The Financial Burden of Health
Care Expenses for Families
with Chronic Conditions in
High-Deductible Health Plans
Alison Galbraith, Charlene Gay, Dennis Ross-Degnan, Stephen
Soumerai, Meredith Rosenthal, Tracy Lieu
Center for Child Health Care Studies, Department of
Ambulatory Care and Prevention, Harvard Medical
School and Harvard Pilgrim Health Care; Harvard
School of Public Health; Children’s Hospital Boston
Funded by the Robert Wood Johnson Foundation HCFO Program
Background
• High-deductible health plans (HDHPs)
are controversial, increasing in
prevalence
• Promoted as a way to control costs by
increasing enrollee responsibility for
health care expenses
HDHP characteristics
• Deductibles > $1,000 per individual and
> $2,000 per family per year
• May have tax-exempt accounts to use
for health care expenses (HRAs, HSAs)
• Lower premiums
Financial burden
due to health care expenses
• Increasingly prevalent
• More common with chronic conditions
• Early data suggest more likely in HDHPs
– 20% of adults in HDHPs have problems paying
medical bills vs. 14% in traditional plans
• Concern that HDHPs will be difficult to afford
for vulnerable groups
Tu 2009; Commonwealth Biennial Survey 2005
Families in HDHPs
• One-third of HDHP enrollees have
family coverage
• 18% of privately-insured children are in
HDHPs
EBRI/Commonwealth Survey 2008; Cohen NCHS Data Brief 2009
Objective
• To examine the financial burden of
health care expenses for families with
chronic conditions in HDHPs compared
to traditional plans
Methods
• Design: Cross-sectional mail and phone
survey conducted April – December 2008
• Setting: Employer-sponsored health plans in
Massachusetts offered by Harvard Pilgrim
– HDHPs first offered in 2002
– HRAs and HSAs available
Harvard Pilgrim HDHPs
• Family deductible $1,000-$6,000 per year
• Applies to:
– Tests, ED visits, hospitalizations, PT/OT
• Does not apply to:
– Selected preventive services
• Covered at no cost
– Office visits and medications*
• paid with co-pays
*subject to the deductible in HSA-eligible plans
Population
• Families with children ≤ 18 years
– at least one family member with a chronic
condition based on ICD-9 codes
• Enrolled for prior 12 months in either
– HDHP or
– Traditional plan (controls)
• randomly selected 2:1
• Primary outcome: parent report of any
of 6 measures of financial burden due to
health care costs for any family member
in prior 12 months
• Analyses:
– chi square tests
– multivariate logistic regression
Results
• Response rate = 45.8%
• Study sample included 297 families in
HDHPs and 523 families in traditional
plans
Characteristics of survey families
HDHP
% (n=297)
Traditional plan
% (n=523)
Number of family members
2
3
4
5+
2.4
16.2
50.8
30.6
4.0
19.5
43.6
32.9
Income < 300% FPL
27.1
21.9
Non-white race/ethnicity (parent) *
7.4
12.7
Parent without college degree
30.5
33.9
Child with special health care need
45.8
46.0
Adult with chronic condition
50.7
51.2
No choice of plans
23.8
19.7
Covered through Association *
67.3
42.3
Drug coverage *
64.3
88.9
Account for medical expenses *
21.0
29.9
* p < 0.05
Unexpected costs and worry
HDHP
% (n=297)
Traditional
plan
% (n=523)
Had unexpected events causing high
health care costs
34.5
21.7
Worried very often/frequently about
health care costs
41.4
28.0
All p values < 0.001
Financial burden
due to health care costs
HDHP
% (n=297)
Traditional
plan
% (n=523)
Problems paying medical bills
26.7
15.1
Borrowed or increased use of credit
32.4
14.3
Used savings
35.8
17.5
Set up payment plan with hospital or
doctor’s office
25.3
8.7
Bill sent to collections
21.8
8.7
Trouble paying for other basic needs
20.6
10.0
Any of the above
56.4
32.6
All p values < 0.001
Any financial burden
due to health care costs
OR (95% CI)
(n=767)
HDHP (vs. traditional plan)
2.69 (1.93-3.75)
Number of family members
0.91 (0.77-1.08)
Income < 300% FPL
2.47 (1.70-3.61)
Parent without college degree
1.39 (0.92-1.83)
Child with special health care need
1.39 (1.01-1.91)
Adult with chronic condition
1.62 (1.19-2.21)
Covered through an Association
1.22 (0.84-1.78)
Drug coverage
1.04 (0.69-1.61)
Account for medical expenses
0.91 (0.61-1.36)
Limitations
• Self-reported data
• Generalizability
• Selection effects
• Unmeasured confounders
Conclusions
• Financial burden for families with chronic
conditions in HDHPs is substantial and
greater than in traditional plans
• Financial burden is also greater for
families with low-income, and with
children and adults with chronic
conditions
Implications
• Even with lower premiums, HDHPs may
be difficult to afford for families with
chronic conditions
• Increased financial burden in HDHPs a
particular concern during economic
downturn
Implications
• Elevated financial burden in HDHPs
may constrain families’ ability to pay for
necessary health care and other
services
• Providers may have more trouble
collecting payment for services from
patients in HDHPs
Implications
• Affordability raises questions about role
of HDHPs in health reform
• Low-income uninsured may lack
financial protection against large upfront costs in HDHPs