Abstract
Most people with commercial health insurance in the US have high-deductible plans, but the association of such plans with major health outcomes is unknown. To describe the association between enrollment in high-deductible health plans and the risk of major adverse cardiovascular outcomes. This cohort study examined matched groups before and after an insurance design change. Data were from a large national commercial (and Medicare Advantage) health insurance claims data set that included members enrolled between January 1, 2003, and December 31, 2014. The study group included 156 962 individuals with risk factors for cardiovascular disease who were continuously enrolled in low-deductible (≤$500) health plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans with typical value-based features after an employer-mandated switch. The matched control group included 1 467 758 individuals with the same risk factors who were contemporaneously enrolled in low-deductible plans. Data were analyzed from December 2017 to March 2020. Employer-mandated transition to a high-deductible health plan. Time to first major adverse cardiovascular event defined as myocardial infarction or stroke. The study group included 156 962 individuals and the control group included 1 467 758 individuals; the mean age of members was 53 years (SD: high-deductible group, 6.7 years; control group, 6.9 years), 47% were female, and approximately 48% lived in low-income neighborhoods. First major adverse cardiovascular events among high-deductible health plan members did not differ relative to controls at follow-up vs baseline (adjusted hazard ratio, 1.00; 95% CI, 0.89-1.13). Findings were similar among subgroups with diabetes (adjusted hazard ratio, 0.93; 95% CI, 0.75-1.16) and with other cardiovascular risk factors (adjusted hazard ratio, 0.93; 95% CI, 0.81-1.07). Mandated enrollment in high-deductible health plans with typical value-based features was not associated with increased risk of major adverse cardiovascular events.
Highlights
First major adverse cardiovascular events among high-deductible health plan members did not differ relative to controls at follow-up vs baseline
Findings were similar among subgroups with diabetes and with other cardiovascular risk factors
We hypothesized that people with risk factors for cardiovascular disease would experience increases in major adverse cardiovascular events after an employer-mandated switch from low-deductible health plans to high-deductible health plans (HDHPs) relative to people who remained in low-deductible plans
Summary
Cardiovascular disease kills more people in the US than any other condition, accounting for 30% of deaths in 2017.1 Decades of improvements in cardiovascular mortality began slowing in about 2010,2-6 and major adverse cardiovascular events, such as stroke and myocardial infarction, began increasing among adults under age 65.7 The reasons for these trends are unclear, but experts have proposed causes such as the earlier onset of cardiovascular risk factors,[2] stagnation of preventive care,[7] and less generous health insurance coverage in the US.[7]Concerns about the contribution of health insurance to these trends are based on the rapid expansion of high-deductible health plans (HDHPs) and previous research about the health effects associated with high out-of-pocket costs.[8,9,10,11] High-deductible plans, which require potential annual out-of-pocket spending of approximately $1000 to $7000 per person for most nonpreventive care, cover most commercially insured people in the US. The RAND Health Insurance Experiment of the 1970s to 1980s detected suboptimal blood pressure control among the poorest and sickest individuals subject to high cost sharing, and investigators predicted a 16% mortality increase.[8] More recent research detected adverse short-term health outcomes among low-income patients with diabetes in HDHPs9,10 as well as delays in receiving major cardiovascular care.[11] We hypothesized that people with risk factors for cardiovascular disease would experience increases in major adverse cardiovascular events after an employer-mandated switch from low-deductible health plans to HDHPs relative to people who remained in low-deductible plans
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