Generous Plans Research Articles

Out-of-Pocket Spending for Non–Birth-Related Hospitalizations of Privately Insured US Children, 2017 to 2019

Privately insured US children account for 40% of non-birth-related pediatric hospitalizations. However, there are no national data on the magnitude or correlates of out-of-pocket spending for these hospitalizations. To estimate out-of-pocket spending for non-birth-related hospitalizations among privately insured children and identify factors associated with this spending. This study is a cross-sectional analysis of the IBM MarketScan Commercial Database, which reports claims from 25 to 27 million privately insured enrollees annually. In the primary analysis, all non-birth-related hospitalizations of children 18 years and younger from 2017 through 2019 were included. In a secondary analysis focused on insurance benefit design, hospitalizations that could be linked to the IBM MarketScan Benefit Plan Design Database and were covered by plans with a family deductible and inpatient coinsurance requirements were analyzed. In the primary analysis, factors associated with out-of-pocket spending per hospitalization (sum of deductibles, coinsurance, and copayments) were identified using a generalized linear model. In the secondary analysis, variation in out-of-pocket spending was assessed by level of deductible and inpatient coinsurance requirements. Among 183 780 hospitalizations in the primary analysis, 93 186 (50.7%) were for female children, and the median (IQR) age of hospitalized children was 12 (4-16) years. A total of 145 108 hospitalizations (79.0%) were for children with a chronic condition and 44 282 (24.1%) were covered by a high-deductible health plan. Mean (SD) total spending per hospitalization was $28 425 ($74 715). Mean (SD) and median (IQR) out-of-pocket spending per hospitalization were $1313 ($1734) and $656 ($0-$2011), respectively. Out-of-pocket spending exceeded $3000 for 25 700 hospitalizations (14.0%). Factors associated with higher out-of-pocket spending included hospitalization in quarter 1 compared with quarter 4 (average marginal effect [AME], $637; 99% CI, $609-$665) and lack of chronic conditions compared with having a complex chronic condition (AME, $732; 99% CI, $696-$767). The secondary analysis included 72 165 hospitalizations. Among hospitalizations covered by the least generous plans (deductible of $3000 or more and coinsurance of 20% or more) and most generous plans (deductible less than $1000 and coinsurance of 1% to 19%), mean (SD) out-of-pocket spending was $1974 ($1999) and $826 ($798), respectively (AME, $1123; 99% CI, $1069-$1179). In this cross-sectional study, out-of-pocket spending for non-birth-related pediatric hospitalizations were substantial, especially when they occurred early in the year, involved children without chronic conditions, or were covered by plans with high cost-sharing requirements.

The best housing estate in Czechoslovakia

The Brno housing estate Lesna is undoubtedly an important achievement of Czechoslovak urbanism and architecture of the 1960s. It was built on the southern slopes north of Brno in 1962–1970 according to a project by a team of architects Frantisek Zounek, Viktor Rudis, Miroslav Dufek and Ladislav Volak. Although it was a standard housing construction made of prefabricated components, the architects did not want to hide its technical expression. They also fully copied it into the very urban arrangement of long blocks, which contributed to the fulfillment of the vision of the garden city. Close cooperation between the supplier, investor and designer was ensured already in the phase of elaboration of the project task. The architecture of residential buildings is based on the diligent efforts of the whole team to promote the use of a lightweight facade of a prefabricated house using parapet panels and strip glazing in the B 60 construction system. The unusually high-quality solution of the public space in the Lesna housing estate was mainly due to the time of its creation. Political liberalization in the 1960s allowed architects to come up with a generous plan for a free stop and thus perfectly fulfill the vision of a garden city. The population density of the Lesna housing estate, less than two hundred inhabitants per hectare, was multiplied by up to four hundred inhabitants per hectare in other housing estates of the "president Gustav Husak" era due to tightening economic indicators. Public greenery respecting the natural elements of the rugged relief required a different professional approach due to the extent of the exterior design. It was common practice that landscaping were carried out on residential complexes with a delay of several months and years after the first inhabitants moved in. The architects managed to reverse this common practice, so the first inhabitants moved to finished houses with access sidewalks, planted greenery and functioning residential amenities. This could not have been imagined by its inhabitants in the later realizations of housing estates. That is why the Brno housing estate Lesna is rightly called the best.

Disentangling moral hazard and adverse selection in private health insurance

Moral hazard and adverse selection create inefficiencies in private health insurance markets and understanding the relative importance of each factor is critical for addressing these inefficiencies. We use claims data from a large firm which changed health insurance plan options to isolate moral hazard from plan selection, estimating a discrete choice model to predict household plan preferences and attrition. Variation in plan preferences identifies the differential causal impact of each health insurance plan on the entire distribution of medical expenditures. Our estimates imply that 53% of the additional medical spending observed in the most generous plan in our data relative to the least generous is due to adverse selection. We find that quantifying adverse selection by using prior medical expenditures overstates the true magnitude of selection due to mean reversion. We also statistically reject that individual health care consumption responds solely to the end-of-the-year marginal price.

Subscriber continuity in health insurance plans: factors associated with re-enrollment and coverage changes

Aims: This study examined the extent to which Marketplace health insurance subscribers re-enroll a second year. Among re-enrollees, we sought to examine movement to more and less generous insurance plans (based on actuarial value), and the extent to which adverse selection, adverse retention, and aging in place are evident from re-enrollment choices made.Methods: Re-enrollment from 2015 to 2016 and 2016 to 2017 and movement to more and less generous insurance plans was examined using enrollment and insurance claims data from two US Federally-facilitated Marketplace insurance carriers operating in the state of New Mexico for 2015–2017. Insurance plans are assigned to metal levels based on estimated plan actuarial value: Bronze (60%), Silver (70%), and Gold (80%). Odds ratios (ORs) and 95% confidence intervals (OR CI) were estimated using logistic regressions for subscribers with base-year healthcare utilization. ORs were estimated for (1) re-enrollment in the year following the base year, and (2) movement to a higher or lower actuarial value plan.Results: Approximately 50% of subscribers re-enrolled with the same carrier for 2016 and 60% for 2017. Being enrolled 12 months was the strongest predictor for second year re-enrollment. Older individuals were more likely to re-enroll. Re-enrollment was lower for the insurance carrier with higher second year premium changes. Chronic condition utilization characteristics were positively associated with re-enrollment. Approximately 12% of Bronze subscribers moved to Silver or Gold, and had higher utilization after re-enrollment. Among Silver subscribers, 6% moved to Gold and 6% to Bronze. Approximately 37% of Gold subscribers moved to Silver or Bronze.Discussion: Re-enrollment was similar to published non-group insurance rates. Adverse selection and aging in place were observed. Evidence was weak for adverse retention. Some coverage change choices were rational, while others suggest subscribers may have difficulty making insurance choice decisions.

175-OR: Impact of High-Deductible Health Plan Enrollment on the Timing of Diabetic Retinopathy Care and Vision Loss Diagnosis

High-deductible health plans (HDHP) that require large out-of-pocket payments for retinopathy screening and ophthalmologist visits could delay retinopathy screening, retinopathy diagnosis, and vision loss diagnosis. We studied 2004-2014 data in a large commercial and Medicare Advantage claims database. We included a national sample of 39,798 HDHP members with diabetes enrolled for 1 year in a low deductible (≤$500) plan followed by up to 4 years in a HDHP (≥$1000) after an employer-mandated switch. We matched HDHP patients to 305,852 contemporaneous controls whose employers offered only low-deductible plans. Outcomes included time to first: (a) retinopathy screening, (b) diagnosis of mild-to-moderate and (c) severe non-proliferative diabetic retinopathy, and (d) vision loss diagnosis. We used Cox proportional hazards models adjusted for multiple baseline characteristics to estimate baseline and follow-up hazard ratios. At baseline, adjusted hazard ratios (aHRs) between HDHP members and controls were not statistically different. At follow up, HDHP members experienced delays in first retinopathy screening (aHR: 0.89 [085, 0.92]), diagnosis of mild-to-moderate non-proliferative diabetic retinopathy (aHR: 0.82 [0.76, 0.89]), diagnosis of severe non-proliferative diabetic retinopathy (aHR: 0.90 [0.81, 1.00]), and vision loss diagnosis (aHR: 0.93 [0.88, 0.99]). HDHP members with diabetes experienced delayed retinopathy screening, retinopathy diagnosis, and vision loss diagnosis compared with similar patients in more generous health plans. Reducing financial barriers to care might improve retinopathy outcomes. Disclosure J. Wharam: None. F. Zhang: None. C. Lu: None. T. Stryjewski: Other Relationship; Self; Aldeyra Therapeutics, Pykus Therapeutics. K. Callaway: None. J. Wallace: None. J.P. Newhouse: None. D. Ross-Degnan: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Introduction

Introduction

Costs after incident breast cancer diagnosis among high-deductible health plan members.

120 Background: High-deductible health plans (HDHP) are associated with breast cancer treatment delays of up to 10 months, but their impact on health outcomes is unknown. We hypothesized that, compared with women in generous plans, HDHP members would present with more advanced disease and thus experience higher total costs of early care. Methods: We studied 2004-2014 claims data from a large US health insurer. We included women aged 25-64 who were in traditional low-deductible (≤$500) health plans for 1 baseline year then experienced either an employer-mandated switch to HDHPs (≥$1000) for up to 4 or years or an employer-mandated continuation in low deductible plans. We defined the HDHP switch date as the index date. We then restricted to women who developed incident breast cancer after the index date. Using baseline characteristics, we closely matched HDHP members with incident breast cancer to contemporaneous women with incident breast cancer who remained in low-deductible plans. We measured total costs of all health care services in the 60 days after incident breast cancer diagnosis as a proxy for the intensity of incident breast cancer care. We used negative binomial regression adjusted for baseline characteristics to compare total 60-day costs among HDHP and control members. We also subset analyses to low-income women. Results: We included 1514 HDHP members and 9283 matched controls. 60-day costs after incident breast cancer diagnosis were $24,151 (95% CI: $22,766, $25,535) among HDHP members and $22,474 ($21,952, $22,996) among controls, an absolute difference of $1677 ($197, $3156) and a relative difference of 7.5% (8.1%, 14.1%). Low-income HDHP members had corresponding absolute and relative differences of $2653 ($368, $4939) and 12.5% (1.5%, 23.5). Conclusions: HDHP members with incident breast cancer had 7.5% higher health care costs in the 60 days after incident breast cancer than women with more generous coverage, a finding driven 12.5% higher costs among low-income HDHP members. Results raise concerns that delays in breast cancer care among HDHP members are associated with more advanced disease and adverse outcomes.

The Two Margin Problem in Insurance Markets

Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical framework that extends the workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful trade-off on the other margin in terms of prices, enrollment, and welfare. For example, while a larger penalty for opting to remain uninsured reduces the uninsurance rate, it also tends to lead to unraveling of generous coverage because the newly insured are healthier and sort into less generous plans, driving down the relative prices of those plans. While risk adjustment transfers shift enrollment from lower- to higher-generosity plans, they also sometimes increase the uninsurance rate by raising the prices of less generous plans, which are the entry points into the market. We illustrate these trade-offs in an empirical sufficient statistics approach that is tightly linked to the graphical framework. Using data from Massachusetts, we show that in many policy environments these trade-offs can be empirically meaningful and can cause these policies to have unexpected consequences for overall social welfare.

Selection in Health Insurance Markets and Its Policy Remedies.

Selection (adverse or advantageous) is the central problem that inhibits the smooth, efficient functioning of competitive health insurance markets. Even—and perhaps especially—when consumers are well-informed decision makers and insurance markets are highly competitive and offer choice, such markets may function inefficiently due to risk selection. Selection can cause markets to unravel with skyrocketing premiums and can cause consumers to be under- or overinsured. In its simplest form, adverse selection arises due to the tendency of those who expect to incur high health care costs in the future to be the most motivated purchasers. The costlier enrollees are more likely to become insured rather than to remain uninsured, and conditional on having health insurance, the costlier enrollees sort themselves to the more generous plans in the choice set. These dual problems represent the primary concerns for policymakers designing regulations for health insurance markets. In this essay, we review the theory and evidence concerning selection in competitive health insurance markets and discuss the common policy tools used to address the problems it creates. We emphasize the two markets that seem especially likely to be targets of reform in the short and medium term: Medicare Advantage (the private plan option available under Medicare) and the state-level individual insurance markets.

Trends over time in enrollment in non-group health insurance plans by tobacco use in the United States.

Healthcare.gov was created to facilitate the market for non-group insurance in states that did not establish their own marketplaces. In Healthcare.gov, families are asked to report their tobacco use status, and tobacco use surcharges of up to 50% may result. We tabulate enrollment information for 35 states offering insurance plans through Healthcare.gov in both 2014 and 2016. The Centers for Medicare and Medicaid Services provided counts of enrollees indicating tobacco use, by state, year, and risk level. The number of enrollees increased from 5.0 million in 2014 to 9.4 million in 2016. From 2014 to 2016, the number of enrollees rose 39% for tobacco users and 90% for non-tobacco users. Reported non-tobacco user enrollment rose faster than reported tobacco user enrollment in 30 out of 35 states. Reported tobacco users are enrolling in marketplace plans at a lower rate and are more likely to enroll in less generous plans. The decline in smoking as reported when purchasing insurance on Healthcare.gov surpasses declines in smoking observed in other data sources, which suggests that tobacco users may be decreasingly likely to report their tobacco use status accurately to avoid surcharges. Finally, we find no evidence of the surcharges being associated with lower enrollment among self-reported tobacco users, or in rates of smoking.

Plan Selection in the Non-Group Market in the First Year of the Health Insurance Marketplace.

BACKGROUND The Affordable Care Act (ACA)-created Marketplaces reduced barriers to entry in the non-group health insurance market. Although tax credits were available to individuals who enrolled in qualified health plans (QHPs) beginning in 2014, many individuals chose not to switch plans. We examined characteristics associated with switching from a non-ACA compliant plan to a QHP in 2014 and, conditional on switching, the characteristics associated with selection of a specific plan level.METHODS Using claims data from a large commercial insurer, we examined characteristics associated with switching to a QHP in 2014. For those who did switch, we used a multinomial logit model to estimate odds of selecting different metal levels-representing varying degrees of coverage-for a group of the highest and lowest risk individuals.RESULTS We found individuals most likely to benefit from the premium and benefit requirements on QHPs were more likely to switch to QHPs. Individuals at high-risk for high health care expenditures who had advance premium tax credits (APTCs) had lower odds of choosing a less generous plan compared to individuals without APTCs (odds of bronze plan over silver: 0.40, CI: 0.30 - 0.55), while individuals at low-risk of being high cost with APTCs were more likely to select a plan with a lower premium (odds bronze plan over silver: 1.35, CI: 1.09 - 1.66).LIMITATIONS This study was conducted with data from 1 health plan, limiting its national generalizability; however, this study is a good representation of activity within the state.CONCLUSIONS APTCs are important for ensuring that less healthy individuals are able to afford adequate levels of coverage.

Efficiency in Plan Choice with Risk Adjustment and Risk-Based Pricing in Health Insurance Exchanges

This paper explores the impacts of risk adjustment and risk-based pricing on the efficiency of consumer insurance selection in the Health Insurance Exchanges (HIEs) created by the health-care reform in the U.S. Selecting a population likely to participate in the HIEs from the Medical Expenditure Panel Survey, consumer choice between plans with different levels of generosity is simulated under various scenarios of policy implementation. The results show that risk-based pricing could, in general, improve or impair efficiency, depending on the heterogeneity of the health-care spending of the enrollees and the selection of rating bands, while risk adjustment always encourages consumers to enrol in the more generous plans, which, in the model, implies improvement in efficiency.

How product standardization affects choice: Evidence from the Massachusetts Health Insurance Exchange

This paper examines the effect of choice architecture on Massachusetts' Health Insurance Exchange. A policy change standardized cost-sharing parameters of plans across insurers and altered information presentation. Post-change, consumers chose more generous plans and different brands, but were not more price-sensitive. We use a discrete choice model that allows the policy to affect how attributes are valued to decompose the policy's effects into a valuation effect and a product availability effect. The brand shifts are largely explained by the availability effect and the generosity shift by the valuation effect. A hypothetical choice experiment replicates our results and explores alternative counterfactuals.

Abstract IA40: Maximizing the benefits of precision medicine for cancer disparities

Abstract Disparities, defined as differences that are unnecessary and avoidable, exist in cancer incidence, mortality, and survival. They occur by race/ethnicity, socioeconomic status, geography (rural versus urban), and other factors. Although cancer deaths for all types of cancer decreased for both African-Americans and whites in the United States between 1999 and 2011, for example, African-American males and females had both higher cancer incidence and cancer mortality than white males and females and showed less marked improvement over that time period. Warnecke and colleagues published a multi-level framework of the determinants of cancer disparities that included three basic levels, namely distal, intermediate, and proximal.1 Distal determinants include population-level social conditions such as variation in rates of disease or poverty. Their roots are embedded in shared social norms or social practices and socioeconomic disadvantage. Intermediate determinants include the immediate social and physical contexts and social relationships in which distal effects are experienced, such as neighborhoods. Proximal determinants include biological and genetic factors and individual-level factors like health behavior. The sequencing of the human genome and increased understanding of its function have allowed the identification of genetic variants that lead to common diseases like cancer. Yet, awareness is growing, too, that genetic variants alone cannot account for cancer expression and outcomes. Consistent with the Warnecke et al. framework, it seems to be the case that social, environmental, and behavioral factors interact with genetic predisposition to produce disease, and that differential exposures and behaviors across populations and subpopulations might help to explain cancer disparities. Both the genetic variants and the exposures and behaviors must be present to produce cancers. The Precision Medicine Initiative (PMI), announced by President Obama on January 30, 2015 seeks to advance our understanding of genetic variations within diseases and develop treatments for them, beginning with cancer. President Obama requested $215 million in the next fiscal year to collect genetic data and data from electronic medical records, lab test results, and information about diet, tobacco use, lifestyle, and environment on 1,000,000 Americans. In this presentation, we argue that while the PMI has the potential to reduce cancer disparities: (1) preventing cancer and reducing death rates for everyone in the population requires collecting and analyzing consistent, accurate, reliable, and sufficiently detailed data that represent all segments of the population and that (2) developing risk assessments and interventions that are effective for everyone requires evidence on the distribution and impact of causes across subpopulations. Collecting and analyzing data that represents all segments of the population poses significant challenges essential for the PMI to contribute to decreasing disparities in cancer and other common diseases. Minority groups historically have had low participation in research, such as in clinical research trials. The 1993 NIH Revitalization Act (http://orwh.od.nih.gov/about/pdf/NIH-Revitalization-Act-1993.pdf) established a mandate that funded research would be based on valid analysis of whether the variables being studied in the trial affect minority groups. Yet a 2014 review found that only 20% of randomized controlled studies in a major cancer journal reported analyzing results by race/ethnicity.2 Likewise, a survey of its members and the general public by the American Association for the Advancement of Science (AAAS) found that while 92% of AAAS scientists considered US scientific achievement to be the best in the world or above average, only 54% of the public endorsed this ranking.3 The presentation will conclude with two recommendations for improving the PMI's role in eliminating cancer and other disparities. First, make the effort to recruit a cohort that reflects the US population in terms of race/ethnicity, socioeconomic status, and geography. Second, do not recruit entirely from clinic populations or rely entirely on electronic medical records for social data, because this will miss those most without consistent health care, a group for whom disparities are rife. In addition, for Precision Medicine practice to contribute to the elimination of disparities, it will be important that: (1) the cost of genetic testing is covered under Medicaid, other public insurance, and less generous marketplace insurance plans; (2) the collection of social variables be systematized so that they capture the lives of minority groups; and (3) the capacity of genetic counseling is increased and that counseling services are available to all who have genetic testing.

Plan generosity in health insurance exchanges: what the Affordable Care Act can teach us about top-down versus bottom-up policy implementation

AbstractThe landmark United States healthcare reform law – the Affordable Care Act – provides an opportunity to study the dynamics of implementation for complex, politically contentious policies. Matland’s Ambiguity-Conflict Model suggests that bottom-up models will dominate in such cases. I exploit variation across states in the implementation of online health insurance marketplaces to test whether the federal- (top-down) or state-managed (bottom-up) implementation model produced better outcomes. Specifically, the study examines if state, federal or partnership exchanges were most effective at offering generous plans for consumers based on premiums, deductibles and copayments in 2014, the first year of operation. The results unambiguously indicate that state exchanges were most successful. The findings provide evidence for what Matland suspected – that bottom-up models, by providing more discretion to local implementers to adapt to contexts and build coalitions, are superior for high-conflict, high-ambiguity policies.

Does health plan generosity enhance hospital market power?

We test whether the generosity of employer-sponsored health insurance facilitates the exercise of market power by hospitals. We construct indices of health plan generosity and the price and volume of hospital services using data from Truven MarketScan for 601 counties from 2001 to 2007. We use variation in the industry and union status of covered workers within a county over time to identify the causal effects of generosity. Although OLS estimates fail to reject the hypothesis that generosity facilitates the exercise of hospital market power, IV estimates show a statistically significant and economically important positive effect of plan generosity on hospital prices in uncompetitive markets, but not in competitive markets. Our results suggest that most of the aggregate effect of hospital market structure on prices found in previous work may be coming from areas with generous plans.

Plan Generosity in Health Insurance Exchanges: What the Affordable Care Act Can Teach Us About Top-Down vs. Bottom-Up Policy Implementation

The landmark United States health care reform law, the Affordable Care Act, contained the seeds of a natural experiment in policy implementation. The law envisioned the creation of online marketplaces that would offer affordable health insurance plans to consumers. It intended each state to develop its own exchange but stipulated that the federal government would create exchanges if states opted not to do so. In 2014, 27 federal, 16 state, and 7 partnership exchanges launched. I use the variation in implementation across states to test whether a top-down or bottom-up framework more closely explains the observed outcomes. The study examines if state, federal, or partnership exchanges were most effective at offering generous plans based on premiums, deductibles, and copayments. The results unambiguously indicate that state exchanges were most successful. The findings align closely with the bottom-up implementation perspective, which focuses on the influence of discretion at lower-levels of implementation hierarchies.

The effects of retiree health insurance plan characteristics on retirees’ choice and employers’ costs

To moderate the rate of growth of retiree health insurance costs, employers can modify plans and move retirees into less expensive plans. We examine policy modifications implemented by the North Carolina State Health Plan. We investigate whether incentives produce the desired plan elections and whether these changes, along with cost shifting, produce the expected reductions in cost growth. Using individual-level administrative data, along with aggregated data on expenditures for retirees, we estimate the effects of the introduction and subsequent repeal of a Comprehensive Wellness Initiative for non-Medicare eligible retirees, as well as increases in coinsurance and copayments and the introduction of a premium for all retirees. Over a third of non-Medicare retirees shifted into the least generous plan between June 2009 and December 2012. The level effects on annual costs and unfunded accrued liabilities were relatively modest, but growth rates were diminished. Increases in the retiree premiums reduced the state's projected costs.

Moral Hazard and Adverse Selection in Private Health Insurance

Moral hazard and adverse selection create inefficiencies in private health insurance markets. The authors use claims data from a large firm to study the independent roles of both moral hazard and adverse selection. Previous studies have attempted to estimate moral hazard in private health insurance by assuming that individuals respond only to the spot price, end-of-year price, average price, or a related metric. There is little economic justification for such assumptions and, in fact, economic intuition suggests that the nonlinear budget constraints generated by health insurance plans make these assumptions especially poor. They study the differential impact of the health insurance plans offered by the firm on the entire distribution of medical expenditures without parameterizing the plans by a specific metric. They use a new instrumental variable quantile estimation technique introduced in Powell (2013b) that provides the quantile treatment effects for each plan, while conditioning on a set of covariates for identification purposes. This technique allows us to map the resulting estimated medical expenditure distributions to the nonlinear budget sets generated by each plan. Their method also allows them to separate moral hazard from adverse selection and estimate their relative importance. They estimate that 77% of the additional medical spending observed in the most generous plan in their data relative to the least generous is due to adverse selection. The remainder can be attributed to moral hazard. A policy which resulted in each person enrolling in the least generous plan would cause the annual premium of that plan to rise by over $1,500.

Measuring the Financial Exposure from Medical Care Spending Among Families with Employer Sponsored Insurance.

We develop an empirical method to assess the degree of financial exposure associated with medical care spending among non-elderly US families with employer-sponsored insurance. A key feature of this method is its simplicity - it only requires data on out-of-pocket (OOP) health care spending and total health care spending and does not require detailed knowledge of health insurance benefit design. We apply our method to assess whether families with a chronically ill member face more financial exposure given their level of total spending relative to families with no chronically ill members. We find that the insured chronically ill face more financial exposure than the insured non-chronically ill. Additional analyses suggest that the reason for this additional financial exposure is not that families with a chronically ill member are in different, less generous plans, on average. Rather, families with a chronically ill member have higher spending on certain types of medical services (e.g., pharmaceuticals) that face higher levels of coinsurance. Given recent work on value-based insurance design and coinsurance as an obstacle to medication adherence, our findings suggest that the current design of health plans could jeopardize both the health and the financial well-being of the chronically ill.