Lower-income families with high deductible more likely to forgo medical procedures

**Kullgren J. Arch Intern Med. 2010;170:1918-1925.**

Issue: January 2011

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, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia VA Medical Center and the University of Pennsylvania.

“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 higher incomes.”

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 high-deductible 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 co-pays).

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 family’s income, or providing income-based cost-sharing subsidies,” the researchers wrote.

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