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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Veröffentlicht in:Health services research Jg. 60; H. 6; S. e14656 - n/a
Hauptverfasser: Baig, Khrysta A., Fry, Carrie E., Buntin, Melinda B., Powers, Alvin C., Dusetzina, Stacie B.
Format: Journal Article
Sprache:Englisch
Veröffentlicht: Oxford, UK Blackwell Publishing Ltd 01.12.2025
Health Research and Educational Trust
Schlagworte:
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
United States
employer‐sponsored health insurance
cost‐related nonadherence
value‐based insurance design
insulin out‐of‐pocket caps
insulin cost‐sharing caps
ISSN:0017-9124, 1475-6773, 1475-6773
Online-Zugang:Volltext
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Zusammenfassung: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.
Bibliographie: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.
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ISSN:0017-9124
1475-6773
1475-6773
DOI:10.1111/1475-6773.14656