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Cole MB, Ellison JE, Trivedi AN. Association Between High-Deductible Health Plans and Disparities in Access to Care Among Cancer Survivors. JAMA Netw Open. 2020;3(6):e208965. doi:10.1001/jamanetworkopen.2020.8965
Enrollment in high-deductible health plans (HDHPs), which increased from 8% in 2009 to 30% in 2019 among people with employer-sponsored coverage,1 is associated with less use of health care, including cancer screening and treatment.2,3 High-deductible health plans may have greater consequences for racial/ethnic minorities, given evidence that other forms of cost sharing contribute to disparities in care.4 However, few studies have examined the association between HDHPs and racial/ethnic disparities. This study examined the differential association between HDHP enrollment and access to care by race/ethnicity among cancer survivors, a population that often faces substantial cost-related barriers to care.5
We identified privately insured adults aged 18 to 64 years with a past or current cancer diagnosis (N = 3713, representing 1.16 million patients nationally) using pooled 2013-2018 National Health Interview Survey data. Boston University’s Institutional Review Board deemed the study exempt because the data were publicly available. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Doubly robust ordinary least squares regression models with stabilized inverse probability of treatment weights (IPTWs), which were based on propensity scores and multiplied by survey weights, estimated the association between HDHP enrollment and 8 measures of cost-related barriers to accessing care (eg, skipping medication to save money, inability to afford a specialist). Propensity scores, which balanced on observable covariates for patients with vs without an HDHP, included 16 patient-level sociodemographic and clinical covariates (Table 1). The parameter of interest was an interaction between HDHP enrollment and self-reported race/ethnicity; black vs non-Hispanic white was the main comparison of interest. Models were further adjusted for year and for the covariates included in the propensity score and used robust variance estimators. P values were 2-tailed, and statistical significance was set at α = .05. Analyses were performed using Stata statistical software, version 15.0 (StataCorp).
Among the 3713 cancer survivors whose data were included in the analysis, 2407 (64.8%) were women, 1305 (35.2%) were men, 3264 (87.9%) were non-Hispanic white individuals, and the mean (SD) age was 53.8 (9.2) years. Compared with cancer survivors not enrolled in an HDHP, cancer survivors enrolled in an HDHP were more likely to be non-Hispanic white individuals (1481 of 1646 [90.0%] vs 1783 of 2067 [86.3%]) and less likely to have diabetes (195 of 1646 [11.8%] vs 321 of 2067 [15.5%]) or hypertension (638 of 1646 [38.8%] vs 900 of 2067 [43.5%]) (Table 1); other characteristics were statistically similar. After applying IPTWs, there were no statistical differences in observed characteristics between the 2 groups.
Forty-four percent of privately insured cancer survivors were enrolled in an HDHP during the study period (2013-2018), although this percentage ranged from 37% in 2013 to 50% in 2018. Enrollment in an HDHP was associated with greater cost-related barriers to accessing care when comparing cancer survivors with vs without an HDHP, and the magnitude of the association was statistically significantly larger for black vs white patients for 4 of 8 measures examined (Table 2). For example, 13 of 57 (22.8%) black vs 118 of 1481 (8.0%) white cancer survivors with an HDHP skipped medication to save money, compared with 9 of 117 (7.7%) black vs 97 of 1783 (5.4%) white cancer survivors without an HDHP (adjusted interaction coefficient = 17.6 percentage points; 95% CI, 3.8-31.3; P = .01). Enrollment in an HDHP also had a greater adverse association with black vs white patients when assessing the use of less medication to save money (adjusted interaction coefficient = 19.7 percentage points; 95% CI, 5.8-33.6; P = .006), delays in filling a prescription to save money (adjusted interaction coefficient = 15.4 percentage points; 95% CI, 0.1-30.7; P = .049), and being unable to afford a specialist (adjusted interaction coefficient = 16.9 percentage points; 95% CI, 1.2-32.7; P = .04).
We found that HDHPs were associated with cost-related barriers to care for cancer survivors, and these barriers were significantly greater for black patients. These findings align with those of studies showing that HDHPs reduce access to and use of cancer-related services2,3 and add to the only known prior study on racial/ethnic disparities in HDHPs, which found no racial/ethnic differences in cardiovascular medication adherence owing to HDHP enrollment.6 Our study limitations included potential unobserved confounding between those with vs without an HDHP, small samples for racial subgroups, and lack of information on plan options. Nonetheless, this study found that the magnitude of association between HDHPs and cost-related barriers to care is larger among black cancer survivors relative to their white counterparts, elucidating the potential for HDHPs to widen documented racial/ethnic disparities in cancer outcomes.
Accepted for Publication: April 19, 2020.
Published: June 24, 2020. doi:10.1001/jamanetworkopen.2020.8965
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Cole MB et al. JAMA Network Open.
Corresponding Author: Megan B. Cole, PhD, MPH, Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Talbot Bldg 240W, Boston, MA 02118 (email@example.com).
Author Contributions: Dr Cole had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Cole.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Cole.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cole.
Obtained funding: Cole.
Administrative, technical, or material support: Cole, Ellison.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by a Peter Paul Career Development Award from Boston University (Dr Cole).
Role of the Funder/Sponsor: Boston University 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.
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