Study: High-deductible Plans May Impede Preventive Care

Low-income Patients Not Benefitting as Expected From ACA

June 12, 2018 11:57 am News Staff

In a first-of-its-kind national study, researchers have found that Americans with high-deductible health plans (HDHPs) but no health savings accounts (HSAs) are less likely to see primary care physicians, receive preventive care or seek subspecialty services.

[stethoscope on a pile of hundred dollar bills]

The study(www.graham-center.org) by researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, titled "Privately insured adults in HDHP with higher deductibles reduce rates of primary care and preventive services," was published in the May 23 issue of Translational Behavioral Medicine. The authors examined pooled data from the 2011-2014 Medical Expenditure Panel Survey(meps.ahrq.gov) for 25,965 privately insured adults ages 18-64, dividing those data into four insurance types: no deductible, low deductible (less than $1,250 for an individual or less than $2,500 per family), HDHP with HSA and HDHP without HSA.

Among the findings were that compared to individuals with no deductibles, those enrolled in HDHPs without HSAs were 7 percent less likely to be screened for breast cancer and 4 percent less likely to be screened for hypertension, and had 8 percent lower rates of flu vaccination.

Story Highlights
  • A recent study found that individuals with high-deductible health plans (HDHPs) but no health savings accounts are less likely to see primary care physicians, receive preventive care or seek subspecialty services.
  • Many HDHP enrollees do not know that the Patient Protection and Affordable Care Act exempts preventive care such as screening tests and immunizations from deductibles.
  • Study authors call for educating HDHP enrollees about these exemptions.

The AAFP acknowledges that HDHPs represent one avenue aimed at making health care coverage more affordable to many Americans but also recognizes that high out-of-pocket costs can limit care for low- and middle-income Americans. The recently introduced Primary Care Patient Protection Act (PCPPA), which the Academy supports, would allow those with HDHPs to see their primary care physicians twice a year without additional cost.

The study authors noted that although more individuals have health insurance under the Patient Protection and Affordable Care Act (ACA), premiums and deductibles have increased, leaving many Americans unable to afford these costs.

"According to the ACA, preventive care services are exempted from out-of-pocket charges, including the deductible, so one would expect to see similar rates of receipt of preventive services and lower-cost primary care visits," the authors noted. "In contrast, we found reduction in the number of primary care visits among individuals with deductibles, particularly higher deductibles, except for those with health savings accounts."

The reason for this disconnect? "Many HDHP insurance plan enrollees are unaware that the ACA covers preventive care office visits, screening tests, immunizations and counseling with no out-of-pocket charges, and thus do not benefit from preventive care services and recommendations," the authors explained.

The authors cited one study(www.healthaffairs.org) that noted nearly 20 percent of individuals with HDHPs do not know preventive services are exempt from deductibles, as well as a survey(www.commonwealthfund.org) that found even individuals with high income had trouble paying deductibles.

"The financial burden of out-of-pocket expenses from HDHPs if one is chronically ill can result in difficulty paying medical bills and lead to accrual of medical debt over time," the authors wrote. "People experiencing medical debt further delay or avoid obtaining care when needed."

The long-term consequences, they warn, "include failure to detect early-stage chronic disease, avoidable progression of chronic disease, more absenteeism and reduced productivity."

Although the study "cannot determine whether a causal relationship exists between uptake of preventive care services and HDHPs," the authors wrote, it nevertheless establishes that HDHP enrollees without HSAs see family physicians less often and lose opportunities for preventive care.

This result, they pointed out, offsets the "promised downstream cost savings" of the ACA because the costs of HDHPs interrupt "primary care's promise to reduce high-cost emergency and hospital care through continuous, comprehensive and coordinated care."

Simply put, said the authors, health maintenance and disease prevention rely on minimizing financial barriers to accessing primary care.

"To maximize essential medical care with no out-of-pocket costs, individuals with HDHPs should be identified and educated about the cost exemption of preventive care and the benefit of preventive care and primary care visits," the authors wrote. "As the ACA is modified or repealed, prevention benefits should remain cost-free, and primary care visits should be low cost."

More From AAFP
In the Trenches: Patients on High-Deductible Plans Need Primary Care Coverage
(5/9/2017)