High-deductible Health Insurance Research Articles

Racial Wealth Inequality and Access to Care with High-Deductible Health Insurance

This paper evaluates racial inequalities in health-care affordability between high-deductible and conventional insurance. Using the 2011-2017 National Health Interview Survey, the study finds that Blacks in high-deductible plans are not disproportionately higher income, nor more engaged in other savings vehicles, unlike their White counterparts, indicating they may be income constrained rather than desiring to partially self-insure. Furthermore, conditional on income, wealth explained more of the racial disparity in health-care access among high-deductible enrollees than conventional enrollees, consistent with the hypothesis that benefit designs relying on households' cash reserves would yield greater disparities due to the magnitude of racial inequalities in assets.

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions.

Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.

Trend and effects of high-deductible health insurance plans in the health care system: financial access problems in management of cognitive impairment.

BACKGROUND: High-deductible health plans (HDHPs) are characterized by higher deductibles and lower monthly premiums compared with a typical health plan. HDHPs may reduce, or delay, needed care, which will ultimately lead to poorer access to care for chronically affected participants. OBJECTIVES: To (1) investigate the HDHP enrollment trend and (2) determine the effects of HDHPs on financial access problems for individuals with self-reported cognitive impairment. METHODS: Data between 2010 and 2018 were obtained from the National Health Interview Survey (NHIS). Individuals with cognitive impairment were identified if they were limited by memory difficulties. Problems regarding financial access to health care were assessed based on 6 survey questions from the Centers for Disease Control and Prevention. Multivariable logistic regressions were implemented to evaluate the effects of HDHPs. RESULTS: This study identified 1,148 individuals with cognitive impairment, representing 3.9 million individuals in the United States from 2010 to 2018. A nearly 2-fold increase in HDHP enrollment with cognitive impairment was observed from 2010 (20.9%) to 2018 (41.9%). This increase is similar to that reported for noncognitively impaired individuals. After controlling for possible confounding variables, cognitively impaired individuals with HDPHs were more likely to have overall financial access difficulties compared with those without HDHPs (OR = 1.17, 95% CI = 0.88-1.56, P = 0.271), but this likelihood was not statistically significant. CONCLUSIONS: HDHPs are intended to support effective care options and reduce health care costs. However, our research found that among individuals with cognitive impairment, those with HDHPs experienced some financial access problems, such as affording medical care, follow-up care, and specialists, than those without HDHPs, indicating that HDHPs might have unintended consequences for health care usage. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest or financial interests to disclose.

December Is Coming: A Time Trend Analysis of Monthly Variation in Adult Elective Anesthesia Caseload across Florida and Texas Locations of a Large Multistate Practice.

Anesthesia staffing models rely on predictable surgical case volumes. Previous studies have found no relationship between month of the year and surgical volume. However, seasonal events and greater use of high-deductible health insurance plans may cause U.S. patients to schedule elective surgery later in the calendar year. The hypothesis was that elective anesthesia caseloads would be higher in December than in other months. This review analyzed yearly adult case data in Florida and Texas locations of a multistate anesthesia practice from 2017 to 2019. To focus on elective caseload, the study excluded obstetric, weekend, and holiday cases. Time trend decomposition analysis was used with seasonal variation to assess differences between December and other months in daily caseload and their relationship to age and insurance subgroups. A total of 3,504,394 adult cases were included in the analyses. Overall, daily caseloads increased by 2.5 ± 0.1 cases per day across the 3-yr data set. After adjusting for time trends, the average daily December caseload in 2017 was 5,039 cases (95% CI, 4,900 to 5,177), a 20% increase over the January-to-November baseline (4,196 cases; 95% CI, 4,158 to 4,235; P < 0.0001). This increase was replicated in 2018: 5,567 cases in December (95% CI, 5,434 to 5,700) versus 4,589 cases at baseline (95% CI, 4,538 to 4,641), a 21.3% increase; and in 2019: 6,103 cases in December (95% CI, 5,871 to 6,334) versus 5,045 cases at baseline (95% CI, 4,984 to 5,107), a 21% increase (both P < 0.001). The proportion of commercially insured patients and those aged 18 to 64 yr was also higher in December than in other months. In this 3-yr retrospective analysis, it was observed that, after accounting for time trends, elective anesthesia caseloads were higher in December than in other months of the year. Proportions of commercially insured and younger patients were also higher in December. When compared to previous studies finding no increase, this pattern suggests a recent shift in elective surgical scheduling behavior.

The Effects of High-Deductible Health Insurance on Health Trends and Lifestyle

The Effects of High-Deductible Health Insurance on Health Trends and Lifestyle

The Changing Health Insurance Coverage Landscape in the United States.

Changes in the health insurance coverage landscape in the United States during the past decade have important implications for receipt and affordability of cancer care. In this paper, we summarize evidence for the association between health insurance coverage and cancer prevention and treatment. We then discuss ongoing changes in health care coverage, including implementation of provisions of the Affordable Care Act, increasing prevalence of high-deductible health insurance plans, and factors that affect health care delivery, with a focus on vertical integration of hospitals and providers. We summarize the evidence for the effects of the changes in health coverage on care and discuss areas for future research with the goal of informing efforts to improve cancer care delivery and outcomes in the United States.

Assessment of Accuracy and Usability of a Fee Estimator for Ambulatory Care in an Integrated Health Care Delivery Network

Given increased enrollment in high-deductible health insurance plans and mandates from the Patient Protection and Affordable Care Act, individualized price transparency tools are needed. To assess accuracy and initial user experience of a cost estimation tool for ambulatory procedures delivered via an online patient portal and informed by real-time data feeds from third-party payers. This quality improvement study included patients aged 18 years and older at an integrated health care system in Northern California. Data from patients who used the cost estimator tool from August 21, 2018, to April 9, 2019, and who had matching explanation of benefits statements were used to assess accuracy of the tool. User experience was assessed with a brief survey completed online or via postal mail. Data were analyzed from April 15, 2019, to October 11, 2019. Tool accuracy and user experience and satisfaction. As of April 30, 2019, 4610 estimates (3569 [77.4%] via internet; 1041 [22.6%] via telephone) were produced using the cost estimator tool. Among 342 individuals who had an estimate and a matching explanation of benefits statement, 287 estimates (83.9%) were accurate. All 342 individuals with an estimate and an explanation of benefits statement were invited to participate in a user survey, and 125 individuals completed the survey (36.5% response rate). Survey respondents included 92 (73.6%) women, 72 (57.6%) non-Hispanic white participants , 91 participants (72.8%) with a college degree or higher, and 55 participants (44.0%) with an income of $100 000 per year or higher. Mean (SD) age was 46.8 (13.1) years. Ninety-nine participants (79.2%) found the tool easy to use, 109 participants (87.2%) would use it again, and 100 participants (80.0%) would recommend it to others. Seven participants (5.6%) reported contacting a clinician about the estimate, and 12 participants (9.6%) changed their decision based on the estimate. This quality improvement study is the first report of an online cost estimator in an integrated health care delivery network. The findings suggest that the tool, informed by real-time data feeds from third-party payers, was easy to use and provided accurate results. Increasing the number of searchable services and sharing best practices with other health care systems who share the same portal platform are the next steps for the tool.

Rising medication costs for patients with neurologic disorders.

Costs for health care are rising in the United States,1 and high drug prices are a large part of those costs. These prices, even for some drugs that have been available for a long time, are growing faster than other health care costs. In addition, the way patients pay for care has changed. In the last few years, high-deductible health insurance plans are more common. This means that patients are paying more out-of-pocket than they would have before. Rising costs of medical care, higher drug prices, and more out-of-pocket expenses means the topic of drug costs is important to patients.

Responses to losses in high-deductible health insurance: persistence, emotions, and rationality

AbstractThere have been few empirical studies on how consumers respond to their loss experience over time when choosing between high- and low-deductible health insurance plans. To address this question, we designed a ten-period web-based experiment to explore how subjects respond to the presence or absence of illness-related costs in a given period when making their future health insurance choices when they are explicitly informed that future premiums or loss probabilities will not change over time. A sizable minority of the respondents who initially chose high-deductible plans switched after a loss, and switching is more likely if they self-report negative emotional responses to experiencing an uninsured loss. Switching from low- to high-deductible plans is less likely and less responsive to loss experience. The study reveals that many individuals make their health insurance choices by considering factors not included in classical economic models of choice.

Switching to High-Deductible Health Plans: It Is Going to Be a Bumpy Ride

In their study, Wharam and colleagues take a useful step in evaluation of high-deductible health insurance plans. The editorialist discusses the findings and the difficulty of determining the value...

Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost

Navigating health insurance and health care choices requires considerable health insurance literacy. Although recommended preventive services are exempt from out-of-pocket costs under the Affordable Care Act, many people may remain unaware of this provision and its effect on their required payment. Little is known about the association between individuals' health insurance literacy and their use of preventive or nonpreventive health care services. To assess the association between health insurance literacy and self-reported avoidance of health care services owing to cost. In this survey study, a US national, geographically diverse, nonprobability sample of 506 US residents aged 18 years or older with current health insurance coverage was recruited to participate in an online survey between February 22 and 23, 2016. The validated 21-item Health Insurance Literacy Measure (HILM) assessed individuals' self-rated confidence in selecting and using health insurance (score range, 0-84, with higher scores indicating greater levels of health insurance literacy). Dependent variables included delayed or foregone preventive and nonpreventive services in the past 12 months owing to perceived costs, and preventive and nonpreventive use of services. Covariates included age, sex, race/ethnicity, income, educational level, high-deductible health insurance plan, health literacy, numeracy, and chronic health conditions. Analyses included descriptive statistics and bivariate and multivariable logistic regression. A total of 506 of 511 participants who began the survey completed it (participation rate, 99.0%). Of the 506 participants, 339 (67.0%) were younger than 35 years (mean [SD] age, 34 [10.4] years), 228 (45.1%) were women, 406 of 504 who reported race (80.6%) were white, and 245 (48.4%) attended college for 4 or more years. A total of 228 participants (45.1%) had 1 or more chronic health condition, 361 of 500 (72.2%) who responded to the survey item had seen a physician in the outpatient setting in the past 12 months, and 446 of the 501 (89.0%) who responded to the survey item had their health insurance plan for 12 or more months. One hundred fifty respondents (29.6%) reported having delayed or foregone care because of cost. The mean (SD) HILM score was 63.5 (12.3). In multivariable logistic regression, each 12-point increase in HILM score was associated with a lower likelihood of both delayed or foregone preventive care (adjusted odds ratio [aOR], 0.61; 95% CI, 0.48-0.78) and delayed or foregone nonpreventive care (aOR, 0.71; 95% CI, 0.55-0.91). This study's findings suggest that lower health insurance literacy may be associated with greater avoidance of both preventive and nonpreventive services. It appears that to improve appropriate use of recommended health care services, including preventive health services, clinicians, health plans, and policymakers may need to communicate health insurance concepts in accessible ways regardless of individuals' health insurance literacy. Plain language communication may be able to improve patients' understanding of services exempt from out-of-pocket costs.

2EMF Understanding Emergency Medicine Providers’ Perceptions of the ACA in a Renewed Era of Health Care Reform: National Survey and Qualitative Mixed-Methods Approach

The 2010 ACA has been a source of divisive political conversation and widespread health care reform. In recent months, it has been the center of renewed national attention as many of the law’s key provisions face potential restructuring or repeal. Amidst the changing health system, emergency physicians take on a unique role, serving as the first point of contact for many patients. The objective of this study was to understand their perspectives, illustrating how current and future emergency physicians view the ACA and its impact on patients. The study consisted of 3 parts: a survey of a nationally representative subset of FACEP; a survey of current medical students intending to go into emergency medicine at 8 US medical schools; and a series of 35 qualitative in-depth interviews with current medical students, residents, and emergency physicians across the Yale New Haven Health System. All study parts were completed between September 2017-April 2018. Data were analyzed using descriptive statistics and a grounded theory approach. In order to compare outcomes between surveys, FACEP and medical students were matched on sex, race/ethnicity, and political ideology using coarsened-exact matching. A total of 945 FACEP and 137 medical students interested in EM completed the surveys (response rate: ≥98% FACEP and 36.9% of all medical students surveyed of whom 8.3% were interested in emergency medicine). Overall, 48.5% of physicians indicated having “good knowledge” of the ACA, 59.3% indicated support for the law, and 54.1% indicated that the ACA has resulted in better care for emergency medicine patients. Disagreement with parts of the law (31.9%) and issues with ACA design/implementation (18.8%) were cited as the most common reasons for opposition. Compared to practicing physicians, medical students planning a career in emergency medicine were significantly more likely to self-identify as having “good knowledge” of the ACA (RR[95% CI]: 2.10[1.90-2.31), indicate support for the ACA (1.53[1.39-1.69]), and believe that the ACA has resulted in better overall care for patients (1.35[1.23-1.49]). When asked in interviews about their perceived knowledge of the ACA, EM providers at Yale were more cautious about their proficiency (10/35 reported having “good knowledge”). All acknowledged at least partial support of the law, noting in select comments that “broadening of health care coverage is a moral imperative [⋯] no other viable alternatives have been proposed.” (resident) and that “while I struggle with the law as a whole, everyone deserves health insurance” (physician). All denied changes in their desire to practice medicine and the way that they perceive their work. They did, however, acknowledge an increased number of insured adult patients, awareness of cost-shifting within the hospital system, and concerns among patients with high-deductible private health insurance plans “about the costs of things like observation versus admission.” Both pediatric and adult providers reported seeing more patients. Despite differences in political ideology and concerns about aspects of the ACA, a majority of practicing physicians and medical students report support for the ACA. Future emergency physicians and residents were significantly more likely than board-certified physicians to favorably view the law and its impact on patients, providing insight into the potential direction of health care reform inspired by the next generation of front-line physicians.

Health Savings Accounts: Consumer Contribution Strategies and Policy Implications.

Background. Health savings accounts (HSAs) are tax-advantaged savings accounts available only to households with high-deductible health insurance. This article provides initial answers to two questions: 1) How should a household budget for its annual HSA contributions? 2) Do current contribution limits provide households with the flexibility to use HSAs efficiently? To answer these questions, we formulate the household’s problem as one of determining a contribution strategy for minimizing total expected discounted medical costs. Methods. We use the 2002–2014 Medical Expenditure Panel Survey to develop a novel data-driven model for forecasting a household’s health care costs based on its current cost percentile and other characteristics. A dynamic policy, in which the contribution each year brings the HSA balance up to a household-specific threshold, is derived. This is compared to a simpler static policy in which the target HSA balance is simply the plan’s out-of-pocket maximum, with contributions in any year capped by a limit. Results. We find that: 1) the dynamic policy can save a household up to 19% in costs compared to the static one that is a proxy for typical contribution behavior; and 2) the recommended contribution amounts for 9% to 11% of households in a given year materially exceed what is currently allowed by the federal government. Conclusions. The dynamic policy derived from our data-analytic framework is able to unlock significant tax savings for health care consumers. To allow all households to use HSAs in a tax-efficient manner, a two-tiered contribution policy is needed: Allow unlimited contributions up to some balance, and then impose restrictions thereafter. The resulting impact on overall tax receipts is estimated to be well below what is currently allowed by legislation.

Health Savings Accounts: Consumer Contribution Strategies &amp; Policy Implications

Paper available from https://journals.sagepub.com/doi/full/10.1177/2381468318809373 Health Savings Accounts (HSAs) are tax-advantaged savings accounts available only to households with high-deductible health insurance. This paper provides initial answers to two questions: 1) How should a household budget for its annual HSA contributions; and 2) Do current contribution limits provide households with the flexibility to use HSAs efficiently? To answer these questions, we formulate the household's problem as one of determining a contribution strategy for minimizing total expected discounted medical costs. Methods: We use the 2002-14 Medical Expenditure Panel Survey to develop a novel data-driven model for forecasting a household's healthcare costs based on its current cost percentile and other characteristics. A dynamic policy, in which the contribution each year brings the HSA balance up to a household-specific threshold, is derived. This is compared to a simpler static policy in which the target HSA balance is simply the plan's out-of-pocket maximum, with contributions in any year capped by a limit. Results. We find that: 1) The dynamic policy can save a household up to 19% in costs compared to the static one that is a proxy for typical contribution behavior; and 2) The recommended contribution amounts for 9%-11% of households in a given year materially exceed what is currently allowed by the federal government. Conclusions. The dynamic policy derived from our data-analytic framework is able to unlock significant tax savings for healthcare consumers. To allow all households to use HSAs in a tax-efficient manner, a two-tiered contribution policy is needed: Allow unlimited contributions up to some balance, and then impose restrictions thereafter. The resulting impact on overall tax receipts is estimated to be well below what is currently allowed by legislation.

The Cadillac Tax and Its Potential to Transform How Americans Purchase Health Care Services

This Article examines one of the most contentious provisions of the Affordable Care Act – namely, the 40% excise tax on high-value health insurance provided by employers. This levy, commonly denominated the “Cadillac” tax, is scheduled to take effect in 2020 but has already induced many employers to raise annual deductibles on the health insurance they provide to reduce the value of such insurance and thereby lower their exposure to this new tax. After analyzing the administrative guidance proposed since the Cadillac tax’s enactment, this Article considers how that tax’s effective encouragement of high-deductible health insurance plans has inadvertently made the Health Savings Accounts that President George W. Bush promoted 15 years earlier much more appealing.

The effect of Health Savings Accounts on group health insurance coverage

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2–3 percentage point increase in their group insurance coverage.

Constraining Innovation

Constraining Innovation

Navigating the rise of high-deductible health insurance: childbirth in the bronze age.

This Viewpoint examines the possible implications of high-deductible health plans for out-of-pocket childbirth costs and discusses suggestions for policy responses.

Consumer-directed Health Plans With Health Savings Accounts

Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions or effects on patient care seeking. We examined HSA contributions and their source, patient-reported effects of costs on care seeking, and reports of financial burden. We conducted telephone interviews with 488 adult members of small group of employer-sponsored HSA-eligible plans within an integrated delivery system. HSA contribution sources and amounts varied with 32% receiving an employer contribution and also making their own employee contribution, 35% only receiving an employer contribution (no employee contribution), 19% only making their own contribution (no employer contribution), and 14% with no HSA contribution from either source. After adjustment for respondent characteristics, those who made their own HSA contributions in addition to their employer's contribution were significantly more likely to report that costs affected their care-seeking behavior, compared with those with only employer contributions (39% vs. 31% for emergency department and 60% vs. 49% for office visits, all P<0.05). Respondents who contributed to their HSA or who paid out-of-pocket for care were significantly more likely to report financial burdens than those with only employer contributions (P<0.05). The majority of consumers receive employer contributions to their HSA, but few have fully funded accounts. Those with only an employer contribution reported fewer changes in their care-seeking behavior and were less likely to report experiencing financial burdens.

Selection on Moral Hazard in Health Insurance

We use employee-level panel data from a single firm to explore the possibility that individuals may select insurance coverage in part based on their anticipated behavioral ("moral hazard") response to insurance, a phenomenon we label "selection on moral hazard." Using a model of plan choice and medical utilization, we present evidence of heterogeneous moral hazard as well as selection on it, and explore some of its implications. For example, we show that, at least in our context, abstracting from selection on moral hazard could lead to over-estimates of the spending reduction associated with introducing a high-deductible health insurance option.