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Table 1.  
Characteristics of Nonelderly US Adults by Deductible Category
Characteristics of Nonelderly US Adults by Deductible Category
Table 2.  
Associations Between Deductible Categories and Annual Out-of-Pocket Spending, High Medical Burden, and Cost-Related
Associations Between Deductible Categories and Annual Out-of-Pocket Spending, High Medical Burden, and Cost-Related
1.
Claxton  G, Rae  M, Panchal  N,  et al.  Health benefits in 2015: stable trends in the employer market. Health Aff (Millwood). 2015;34(10):1779-1788.
PubMedArticle
2.
Galbraith  AA, Ross-Degnan  D, Soumerai  SB, Rosenthal  MB, Gay  C, Lieu  TA.  Nearly half of families in high-deductible health plans whose members have chronic conditions face substantial financial burden. Health Aff (Millwood). 2011;30(2):322-331.
PubMedArticle
3.
Galbraith  AA, Soumerai  SB, Ross-Degnan  D, Rosenthal  MB, Gay  C, Lieu  TA.  Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med. 2012;27(9):1105-1111.
PubMedArticle
4.
Kullgren  JT, Galbraith  AA, Hinrichsen  VL,  et al.  Health care use and decision making among lower-income families in high-deductible health plans. Arch Intern Med. 2010;170(21):1918-1925.
PubMedArticle
5.
Fleishman  JA, Cohen  JW.  Using information on clinical conditions to predict high-cost patients. Health Serv Res. 2010;45(2):532-552.
PubMedArticle
6.
Cunningham  PJ.  The share of people with high medical costs increased prior to implementation of the Affordable Care Act. Health Aff (Millwood). 2015;34(1):117-124.
PubMedArticle
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Research Letter
January 09, 2017

Health Insurance Deductibles and Their Associations With Out-of-Pocket Spending and Affordability Barriers Among US Adults With Chronic Conditions

Author Affiliations
  • 1Department of Health Policy and Administration, Pennsylvania State University, University Park
  • 2Penn State Hershey Cancer Institute, Hershey, Pennsylvania
  • 3Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
  • 4Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 5University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
JAMA Intern Med. Published online January 9, 2017. doi:10.1001/jamainternmed.2016.8419

Privately insured Americans increasingly face health plan deductibles,1 which can elevate exposure to financial risk2 and may lead to delayed or foregone care.3,4 It is unknown to what extent these deductibles increase financial risks and decrease the ability to afford care among Americans with chronic conditions who could be more vulnerable to such outcomes. Our objectives were to compare associations between private health plan deductibles and out-of-pocket (OOP) spending, high medical cost burdens, and cost-related access barriers among nonelderly US adults with chronic conditions.

Methods

We analyzed 2011-2013 data from the nationally representative Medical Expenditure Panel Survey (MEPS). The sample consisted of MEPS participants aged 18 to 64 years who were continuously insured by a single, private health plan for the past year. We classified plans as having a high deductible (based on annual Internal Revenue Service definitions), low deductible (ie, a deductible below the Internal Revenue Service threshold for high-deductible plans), or no deductible. Chronic conditions included heart disease, hypertension, diabetes, asthma, joint disease, nonskin cancer, and mood disorders identified using the MEPS Conditions File.5 The Pennsylvania State University Institutional Review Board deemed the research exempt and waived the need for informed consent.

We estimated associations between each deductible category and annual OOP health care spending using multivariate quantile regression. We used multivariate logistic regression to estimate associations between each category and the annual likelihood of spending 10% or more of household income on health care or OOP premiums (ie, high medical cost burden6) and reporting unmet or delayed care due to cost.

Results

Our sample of 17 177 individuals included 4120 persons with a high-deductible plan, 7767 with a low-deductible plan, and 7639 (44.5%) with at least 1 chronic condition (Table 1). Median OOP spending was $225 (95% CI, $165-$285; P < .001) greater in high-deductible and $111 (95% CI, $72-$150; P < .001) greater in low-deductible plans compared with no-deductible plans (Table 2). At the 90th percentile of OOP spending, these differences increased to $1072 (95% CI, $813-$1332; P < .001) for high-deductible and $338 (95% CI, $162-$514; P < .001) for low-deductible compared with no-deductible plans. Higher OOP spending was identified for individuals with hypertension, joint disorders, mood disorders, or multiple chronic conditions in high-deductible and low-deductible plans compared with no-deductible plans. The prevalence of high medical cost burdens was 7.5 percentage-points (95% CI, 4.6-10.4; P < .001) greater in high-deductible and 3.7 percentage-points (95% CI, 0.8-6.6; P < .01) greater in low-deductible plans compared with no-deductible plans. There were no differences in the prevalence of cost-related access barriers between deductible categories except for a 5.8 percentage-point (95% CI, 0.4-11.2; P = .04) greater prevalence among individuals with asthma in high-deductible compared with no-deductible plans.

Discussion

Among chronically ill Americans, both high- and low-deductible plans are associated with greater OOP spending and more frequent high medical cost burdens, but not more frequent delayed or foregone care owing to cost. Although deductibles can be blunted for some low-income individuals in Marketplace plans, many privately insured individuals do not qualify for subsidies and face substantial financial risks. Our finding that deductibles are not associated with more cost-related access barriers for individuals with chronic conditions contrasts with prior findings, perhaps because our estimates are nationally representative rather than from a single regional health insurer.3,4 Furthermore, since the prior work, cost-sharing has risen for all plan types,1 which could make differences between deductible levels more difficult to detect. As more privately insured Americans with chronic conditions face deductibles in employer-sponsored and Marketplace health plans, it will be crucial to monitor not only their OOP health care spending and ability to afford needed care but also their health and financial outcomes.

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Article Information

Corresponding Author: Joel E. Segel, PhD, Department of Health Policy and Administration, Pennsylvania State University, 504 S Ford Bldg, University Park, PA 16802 (jesegel@psu.edu).

Published Online: January 9, 2017. doi:10.1001/jamainternmed.2016.8419

Author Contributions: Dr Segel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Segel.

Administrative, technical, or material support: Segel.

Study supervision: All authors.

Conflict of Interest Disclosures: Dr Kullgren is a Veterans Affairs Health Services Research and Development Service Career Development awardee at the Veterans Affairs Ann Arbor Healthcare System and has received consulting fees from SeeChange Health and HealthMine. No other disclosures were reported.

Funding/Support: Support was provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

References
1.
Claxton  G, Rae  M, Panchal  N,  et al.  Health benefits in 2015: stable trends in the employer market. Health Aff (Millwood). 2015;34(10):1779-1788.
PubMedArticle
2.
Galbraith  AA, Ross-Degnan  D, Soumerai  SB, Rosenthal  MB, Gay  C, Lieu  TA.  Nearly half of families in high-deductible health plans whose members have chronic conditions face substantial financial burden. Health Aff (Millwood). 2011;30(2):322-331.
PubMedArticle
3.
Galbraith  AA, Soumerai  SB, Ross-Degnan  D, Rosenthal  MB, Gay  C, Lieu  TA.  Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med. 2012;27(9):1105-1111.
PubMedArticle
4.
Kullgren  JT, Galbraith  AA, Hinrichsen  VL,  et al.  Health care use and decision making among lower-income families in high-deductible health plans. Arch Intern Med. 2010;170(21):1918-1925.
PubMedArticle
5.
Fleishman  JA, Cohen  JW.  Using information on clinical conditions to predict high-cost patients. Health Serv Res. 2010;45(2):532-552.
PubMedArticle
6.
Cunningham  PJ.  The share of people with high medical costs increased prior to implementation of the Affordable Care Act. Health Aff (Millwood). 2015;34(1):117-124.
PubMedArticle
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