Kullgren JT. Arch Intern Med. 2010;170:1918-1925.
Lower-income families with high-deductible health plans were more likely
to forgo or delay health care due to out-of-pocket expenses, according to
Jeffrey T. Kullgren, MD, MPH, a Robert Wood Johnson Foundation Clinical
Scholar at the Philadelphia VA Medical Center and the University of
Decades of health services research have demonstrated that higher
levels of cost-sharing reduce
health care utilization, sometimes with greater
adverse consequences for low-income patients, the researchers wrote.
Ideally, high-deductible health plans could stimulate patients to become
more sophisticated consumers, but people with low incomes have not demonstrated
the same levels of engagement in managing their health care as those with
Kullgren and researchers from Harvard Medical School conducted a
cross-sectional survey to see how the experience of lower- and higher-income
families with high-deductible health plans compare. The researchers also
hypothesized that lower-income families would demonstrate lesser understanding
of their health plans.
The study participants were identified from the enrollees of
health plans in the Harvard Pilgrim Health Care
system. People were chosen if they had a deductible of at least $1,000 for an
individual or $2,000 for a family. Other criteria included continuous
enrollment in a high-deductible health plan for at least 6 months, at least one
children younger than 18 years enrolled in the plan and annualized
out-of-pocket costs of at least $500 (for doctor visit and prescription drug
Of 2,635 eligible families, surveys were mailed to 750, and 434 surveys
were completed by mail or telephone. The researchers stratified the respondents
into a lower US Census Bureau block group and a higher US Census Bureau block
group. There were no significant differences between the groups in the mean
deductible or the mean out-of-pocket expenses for 6 months.
For the lower-income group, 51.1% reported having delayed or forgone
adult care due to cost compared with 34.8% of the higher-income group. Those
from the lower-income group were also more likely to delay or forgo operations
or procedures due to cost: 19.8% vs. 6% of those in the higher-income group.
Those in lower-income families were not more likely than higher-income
families to find their health plan difficult to understand. Most respondents
from each group also reported that they would be more likely to talk to their
physicians about delaying services due to cost.
Based on our findings
policymakers could consider reducing
deductibles for lower-income families, limiting deductibles to a proportion of
a familys income, or providing income-based cost-sharing subsidies,
the researchers wrote.