Prescription drug affordability remains a persistent challenge for U.S. patients despite insurance coverage. Over the past decade, shifts in benefit design, such as the rise of high-deductible health plans, have reshaped patient cost exposure. While prior research has emphasized aggregate trends, few studies have examined distributional impacts and subgroup disparities. A focus on the “average beneficiary” can mask disproportionate burdens among patients using branded drugs, those with chronic conditions and lower-income households.
A recent study examines changes in branded prescription drug out-of-pocket (OOP) spending for insured U.S. adults, comparing patient costs across health and socioeconomic groups and analyzing shifts in utilization, cost-sharing design, and relative affordability. J&J researchers conducted repeated retrospective cross-sectional analyses of data using MarketScan and Optum SES databases from 2014 to 2023 of adults aged 18–64 with continuous commercial coverage and at least one annual branded pharmacy claim.
The findings reveal that among commercially insured patients who rely on branded medicines, OOP rose sharply over the study period. Even after adjusting for inflation, total OOP costs more than doubled from 2014 to 2023, with the steepest growth after 2018 and the highest levels among those with the greatest clinical needs. Patients with multiple comorbidities and lower-income households faced disproportionate burdens, underscoring how average trends can mask substantial heterogeneity in patient exposure and affordability.
While the study design is descriptive and does not establish causality, the observed patterns appear consistent with patients’ growing exposure to variable-cost-sharing benefit designs and less consistent with underlying changes in drug prices, premiums, or broad utilization trends as the primary drivers of rising burdens. The growing role of deductibles and especially coinsurance suggests that financial risk is increasingly being shifted onto patients, raising concerns that disparities may further deepen as a result.
The study emphasizes the need for additional research on patient subgroups beyond the “average beneficiary” to inform insurance benefit structures that improve affordability and better protect high-need populations.
This research was funded by Johnson & Johnson Innovative Medicine. For full details on the study design, methods and limitations, see: Adjei K, Chang HY, Neumann U. Out-of-Pocket Cost Burden for Prescription Drugs: Trends and Disparities in Commercial Insurance Design. Poster presented at: Academy of Managed Care Pharmacy (AMCP) 2026; April 13-16, 2026; Nashville, TN; Journal of Managed Care & Specialty Pharmacy 2026 32:4-a Suppl, S1-S142. https://www.jmcp.org/doi/epdf/10.18553/jmcp.2026.32.4-a.s1
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