High Deductible Health Insurance Plans Linked to Delayed or Foregone Care

A new study by a team of Harvard researchers published in the Journal of General Internal Medicine has found that families and individuals enrolled in high-deductible health insurance plans report delaying or foregoing health care for chronic conditions at higher rates than those on traditional plans without high deductibles. And, lower income families on high-deductible plans delay or forgo care at greater rates than those with higher incomes.

The study, by Alison A. Galbraith and colleagues, appears in the January online issue of the Journal of General Internal Medicine.

“High-deductible health plans (HDHPs) are an increasingly common strategy to contain health care costs. Individuals with chronic conditions are at particular risk for increased out-of-pocket costs in HDHPs and resulting cost-related underuse of essential health care,” the authors wrote in an introduction to the study.

High-Deductible plans, usually paired with a health savings account, have grown in popularity among employers as a cost-containment measure. High-deductible plans cost lower premiums in return for high deductibles that must be met before coverage is available. According to statistics reported by the Washington Post, enrollment in high-deductible plans has more than doubled in the past two years among those with employer sponsored insurance, from 8 percent in 2009 to 17 percent last year.

Study Design

In order to measure whether families with chronic conditions in high-deductible plans have higher rates of delayed or forgone care due to cost, compared with those in traditional health insurance plans, the researchers surveyed 208 families in high-deductible plans and 370 in traditional plans in Massachusetts.

The study participants included families with children that had at least one member with a chronic condition. The families had employer-sponsored insurance in a Massachusetts health plan and more than 12 months of enrollment in a high-deductible or a traditional plan.

The high-deductible plans in the study had family deductibles of $1,000 to $6,000 per year, and covered services such as emergency department visits, diagnostic tests and physical therapy, the authors reported. The traditional plans in the study did not have a deductible and averaged around $16 for a physician office visit co-payment.

The participants were asked in a mail and phone survey to report any instances where adults or children in the family delayed or went without care due to cost (acute care, emergency department visits, chronic care, checkups, or tests) during the prior 12 months.

Findings

The authors found “that the odds of reporting [delayed/forgone care] were three to four times greater for adults and children in HDHP [high-deductible plan] families compared to traditional plan families.”

“Membership in an HDHP and lower income were each independently associated with higher probability of delayed/forgone care due to cost,” the authors wrote.

“For adult family members, the predicted probability of delayed/forgone care due to cost was higher in HDHPs than in traditional plans [40.0% vs 15.1% among families with incomes <400% of the federal poverty level (FPL) and 16.0% vs 4.8% among those with incomes ≥400% FPL],” the researchers found. “Similar associations were observed for children.”

In addition, the researchers found that in families where a child had a chronic condition, the healthier adult tended to be the one reporting foregone care. On the other hand, where an adult family member had a chronic health condition, care for the children was delayed. These results were even more pronounced for lower income families, which tended to delay care at higher rates, as reflected in the overall percentages reported above.

Conclusions

“Among families with chronic conditions, reporting of delayed/forgone care due to cost is higher for both adults and children in HDHPs than in traditional plans. Families with lower incomes are also at higher risk for delayed/forgone care,” the researchers concluded.

“One of the things that was fascinating was we tried to look at interfamilial effects,” the study’s lead author, Alison Galbraith, told the Washington Post. “If you have someone who has a chronic condition, … it looks like the healthy people are cutting back. Those are the people to worry about.”

The new study did not examine whether the delayed care was essential. If the delayed or foregone care is truly essential, then given the proliferation of high-deductible plans, this could have profound implications for health care in the U.S. It could lead to more serious health care complications in the future for those foregoing care, which in turn could lead to higher health care costs.

The authors noted that high-deductible plans may become more prevalent for individuals as well, if they are included on the health insurance exchanges for individuals that will go into effect under the Affordable Care Act.

Further study is needed to measure whether essential care is indeed being delayed or foregone due to high-deductible plans, or whether these plans are working as they were intended, by encouraging individuals not to seek care they don’t need.

More Information

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