No Evidence Chronically Ill or Patients With High Deductibles Forego Medical Care Interview with:

Joel Segel, Ph.D. Assistant Professor Department of Health Policy and Administration The Pennsylvania State University University Park, PA 16802

Dr. Joel Segel

Joel Segel, Ph.D.
Assistant Professor
Department of Health Policy and Administration
The Pennsylvania State University
University Park, PA 16802 What is the background for this study?

Response: Americans’ health insurance plans increasingly include deductibles, which require patients to pay a certain amount out-of-pocket before the health plan will cover most services. In addition, the levels of these deductibles have been increasing with more and more Americans enrolling in high-deductible health plans (HDHP’s), which in 2013 were plans with a deductible of $1,250 or more for an individual or $2,500 or more for a family. Furthermore, nearly 40% of those with private insurance have a HDHP including most of the bronze and silver plans on the federal Marketplace. This trend has many worried that patients are facing greater financial risk and may delay or forego necessary care because of costs. A population that may be most vulnerable to these problems are Americans with common chronic conditions. What are the main findings?

Response: In this study we used nationally representative Medical Expenditure Panel Survey data from 2011-2013 to estimate associations between deductible level (none, low, and high) and three different outcomes—out-of-pocket spending, spending at least 10% of family income on health-related costs (i.e. a high medical cost burden), and reporting having to delay or forego care due to cost.

For individuals with a chronic condition we found significantly greater out-of-pocket spending for those with either a low-deductible or high-deductible plan, as well as a significantly increased probability of experiencing a high medical cost burden. The elevated financial burden was particularly pronounced for those with hypertension, joint disorders, mood disorders, or multiple chronic conditions.

However, we did not find evidence that the chronically ill with high-deductible health plans are any more likely to report having to delay or forego care due to cost. This could be in part due to individuals receiving necessary care but shouldering an increasing financial burden; but it remains crucial to continue to monitor to ensure that patients really are receiving necessary care. What should readers take away from your report?

Response: American adults with chronic conditions and high-deductible health plans face a significantly greater financial burden than those in plans with no deductible. However, even chronically ill adults with low-deductible plans face significant financial risk. And yet we are not seeing evidence that either group is more likely to report having to delay or forego care due to cost. What recommendations do you have for future research as a result of this study?

Response: Future research is needed to understand if there are ways these financial burdens can be mitigated in the chronically ill population with low- and high-deductible plans. In addition, we were not able to identify the actual deductible level so future work needs to understand if HDHPs with deductible well above the threshold, including many Marketplace plans, may pose even greater financial burden or significantly increase the likelihood of delaying or foregoing necessary care.

Finally, there is a great deal of uncertainty surrounding the current health insurance system so future research is needed to understand how any potential changes might affect who enrolls in HDHPs, how it affects their financial burden, and whether there issues with delaying care. Is there anything else you would like to add?

Response: Dr. Segel reports no potential financial conflicts interest.

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. Thank you for your contribution to the community.


Segel JE, Kullgren JT. Health Insurance Deductibles and Their Associations With Out-of-Pocket Spending and Affordability Barriers Among US Adults With Chronic Conditions. JAMA Intern Med. Published online January 09, 2017. doi:10.1001/jamainternmed.2016.8419

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on January 11, 2017 by Marie Benz MD FAAD