Abstract
PurposeTo determine whether negative associations between enrollment in a high-deductible health plan (HDHP) and one exemplar unhealthy behavior – daily smoking – are found only among people who chose these plans.DesignCross-sectional analysis of nationally-representative data.SettingUnited States from 2007 to 2008.Subjects6,941 privately insured non-elderly adult participants in the 2007 Health Tracking Household Survey.MeasuresSelf-reported smoking status.AnalysisWe classified subjects as HDHP or traditional health plan enrollees with employer-sponsored insurance (ESI) and no choice of plans, ESI with a choice of plans, or coverage through the non-group market. We used multivariate logistic regression to measure associations between HDHP enrollment and daily smoking within each of the 3 coverage source groups while controlling for potential confounders.ResultsHDHP enrollment was associated with lower odds of smoking among individuals with ESI and a choice of plans (AOR 0.55, 95% CI 0.33–0.90) and those with non-group coverage (AOR 0.64, 95% CI 0.34–1.22), though the latter association was not statistically significant. HDHP enrollment was not associated with lower odds of smoking among individuals with ESI and no choice of plans (AOR 1.04, 95% CI 0.69–1.56).ConclusionsHDHP enrollment is associated with lower odds of smoking only among individuals who chose to enroll in an HDHP. Lower rates of unhealthy behaviors among HDHP enrollees may be a reflection of individuals who choose these plans.
Highlights
One policy approach promoted as a way to reduce rates of unhealthy behaviors in the United States is greater enrollment in high-deductible health plans (HDHPs) [1,2], which are private health insurance plans that feature deductibles of at least $1,100 per individual and $2,200 per family before most services are covered
HDHP enrollment was associated with lower odds of smoking among individuals with employer-sponsored insurance (ESI) and a choice of plans (AOR 0.55, 95% CI 0.33–0.90) and those with non-group coverage (AOR 0.64, 95% CI 0.34–1.22), though the latter association was not statistically significant
HDHP enrollment was not associated with lower odds of smoking among individuals with ESI and no choice of plans (AOR 1.04, 95% CI 0.69–1.56)
Summary
One policy approach promoted as a way to reduce rates of unhealthy behaviors in the United States is greater enrollment in high-deductible health plans (HDHPs) [1,2], which are private health insurance plans that feature deductibles of at least $1,100 per individual and $2,200 per family before most services are covered. The theoretical basis for believing HDHPs might change health behavior is based on the idea that because health insurance protects beneficiaries from facing the full financial consequences of medical care, beneficiaries might engage in more unhealthy behaviors than they would without this financial protection. This behavioral response to insurance, ex ante moral hazard, has little empirical support in the health services research literature [5,6,7,8]. The objective of this study was to test whether choice of health plan, rather than ex ante moral hazard, can explain the healthier behaviors among HDHP enrollees by determining whether lower odds of one exemplar unhealthy behavior – daily smoking – are found only among HDHP enrollees who could choose their plan
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