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HDHPs Pose Burden for Low-Income Adults With Chronic Conditions, Study Finds

Allison Inserro
A new study examining the effect of high-deductible health plans (HDHPs) on low-income adults with multiple chronic conditions found that almost half had a family out-of-pocket (OOP) healthcare burden exceeding 20% of family disposable income.
A new study examining the effect of high-deductible health plans (HDHPs) on low-income adults with multiple chronic conditions found that almost half had a family out-of-pocket (OOP) healthcare burden exceeding 20% of family disposable income. High OOP costs may create a barrier to achieving effective treatment to manage multiple chronic conditions, the authors wrote in the research letter published in JAMA Internal Medicine.

HDHPs are health insurance policies with higher deductibles than traditional insurance plans. Individuals with HDHPs pay lower monthly insurance premiums but pay more OOP for medical expenses until their deductible is met. The growth in HDHP enrollment has been fastest among those with employment-based coverage.  Researchers used 2011-2015 Medical Expenditure Panel Survey Household Component data for 33,619 adults, 19 to 64 years of age enrolled in employer-sponsored insurance plans. Low-income adults were identified as those with family income less than 250% of the federal poverty level, and OOP healthcare costs exceeding 20% was used as a measure of high burden.

The authors wrote that while only 22% of the overall low-income population had full-year employer-sponsored insurance, their financial burden is worrisome because they are not eligible for the premium and cost-sharing subsidies in the healthcare marketplaces created by the Affordable Care Act (ACA). They may also be ineligible for Medicaid depending on their income and whether their state expanded Medicaid, as allowed under the ACA.

The prevalence of a 20% burden was 7.3% (95% CI, 6.4%-8.3%; P <.001) for those enrolled in a HDHP vs 5.9% (95% CI, 5.2%- 6.6%; P = .001) for those enrolled in a low-deductible health plan and 4.3% (95% CI, 3.7%-4.9%) for those enrolled in a no-deductible health plan.

Among low-income adults with no chronic condition or only 1 chronic condition, the prevalence of 20% burden among those enrolled in a HDHP was 20.6% (95% CI, 16.6%-24.6%; P <.001) and the prevalence among those enrolled in a low-deductible plan was 17.5% (95% CI, 15.%-20%; P <.001), compared with 11% (95% CI, 8.5%-13.4%) among those enrolled in a no-deductible plan.

The prevalence of 20% burden was higher for those with 2 or more chronic conditions, at 46.9% (95% CI, 37.5%-56.3%; P <.001) for those enrolled in a high-deductible plan and 36.9% (95% CI, 31.3%-42.5%; P = .001) for those enrolled in a low-deductible plan, compared with 22% (95% CI, 14.9%-29.%) among those enrolled in a no-deductible plan. The differences in burden across deductible levels remained similar when controlling for sociodemographic factors and self-reported health status

Among low-income adults, those with high-deductible or low-deductible plans were more likely to face 20% burdens than those with no-deductible plans among individuals with diabetes (42.4% [95% CI, 27.8%- 57.1%]; P = .005; and 31.9% [95% CI, 24.5%-39.3%]; P = .03; vs 19.1% [95% CI, 10.9%-27.4%]) and those with hypertension (38.2% [95% CI, 29.6%-46.8%] and 31.5% [95% CI, 26.4%- 36.6%] vs 18% [95% CI, 12.6%-23.4%]; P <.001).

The CDC said in August that enrollment in HDHPs with and without accompanying health savings accounts surged among working-age adults, while use of traditional health plans decreased.

Reference

Abdus S, Keenan PS. Financial burden of employer-sponsored high-deductible health plans for low-income adults with chronic health conditions. [published online October 8, 2018]. JAMA Intern Med. doi: 10.1001/jamainternmed.2018.4706.

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