Lower-income families in high-deductible health plans appear more likely to delay or forgo medical care based on cost than higher-income families with similar coverage, according to a report in the November 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. However, lower-income families did not report any more troubles understanding or using their plans.
"In the midst of the current economic downturn, many Americans are paying more for their health care," the authors write as background information in the article. "One way in which a growing number of families are facing higher levels of cost-sharing for health care is enrollment in high-deductible health plans. These plans, which feature annual deductibles of at least $1,000 per individual and at least $2,000 per family before most services are covered, seek to encourage patients to become more cost-effective consumers of health care and frequently offer lower premiums than other types of health insurance."
Families who enrolled in these plans initially had higher incomes, but lower-income families are now equally likely to be enrolled in high-deductible plans. Jeffrey T. Kullgren, M.D., M.P.H., of Robert Wood Johnson Foundation Clinical Scholars, Philadelphia VA Medical Center and the University of Pennsylvania, Philadelphia, and colleagues surveyed 141 lower-income families (incomes less than 300 percent of the federal poverty level) and 273 higher-income families with a high-deductible health plan in 2009. The 22-item questionnaire gathered information about health plan characteristics, attitudes toward health care use, costs, information-seeking behaviors and demographic characteristics.
Overall, respondents from lower-income families were more likely to report that they had delayed or foregone care because of the cost (57 percent vs. 42 percent), including care for an adult (51.1 percent vs. 34.8 percent), care for a child (24.1 percent vs. 13.9 percent) and operations or procedures (19.8 percent vs. 6 percent).
"Respondents from lower-income families were no more likely than those from higher-income families to find their health plan difficult to understand, or feel their family was not well protected from out-of-pocket health care expenses," the authors write. "In addition, respondents from lower-income families were no less likely than respondents from higher-income families to report having tried to find out in advance whether they would have to pay for a specific service before meeting their deductible limit, or how much they would have to pay for a service since joining their health plan."
Participants were also asked how they would respond to three hypothetical scenarios involving services not covered by their plans -- a $100 blood test during a check-up, a $1,000 colonoscopy or a $2,000 magnetic resonance imaging scan for back pain. Most participants, regardless of income level, would talk with their clinician about delaying or making a different plan in all three situations. However, after controlling for other variables, lower-income families were about twice as likely to discuss with their physician the $100 blood test or $1,000 colonoscopy than were higher-income participants.
"These findings suggest that physicians have a central role to play in helping their patients navigate the challenges of decision making in high-deductible health plans," the authors conclude. "Beyond the implications for clinicians, our findings have important implications for federal health reform. Reform legislation that establishes an individual health insurance mandate could lead more families to enroll in plans with high levels of cost-sharing, as has been seen following the implementation of coverage mandates in Massachusetts. If more families do enroll in high-deductible health plans, policymakers should consider strategies to support patients facing high levels of cost sharing."
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