High Deductible Health Plans and Receipt of Recommended Medical Care

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Enrollment in high deductible health plans (HDHPs) has increased 50% in the past 5 years, with more than 45% of privately-insured Americans enrolled in such plans. HDHPs require patients to pay 100% of the costs of most care (excluding some primary or secondary preventive care) out of pocket until a (high) deductible is met. Services provided for chronic disease management are subject to this deductible. Therefore, it is unclear whether this form of insurance supports healthy aging, especially for the 70% of Americans aged 50-64 (an NIA priority population) with chronic illness. High patient cost-sharing has caused decreases in use of both necessary and unnecessary health care. However, it is not known whether reductions in healthcare use mean that patients are not receiving the types of healthcare required to manage their chronic diseases. The overarching goal of this study is to ascertain whether the high cost-sharing design of HDHPs results in chronically-ill patients not receiving the evidence-based, high-quality care recommended for management their illnesses and secondarily, whether the cost barriers built into their design result in poorer health outcomes for HDHP enrollees. We also estimate the magnitude of patient spending required to receive high quality care in HDHPs versus non-HDHPs and investigate any race-, gender-, or income-based disparities in care experienced by HDHP patients. We focus our HDHP investigations on patients who have one or more of the following common chronic illnesses: diabetes, coronary artery disease, heart failure, asthma, hypertension, or major depression. Lastly, we use a temporary benefit design change enacted during the COVID-19 pandemic as an exogenous shock to understand the impact of HDHPs on receipt of recommended medical care. Previously HDHP research has not focused on impacts on populations most in need of services (i.e., those with chronic conditions) and the impact of HDHPs on disparities. We evaluate, for the substantial proportion of mid-life adults with high healthcare needs, whether this common benefit design results in lower utilization of care (due to high patient out-of-pocket costs) and adverse health outcomes. Results from this work are policy-relevant. Findings can inform regulations regarding the exemption of chronic disease management from insurance deductibles and identify the best way to support value-based insurance design. To ensure findings reach decision makers, we will disseminate results through RAND Research Briefs to insurance purchasers, leaders at insurance companies, state departments of insurance, and members of Congress, in addition to traditional mechanisms of dissemination to the scientific community.