High-deductible Plan Effects by Worker Income

Research continues to examine the effect on use of health care from being covered by a high-deductible plan.  In its latest work, the Employee Benefit Research Institute looks at whether these plans appear to have a differential impact based on the level of an employee’s income.   (EBRI Brief)   The study used data from a single large employer over the period 2009 to 2014.  The employer contributed about half the deductible amount into a Health Savings Account for each enrolled employee.  Employees were divided into five income groups, under $50,000, then brackets rising by $25,000, with the last one being over $125,000 (note this is only the employee income, not household).  The primary outcomes tested against income were receipt of certain individual services and overall spending.  High-deductible/HSA plan enrollment was low in the early years of the study but rose to 26% of employees by 2013.  The workers in the HD/HSA plan tended to have higher incomes.  In general, use of health services tended to increase as income increased.  This is expected, what is always unclear is whether low-income people are avoiding needed services because of financial constraints or are higher-income patients getting services they may not really need because they aren’t worried about the cost.

Enrollment in the HD/HSA plan was associated with less use of services across all income levels, but the drop was more substantial among lower-income workers for some services.  Use of office visits for example, fell by .25 visits per year across the whole sample but fell .48 visits for employees with under $50,000 in annual income and only .19 visits for those with $100,000 or more in income.  Much of the visit reduction for lower-income workers was for specialist use.   Prescription drug use fell by .76 fills over the whole sample, but the lowest and highest income workers reduced their drug use about equally, while the middle-income groups had less of a reduction.  Hospital admissions dropped by 2.24 admissions per 1000 persons, but lower-income workers actually had increased use of both inpatient hospital and emergency rooms, although this effect lessens over longer enrollment times.  Interestingly, use of some preventative services fell across the study population, even though they were exempt from the deductible, indicating the general effect of making consumers more aware of the financial costs of health care.   Lower income employees did receive fewer flu vaccinations and preventive physician office visits.  Receipt of cancer screenings was generally not different across income groups.  Overall, the sample averaged $299 less in annual health spending, however, for workers with less than $50,000 in income, the spending decline was $530 compared to $356 for those with over $125,000.  Interestingly, a lesser effect on spending was seen in the middle-income groups.   And some of these calculations did not reach statistical significance.  The study actually provides some comfort in regard to HD/HSA plans, because the effects on utilization are actually quite small.