{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T23:36:54Z","timestamp":1793230614180,"version":"4.5.0"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100007164","name":"Social Science Research Institute, Pennsylvania State University","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100007164","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Prev Sci"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>\n                    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 (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.001). 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 (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.001). 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.\n                  <\/jats:p>","DOI":"10.1007\/s11121-026-01973-5","type":"journal-article","created":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T08:02:52Z","timestamp":1787904172000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["\u201cIs It Free?\u201d: Out-of-Pocket Costs for Annual Checkups Among the Insured"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6380-6077","authenticated-orcid":false,"given":"Sujeong","family":"Park","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erin","family":"Duffy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel Max","family":"Crowley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,28]]},"reference":[{"issue":"4","key":"1973_CR1","doi-asserted-by":"publisher","DOI":"10.1111\/soc4.13081","volume":"17","author":"OA Alawode","year":"2023","unstructured":"Alawode, O. A., & Nicholson, H. L., Jr. (2023). Health literacy and uptake of annual physical checkups among emerging adults in the United States: Findings from the Behavioral Risk Factor Surveillance System. Sociology Compass, 17(4), Article e13081.","journal-title":"Sociology Compass"},{"key":"1973_CR2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpubeco.2024.105152","volume":"236","author":"DM Anderson","year":"2024","unstructured":"Anderson, D. M., Hoagland, A., & Zhu, E. (2024). Medical bill shock and imperfect moral hazard. Journal of Public Economics, 236, Article 105152.","journal-title":"Journal of Public Economics"},{"key":"1973_CR3","unstructured":"Andrews, M. (2024). Her checkup was free. Her Colonoscopy Cost $2,185. https:\/\/kffhealthnews.org\/news\/article\/preventive-care-free-checkup-surprise-billing-bill-of-the-month\/"},{"issue":"4","key":"1973_CR4","doi-asserted-by":"publisher","first-page":"1623","DOI":"10.1093\/qje\/qjv029","volume":"130","author":"K Baicker","year":"2015","unstructured":"Baicker, K., Mullainathan, S., & Schwartzstein, J. (2015). Behavioral hazard in health insurance. The Quarterly Journal of Economics, 130(4), 1623\u20131667.","journal-title":"The Quarterly Journal of Economics"},{"issue":"1","key":"1973_CR5","doi-asserted-by":"publisher","DOI":"10.1007\/s44250-024-00138-x","volume":"3","author":"AE Borsky","year":"2024","unstructured":"Borsky, A. E., Zodet, M., Wolff, T. A., Ngo-Metzger, Q., Mueller, N., & Bierman, A. S. (2024). Disparities in receipt of high-priority clinical preventive services. Discover Health Systems, 3(1), Article 76.","journal-title":"Discover Health Systems"},{"issue":"22","key":"1973_CR6","doi-asserted-by":"publisher","first-page":"2259","DOI":"10.1001\/jama.2021.4922","volume":"325","author":"AS Brett","year":"2021","unstructured":"Brett, A. S. (2021). The routine general medical checkup: Valuable practice or unnecessary ritual? JAMA, 325(22), 2259\u20132261.","journal-title":"JAMA"},{"issue":"3","key":"1973_CR7","doi-asserted-by":"publisher","first-page":"1261","DOI":"10.1093\/qje\/qjx013","volume":"132","author":"ZC Brot-Goldberg","year":"2017","unstructured":"Brot-Goldberg, Z. C., Chandra, A., Handel, B. R., & Kolstad, J. T. (2017). What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. The Quarterly Journal of Economics, 132(3), 1261\u20131318.","journal-title":"The Quarterly Journal of Economics"},{"key":"1973_CR8","unstructured":"Center for Rural Pennsylvania. (2021). Rural Urban Definitions. https:\/\/www.rural.pa.gov\/data\/rural-urban-definitions"},{"issue":"5","key":"1973_CR9","doi-asserted-by":"publisher","first-page":"786","DOI":"10.2105\/AJPH.93.5.786","volume":"93","author":"JE DeVoe","year":"2003","unstructured":"DeVoe, J. E., Fryer, G. E., Phillips, R., & Green, L. (2003). Receipt of preventive care among adults: Insurance status and usual source of care. American Journal of Public Health, 93(5), 786\u2013791.","journal-title":"American Journal of Public Health"},{"issue":"27","key":"1973_CR10","first-page":"738","volume":"64","author":"JB Fox","year":"2015","unstructured":"Fox, J. B., & Shaw, F. E. (2015). Receipt of selected clinical preventive services by adults\u2014United States, 2011\u20132012. Morbidity and Mortality Weekly Report, 64(27), 738.","journal-title":"Morbidity and Mortality Weekly Report"},{"issue":"2","key":"1973_CR11","first-page":"1","volume":"61","author":"TR Frieden","year":"2012","unstructured":"Frieden, T. R. (2012). Use of selected clinical preventive services among adults\u2013United States, 2007\u20132010. MMWR Supplements, 61(2), 1\u20132.","journal-title":"MMWR Supplements"},{"key":"1973_CR12","doi-asserted-by":"publisher","DOI":"10.1016\/j.ypmed.2021.106690","volume":"150","author":"A Hoagland","year":"2021","unstructured":"Hoagland, A., & Shafer, P. (2021). Out-of-pocket costs for preventive care persist almost a decade after the Affordable Care Act. Preventive Medicine, 150, Article 106690.","journal-title":"Preventive Medicine"},{"issue":"1","key":"1973_CR13","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1016\/j.amepre.2024.09.011","volume":"68","author":"A Hoagland","year":"2025","unstructured":"Hoagland, A., Yu, O., & Horn\u00fd, M. (2025). Inequities in unexpected cost-sharing for preventive care in the United States. American Journal of Preventive Medicine, 68(1), 5\u201311.","journal-title":"American Journal of Preventive Medicine"},{"issue":"6","key":"1973_CR14","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1377\/hlthaff.2024.01277","volume":"44","author":"M Horn\u00fd","year":"2025","unstructured":"Horn\u00fd, M., Yu, O., & Hoagland, A. (2025). Claim denials: Low-income patients from disadvantaged racial and ethnic groups experienced the largest burdens. Health Affairs, 44(6), 707\u2013715.","journal-title":"Health Affairs"},{"key":"1973_CR15","unstructured":"Internal Revenue Service. (2015). Coverage of certain preventive services under the Affordable Care Act. https:\/\/www.federalregister.gov\/documents\/2015\/07\/14\/2015-17076\/coverage-of-certain-preventive-services-under-the-affordable-care-act"},{"issue":"1pt2","key":"1973_CR16","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1111\/j.1475-6773.2011.01308.x","volume":"47","author":"JT Kullgren","year":"2012","unstructured":"Kullgren, J. T., McLaughlin, C. G., Mitra, N., & Armstrong, K. (2012). Nonfinancial barriers and access to care for US adults. Health Services Research, 47(1pt2), 462\u2013485.","journal-title":"Health Services Research"},{"key":"1973_CR17","doi-asserted-by":"publisher","DOI":"10.1186\/s13690-021-00556-w","volume":"79","author":"HY Lee","year":"2021","unstructured":"Lee, H. Y., Kim, S., Neese, J., & Lee, M. H. (2021). Does health literacy affect the uptake of annual physical check-ups?: Results from the 2017 US health information national trends survey. Archives of Public Health, 79, Article 38.","journal-title":"Archives of Public Health"},{"issue":"22","key":"1973_CR18","doi-asserted-by":"publisher","first-page":"2294","DOI":"10.1001\/jama.2021.6524","volume":"325","author":"DT Liss","year":"2021","unstructured":"Liss, D. T., Uchida, T., Wilkes, C. L., Radakrishnan, A., & Linder, J. A. (2021). General health checks in adult primary care: A review. JAMA, 325(22), 2294\u20132306.","journal-title":"JAMA"},{"key":"1973_CR19","doi-asserted-by":"publisher","first-page":"s48","DOI":"10.1111\/jrh.12235","volume":"34","author":"J Loftus","year":"2018","unstructured":"Loftus, J., Allen, E. M., Call, K. T., & Everson-Rose, S. A. (2018). Rural-urban differences in access to preventive health care among publicly insured Minnesotans. Journal of Rural Health, 34, s48\u2013s55.","journal-title":"Journal of Rural Health"},{"issue":"9","key":"1973_CR20","doi-asserted-by":"publisher","first-page":"1656","DOI":"10.1377\/hlthaff.2008.0701","volume":"29","author":"MV Maciosek","year":"2010","unstructured":"Maciosek, M. V., Coffield, A. B., Flottemesch, T. J., Edwards, N. M., & Solberg, L. I. (2010). Greater use of preventive services in US health care could save lives at little or no cost. Health Affairs, 29(9), 1656\u20131660.","journal-title":"Health Affairs"},{"issue":"26","key":"1973_CR21","doi-asserted-by":"publisher","first-page":"2635","DOI":"10.1056\/NEJMsa022615","volume":"348","author":"EA McGlynn","year":"2003","unstructured":"McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., & Kerr, E. A. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348(26), 2635\u20132645.","journal-title":"New England Journal of Medicine"},{"key":"1973_CR22","unstructured":"Owusu, M. (2023). Language barrier: An unmet challenge for low screening of colorectal cancer among Hispanic Americans in Texas [Doctoral dissertation, Walden University]."},{"key":"1973_CR23","unstructured":"Penn State Harrisburg, Center for Survey Research. (2024). Penn State Center for Survey Research. https:\/\/csr.hbg.psu.edu\/"},{"issue":"12","key":"1973_CR24","doi-asserted-by":"publisher","first-page":"1347","DOI":"10.1001\/archinte.165.12.1347","volume":"165","author":"AV Prochazka","year":"2005","unstructured":"Prochazka, A. V., Lundahl, K., Pearson, W., Oboler, S. K., & Anderson, R. J. (2005). Support of evidence-based guidelines for the annual physical examination: A survey of primary care providers. Archives of Internal Medicine, 165(12), 1347\u20131352.","journal-title":"Archives of Internal Medicine"},{"key":"1973_CR25","unstructured":"Rosenthal, E. (2024). Ouch. That \u2018free\u2019 annual checkup might cost you. Here\u2019s why. KFF Health News. https:\/\/kffhealthnews.org\/news\/article\/preventive-care-free-annual-checkup-aca-surprise-billing\/"},{"issue":"3","key":"1973_CR26","doi-asserted-by":"publisher","first-page":"e211248","DOI":"10.1001\/jamanetworkopen.2021.1248","volume":"4","author":"PR Shafer","year":"2021","unstructured":"Shafer, P. R., Hoagland, A., & Hsu, H. E. (2021). Trends in well-child visits with out-of-pocket costs in the US before and after the Affordable Care Act. JAMA Network Open, 4(3), e211248.","journal-title":"JAMA Network Open"},{"key":"1973_CR27","doi-asserted-by":"publisher","DOI":"10.1016\/j.pmedr.2019.100924","volume":"15","author":"M Steenland","year":"2019","unstructured":"Steenland, M., Sinaiko, A., Glynn, A., Fitzgerald, T., & Cohen, J. (2019). The effect of the Affordable Care Act on patient out-of-pocket cost and use of preventive cancer screenings in Massachusetts. Preventive Medicine Reports, 15, Article 100924.","journal-title":"Preventive Medicine Reports"},{"issue":"1","key":"1973_CR28","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.53157","volume":"9","author":"A Tran","year":"2026","unstructured":"Tran, A., Laporte, A., Nauenberg, E., & Hoagland, A. (2026). Role of chronic conditions in out-of-pocket costs for preventive care in the US. JAMA Network Open, 9(1), Article e2553157.","journal-title":"JAMA Network Open"},{"issue":"4","key":"1973_CR29","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1056\/NEJMsa070929","volume":"358","author":"AN Trivedi","year":"2008","unstructured":"Trivedi, A. N., Rakowski, W., & Ayanian, J. Z. (2008). Effect of cost sharing on screening mammography in Medicare health plans. The New England Journal of Medicine, 358(4), 375\u2013383.","journal-title":"The New England Journal of Medicine"},{"key":"1973_CR30","unstructured":"U.S. Department of Health and Human Services. (2022). Access to preventive services without cost-sharing: Evidence from the Affordable Care Act. https:\/\/aspe.hhs.gov\/reports\/access-preventive-services-without-cost-sharing"},{"key":"1973_CR31","unstructured":"U.S. Preventive Services Task Force. (2024). Guide to clinical preventive services. https:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/"}],"container-title":["Prevention Science"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11121-026-01973-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11121-026-01973-5","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11121-026-01973-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T08:02:56Z","timestamp":1787904176000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11121-026-01973-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,28]]},"references-count":31,"alternative-id":["1973"],"URL":"https:\/\/doi.org\/10.1007\/s11121-026-01973-5","relation":{},"ISSN":["1389-4986","1573-6695"],"issn-type":[{"value":"1389-4986","type":"print"},{"value":"1573-6695","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,28]]},"assertion":[{"value":"31 October 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 August 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 August 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study was approved by the Institutional Review Board at Pennsylvania State University (IRB Protocol STUDY00025922). All procedures performed in this study involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments.","order":1,"name":"Ethics","label":"Ethics Approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Informed consent was implied through voluntary participation in the online survey.","order":2,"name":"Ethics","label":"Consent to Participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":3,"name":"Ethics","label":"Clinical Trial Number","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Erin Duffy receives grant funding from Arnold Ventures, Gates Ventures, and California Health Care Foundation, and personal fees from Cornerstone Research outside of the submitted work. The other authors declare no conflicts of interest.","order":4,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}