Delaying or Foregoing Healthcare in Families with High-Deductible Health Plans

High-deductible health plans (HDHPs) are one option available to consumers to lower health insurance premiums. HDHPs, characterized by annual deduction requirements of at least 1000 per person and $2000 per family before the majority of services are covered, are designed to encourage patients to become cost-effective consumers of healthcare. In 2009, 23% of all nonelderly individuals with health insurance were enrolled in an HDHP; nearly 50% of adults who purchased health insurance in the nongroup market chose an HDHP. The majority of individuals who have enrolled in Commonwealth Connector, the health insurance exchange in Massachusetts, have opted for policies with HDHP-like designs that have low premiums and high levels of cost-sharing. Although early purchasers of HDHPs had higher incomes than those who purchased plans with low levels of cost-sharing, current analyses reveal that individuals with lower income are as likely as those with higher incomes to be enrolled in an HDHP. Studies have shown that higher levels of cost-sharing reduce utilization of healthcare, particularly among patients with low income; compared with individuals with higher income, those with low income have not shown the same level of engagement in managing their healthcare. Researchers recently conducted a study to test the hypothesis that compared with families with higher income, families with lower income with out-of-pocket expenditures in HDHPs would be more likely to delay or forego healthcare due to cost, have difficulties understanding their plans, demonstrate low levels of research on plan coverage and costs of services, and avoid talking with their physicians about services that required out-of-pocket expenditures. Study results were reported in Archives of Internal Medicine [2010;170(21):1918-1925]. The researchers administered a cross-sectional survey to a stratified sample of families enrolled in HDHPs administered by Harvard Pilgrim Health Care, a nonprofit health insurer based in New England. Harvard Pilgrim offers plans with $1000 per person and $2000 per family deductibles; most preventive services such as routine check-ups, immunizations, and some screening tests are exempt from the deductible, but most diagnostic laboratory and imaging tests are not covered until the deductible has been met. Inclusion criteria were age ≥18 years, continuous enrollment in an HDHP for at least the previous 6 months, at least 1 child <18 years also enrolled in the plan, and annualized family out-of-pocket healthcare expenses (outpatient visits and prescription drug copays) of at least $500. Families with incomes <300% of the federal poverty level were considered lower-income. The primary outcomes were delayed or foregone healthcare services due to cost, difficulty understanding plans, unexpected healthcare costs, information-seeking behavior, and the likelihood of asking physicians about recommended services that were subject to the plan deductible. The analysis utilized multivariate logistic regression to control for potential confounders of associations between income group and primary outcomes. Of the 750 surveys mailed to eligible families, 434 were completed by mail or telephone. In the lower US Census Bureau block group median household income stratum, the response rate was 55%; in the higher US Census Bureau block group median household income stratum, the response rate was 61%. Compared with higher-income families (n=273), lower-income families (n=141) were more likely to report delaying or foregoing care for reasons related to cost for any adult (34.8% vs 51.1%, respectively; P=.002) or child (13.9% vs 24.1%, respectively; P=.01) in the previous 6 months. Controlling for covariates, lower-income families had nearly twice the odds of any cost-related delayed or foregone care in the past 6 months (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83). There were no differences in level of plan understanding, unexpected costs, or information seeking between the 2 income groups. Compared with higher-income families, those in the lower-income group reported they were more likely to ask their physician about a $100 blood test (63% vs 79%, respectively; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (80% vs 89%, respectively; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible. Limitations to the study cited by the researchers include self-reported, cross-sectional data subject to recall bias, the possibility that the data may not be representative of HDHP populations other than that used in the study, and the possibility that families who select HDHPs may differ in unobservable ways from families who do not. In their comments, the researchers suggested that “policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.”