Dr Erlebacher identifies an important limitation of our study. Our survey found that lower-income families reported higher rates of delayed or foregone care due to cost. The study design did not enable us to determine how essential the delayed or foregone services may have been.
Previous studies suggest that cost-sharing affects both essential and less-essential care. The RAND Health Insurance Experiment referenced by Dr Erlebacher showed that patients exposed to high levels of cost sharing reduced their use of highly-effective care and less-effective care in similar proportions.1,2 A more recent study by Hibbard et al3 found that new enrollees in a consumer-directed health plan (CDHP) reduced their use of high-priority office visits as often as their use of low-priority office visits.
Kullgren JT, Lieu TA. More Health Care Is Not Necessarily Better Health Care—Reply. Arch Intern Med. 2011;171(12):1124. doi:10.1001/archinternmed.2011.269