [95% CI: −$460 to $233]). Difference‐in‐differences (DiD) comparing fully insured to self‐funded plans within cap‐states showed larger changes (e.g., 95th‐percentile annual insulin out‐of‐pocket:−$484 [95% CI: −$651 to −$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out‐of‐pocket in no‐cap states). Change in annual total paid for healthcare was not statistically significant (DDD:‐$1082 [95% CI: −$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out‐of‐pocket or total spending on insulin, prescriptions, or healthcare.
Conclusions
Our findings suggest early caps had modest effects on out‐of‐pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. |
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| AbstractList | To estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin users with employer-sponsored insurance.OBJECTIVETo estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin users with employer-sponsored insurance.We evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier claims from insulin users enrolled in fully insured (state-regulated) and self-funded (generally exempt) employer-sponsored plans in 10 states with caps by January 2021 compared to no-cap states pre-/post-cap implementation. Primary outcomes were changes in insulin out-of-pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out-of-pocket and total costs.STUDY SETTING AND DESIGNWe evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier claims from insulin users enrolled in fully insured (state-regulated) and self-funded (generally exempt) employer-sponsored plans in 10 states with caps by January 2021 compared to no-cap states pre-/post-cap implementation. Primary outcomes were changes in insulin out-of-pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out-of-pocket and total costs.In the policy year (no-cap states: 2021), we identified 218,441 insulin-users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self-funded plans; no-cap states: 97,239 in fully insured and 71,237 in self-funded plans) and 215,635 in the year prior.DATA SOURCES AND ANALYTIC SAMPLEIn the policy year (no-cap states: 2021), we identified 218,441 insulin-users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self-funded plans; no-cap states: 97,239 in fully insured and 71,237 in self-funded plans) and 215,635 in the year prior.We found evidence of modest decreases in 30-day standardized (DDD: -$5 [95% CI: -$6 to -$4]; p < 0.001) and annual (DDD: -$67 [95% CI: -$82 to -$51]; p < 0.001) insulin out-of-pocket spending. Savings increased by spending quantile (e.g., 95th-percentile change:-$347 [95% CI: -$460 to $233]). Difference-in-differences (DiD) comparing fully insured to self-funded plans within cap-states showed larger changes (e.g., 95th-percentile annual insulin out-of-pocket:-$484 [95% CI: -$651 to -$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out-of-pocket in no-cap states). Change in annual total paid for healthcare was not statistically significant (DDD:-$1082 [95% CI: -$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out-of-pocket or total spending on insulin, prescriptions, or healthcare.PRINCIPAL FINDINGSWe found evidence of modest decreases in 30-day standardized (DDD: -$5 [95% CI: -$6 to -$4]; p < 0.001) and annual (DDD: -$67 [95% CI: -$82 to -$51]; p < 0.001) insulin out-of-pocket spending. Savings increased by spending quantile (e.g., 95th-percentile change:-$347 [95% CI: -$460 to $233]). Difference-in-differences (DiD) comparing fully insured to self-funded plans within cap-states showed larger changes (e.g., 95th-percentile annual insulin out-of-pocket:-$484 [95% CI: -$651 to -$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out-of-pocket in no-cap states). Change in annual total paid for healthcare was not statistically significant (DDD:-$1082 [95% CI: -$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out-of-pocket or total spending on insulin, prescriptions, or healthcare.Our findings suggest early caps had modest effects on out-of-pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time.CONCLUSIONSOur findings suggest early caps had modest effects on out-of-pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. Study Setting and Design: We evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier claims from insulin users enrolled in fully insured (state-regulated) and self-funded (generally exempt) employer-sponsored plans in 10 states with caps by January 2021 compared to no-cap states pre-/post-cap implementation. Primary outcomes were changes in insulin out-of-pocket spending, total (plan + member) paid for insulin. and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out-of-pocket and total costs. Principal Findings: We found evidence of modest decreases in 30-day standardized (DDD: - $5 [95% CI: -$ 6 to - $4]; p < 0.001) and annual (DDD: -$ 67 [95% CI: - $82 to -$ 51]; p < 0.001) insulin out-of-pocket spending. Savings increased by spending quantile (e.g., 95th-percentile change:- $347 [95% CI: -$ 460 to$233]). Difference-in-differences (DiD) comparing fully insured to self-funded plans within cap-states showed larger changes (e.g., 95th-percentile annual insulin out-of-pocket:-$ 484 [95% CI: - $651 to -$ 318]), likely due to policy spillover effects (i.e., fully insured plans decreased out-of-pocket in no-cap states). Change in annual total paid for healthcare was not statistically significant (DDD:- $1082 [95% CI: -$ 2918 to $755]; p < 0.25). We saw no evidence of caps increasing out-of-pocket or total spending on insulin. prescriptions, or healthcare. Objective: To estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin users with employer-sponsored insurance. Study Setting and Design: We evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier claims from insulin users enrolled in fully insured (state-regulated) and self-funded (generally exempt) employer-sponsored plans in 10 states with caps by January 2021 compared to no-cap states pre-/post-cap implementation. Primary outcomes were changes in insulin out-of-pocket spending, total (plan + member) paid for insulin. and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out-of-pocket and total costs. Data Sources and Analytic Sample: In the policy year (no-cap states: 2021), we identified 218,441 insulin-users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self-funded plans; no-cap states: 97,239 in fully insured and 71,237 in self-funded plans) and 215,635 in the year prior. Principal Findings: We found evidence of modest decreases in 30-day standardized (DDD: -$5 [95% CI: -$6 to -$4]; p < 0.001) and annual (DDD: -$67 [95% CI: -$82 to -$51]; p < 0.001) insulin out-of-pocket spending. Savings increased by spending quantile (e.g., 95th-percentile change:-$347 [95% CI: -$460 to $233]). Difference-in-differences (DiD) comparing fully insured to self-funded plans within cap-states showed larger changes (e.g., 95th-percentile annual insulin out-of-pocket:-$484 [95% CI: -$651 to -$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out-of-pocket in no-cap states). Change in annual total paid for healthcare was not statistically significant (DDD:-$1082 [95% CI: -$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out-of-pocket or total spending on insulin. prescriptions, or healthcare. Conclusions: Our findings suggest early caps had modest effects on out-of-pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. Keywords: cost-related nonadherence | employer-sponsored health insurance | insulin cost-sharing caps | insulin out-of-pocket caps I value-based insurance design Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance. Study Setting and Design We evaluated changes in costs using a quasi‐experimental (triple difference‐in‐differences; “DDD”) design to analyze multi‐carrier claims from insulin users enrolled in fully insured (state‐regulated) and self‐funded (generally exempt) employer‐sponsored plans in 10 states with caps by January 2021 compared to no‐cap states pre‐/post‐cap implementation. Primary outcomes were changes in insulin out‐of‐pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out‐of‐pocket and total costs. Data Sources and Analytic Sample In the policy year (no‐cap states: 2021), we identified 218,441 insulin‐users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self‐funded plans; no‐cap states: 97,239 in fully insured and 71,237 in self‐funded plans) and 215,635 in the year prior. Principal Findings We found evidence of modest decreases in 30‐day standardized (DDD: −$5 [95% CI: −$6 to −$4]; p < 0.001) and annual (DDD: −$67 [95% CI: −$82 to −$51]; p < 0.001) insulin out‐of‐pocket spending. Savings increased by spending quantile (e.g., 95th‐percentile change:−$347 [95% CI: −$460 to $233]). Difference‐in‐differences (DiD) comparing fully insured to self‐funded plans within cap‐states showed larger changes (e.g., 95th‐percentile annual insulin out‐of‐pocket:−$484 [95% CI: −$651 to −$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out‐of‐pocket in no‐cap states). Change in annual total paid for healthcare was not statistically significant (DDD:‐$1082 [95% CI: −$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out‐of‐pocket or total spending on insulin, prescriptions, or healthcare. Conclusions Our findings suggest early caps had modest effects on out‐of‐pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. To estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin users with employer-sponsored insurance. We evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier claims from insulin users enrolled in fully insured (state-regulated) and self-funded (generally exempt) employer-sponsored plans in 10 states with caps by January 2021 compared to no-cap states pre-/post-cap implementation. Primary outcomes were changes in insulin out-of-pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out-of-pocket and total costs. In the policy year (no-cap states: 2021), we identified 218,441 insulin-users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self-funded plans; no-cap states: 97,239 in fully insured and 71,237 in self-funded plans) and 215,635 in the year prior. We found evidence of modest decreases in 30-day standardized (DDD: -$5 [95% CI: -$6 to -$4]; p < 0.001) and annual (DDD: -$67 [95% CI: -$82 to -$51]; p < 0.001) insulin out-of-pocket spending. Savings increased by spending quantile (e.g., 95th-percentile change:-$347 [95% CI: -$460 to $233]). Difference-in-differences (DiD) comparing fully insured to self-funded plans within cap-states showed larger changes (e.g., 95th-percentile annual insulin out-of-pocket:-$484 [95% CI: -$651 to -$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out-of-pocket in no-cap states). Change in annual total paid for healthcare was not statistically significant (DDD:-$1082 [95% CI: -$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out-of-pocket or total spending on insulin, prescriptions, or healthcare. Our findings suggest early caps had modest effects on out-of-pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. ABSTRACT Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin users with employer‐sponsored insurance. Study Setting and Design We evaluated changes in costs using a quasi‐experimental (triple difference‐in‐differences; “DDD”) design to analyze multi‐carrier claims from insulin users enrolled in fully insured (state‐regulated) and self‐funded (generally exempt) employer‐sponsored plans in 10 states with caps by January 2021 compared to no‐cap states pre‐/post‐cap implementation. Primary outcomes were changes in insulin out‐of‐pocket spending, total (plan + member) paid for insulin, and total healthcare costs. Secondary outcomes were intermediary (e.g., pharmaceutical) changes in out‐of‐pocket and total costs. Data Sources and Analytic Sample In the policy year (no‐cap states: 2021), we identified 218,441 insulin‐users in the Health Care Cost Institute 2.0 Dataset (cap states: 27,834 in fully insured and 22,131 in self‐funded plans; no‐cap states: 97,239 in fully insured and 71,237 in self‐funded plans) and 215,635 in the year prior. Principal Findings We found evidence of modest decreases in 30‐day standardized (DDD: −$5 [95% CI: −$6 to −$4]; p < 0.001) and annual (DDD: −$67 [95% CI: −$82 to −$51]; p < 0.001) insulin out‐of‐pocket spending. Savings increased by spending quantile (e.g., 95th‐percentile change:−$347 [95% CI: −$460 to $233]). Difference‐in‐differences (DiD) comparing fully insured to self‐funded plans within cap‐states showed larger changes (e.g., 95th‐percentile annual insulin out‐of‐pocket:−$484 [95% CI: −$651 to −$318]), likely due to policy spillover effects (i.e., fully insured plans decreased out‐of‐pocket in no‐cap states). Change in annual total paid for healthcare was not statistically significant (DDD:‐$1082 [95% CI: −$2918 to $755]; p < 0.25). We saw no evidence of caps increasing out‐of‐pocket or total spending on insulin, prescriptions, or healthcare. Conclusions Our findings suggest early caps had modest effects on out‐of‐pocket spending among fully insured insulin users, with larger savings for those at the top of the spending distribution and no total cost increases. Policy effects may be greater than observed; they likely lag implementation and develop over time. |
| Audience | Trade |
| Author | Baig, Khrysta A. Buntin, Melinda B. Dusetzina, Stacie B. Fry, Carrie E. Powers, Alvin C. |
| Author_xml | – sequence: 1 givenname: Khrysta A. orcidid: 0000-0002-2318-2308 surname: Baig fullname: Baig, Khrysta A. email: khrysta.baig@vanderbilt.edu organization: Vanderbilt University – sequence: 2 givenname: Carrie E. orcidid: 0000-0003-0661-847X surname: Fry fullname: Fry, Carrie E. organization: Vanderbilt University Medical Center – sequence: 3 givenname: Melinda B. surname: Buntin fullname: Buntin, Melinda B. organization: Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Carey Business School – sequence: 4 givenname: Alvin C. surname: Powers fullname: Powers, Alvin C. organization: VA Tennessee Valley Healthcare System – sequence: 5 givenname: Stacie B. surname: Dusetzina fullname: Dusetzina, Stacie B. organization: Vanderbilt University Medical Center |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/40528151$$D View this record in MEDLINE/PubMed |
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| Keywords | employer‐sponsored health insurance cost‐related nonadherence value‐based insurance design insulin out‐of‐pocket caps insulin cost‐sharing caps |
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| Notes | Funding This work was partially supported by the Commonwealth Fund (Dr. Dusetzina's time); Arnold Ventures (Dr. Dusetzina's time); the National Institute of Diabetes and Digestive and Kidney Diseases, DK020593 (Dr. Powers' time); Dr. Powers is a member of the Vanderbilt Diabetes Research and Training Center. ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 14 content type line 23 |
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| References | 2023; 20 2022; 175 2021; 4 2023; 11 2021; 2 2023 2021; 398 2010; 39 2024; 7 2023; 388 2023; 330 2024; 30 2022; 47 2024; 43 2018; 41 2022; 41 2024; 331 2024; 177 2023; 329 2024 2024; 47 2022; 28 e_1_2_15_19_1 e_1_2_15_20_1 e_1_2_15_43_1 e_1_2_15_21_1 e_1_2_15_42_1 e_1_2_15_41_1 e_1_2_15_40_1 e_1_2_15_3_1 e_1_2_15_28_1 e_1_2_15_2_1 e_1_2_15_29_1 e_1_2_15_26_1 e_1_2_15_27_1 e_1_2_15_24_1 e_1_2_15_47_1 e_1_2_15_25_1 e_1_2_15_46_1 e_1_2_15_22_1 e_1_2_15_45_1 e_1_2_15_23_1 e_1_2_15_44_1 e_1_2_15_9_1 e_1_2_15_8_1 e_1_2_15_7_1 e_1_2_15_6_1 e_1_2_15_5_1 e_1_2_15_4_1 e_1_2_15_32_1 e_1_2_15_10_1 e_1_2_15_31_1 e_1_2_15_30_1 Adetunji O. (e_1_2_15_39_1) 2024 e_1_2_15_17_1 e_1_2_15_18_1 e_1_2_15_15_1 e_1_2_15_38_1 e_1_2_15_16_1 e_1_2_15_37_1 e_1_2_15_13_1 e_1_2_15_36_1 e_1_2_15_14_1 e_1_2_15_35_1 e_1_2_15_11_1 e_1_2_15_34_1 e_1_2_15_12_1 e_1_2_15_33_1 |
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Objective
To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for... To estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin users with... Study Setting and Design: We evaluated changes in costs using a quasi-experimental (triple difference-in-differences; "DDD") design to analyze multi-carrier... Objective: To estimate the impact of state-level insulin out-of-pocket caps on changes in out-of-pocket and total costs of insulin and healthcare for insulin... Objective To estimate the impact of state‐level insulin out‐of‐pocket caps on changes in out‐of‐pocket and total costs of insulin and healthcare for insulin... |
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| SubjectTerms | Adult Changes Clinical outcomes Comparative analysis Corporate sponsorship Cost control Costs cost‐related nonadherence Economic aspects Employers employer‐sponsored health insurance Female Health Benefit Plans, Employee - economics Health Benefit Plans, Employee - statistics & numerical data Health care Health care costs Health Care Costs - statistics & numerical data Health care expenditures Health Expenditures - statistics & numerical data Health insurance Health insurance industry Health services Humans Hypoglycemic Agents - economics Hypoglycemic Agents - therapeutic use Insulin Insulin - economics Insulin - therapeutic use insulin cost‐sharing caps insulin out‐of‐pocket caps Insurance Male Medical care, Cost of Middle Aged Prescription drugs Savings Statistical analysis United States value‐based insurance design |
| Title | Insulin Out‐of‐Pocket Spending Caps and Employer‐Sponsored Insurance: Changes in Out‐of‐Pocket and Total Costs for Insulin and Healthcare |
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