"Is It Free?": Out-of-Pocket Costs for Annual Checkups Among the Insured

Preventive services are intended to be provided without cost-sharing under the Affordable Care Act (ACA), yet many patients still incur out-of-pocket (OOP) costs during routine annual checkups where such services are typically delivered. This study examines the prevalence and predictors of OOP payments among insured adults and assesses how both perceived affordability and awareness of ACA preventive care provisions relate to financial experiences and future preventive care intentions. Using original survey data from a statewide sample of 912 insured adults in Pennsylvania who had received an annual checkup within the past 10 years, we found that 23.5% of the sample reported OOP payments for care at their most recent checkup. OOP payments were more common among individuals who perceived healthcare as unaffordable, with an estimated 13 percentage points difference compared to those who viewed care as affordable (p < 0.001). They also paid higher average amounts when they did incur costs. Similarly, ACA policy awareness was also associated with OOP cost exposure. Respondents unaware of ACA protections were 12 percentage points more likely to pay OOP (p < 0.001). Insurance type was strongly associated with the likelihood of payment; compared to respondents with private insurance only, those with Medicaid only, Medicare only, or dual eligibility were significantly less likely to incur out-of-pocket costs. About 13.4% of respondents did not plan to receive or were unsure about receiving a checkup in the coming year. This group had slightly higher prior OOP costs than those planning to continue preventive visits, although the difference was not statistically significant. In a multivariable model, OOP payment experience was not significantly associated with future checkup intention. These findings highlight that even among insured adults, gaps in policy awareness and perceived affordability are associated with OOP costs that may be unexpected to patients. Improved communication about coverage protections and billing practices may help reduce financial barriers and strengthen trust in the healthcare system.