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How Can We Address Barriers to Accessing Needed Care?

Adherence and access to higher-value care can make a big difference in reducing costs for patients and our healthcare system; however, the financial burden of high-deductible health plans and out-of-pocket costs must also be considered.

Published Online: May 10,2017
Robert W. Dubois, MD, PhD
More patients today have health insurance, but they also are being asked to dig deeper into their pockets to cover a larger portion—if not all—of the costs of their healthcare treatments. This situation is made even more difficult by the prevalence of high-deductible health plans (HDHPs), which offer low monthly costs in exchange for higher costs for doctor visits, medicines, or other necessary care.
Recognizing that HDHPs are forcing patients to make trade-offs in the management of their health, insurers, employers, and other healthcare stakeholders have been examining different ways to ensure that patients have access to the right treatments at the right time.  
Growing Use of HDHPs
In response to the Affordable Care Act, more insurers are offering HDHPs. With these plans, premiums are generally lower than in traditional plans because enrollees must meet the higher deductibles before traditional medical and pharmacy coverage begins.
Most HDHPs are offered in conjunction with a health savings account (HSA) or, less often, a health reimbursement account (HRA); both can be accessed by plan enrollees to offset the deductible expense. The intention is that these kinds of plans have the potential to contain healthcare costs and engage enrollees more fully in managing their health and healthcare decisions or, in other words, “have more skin in the game.”1
The use of these plans is continuing to grow, with more than 70% of surveyed employers offering HDHPs.1 In 2016, 39% of individuals younger than 65 years with private insurance were enrolled in an HDHP—up 3% from 2015—and 15% of those were enrolled in an HDHP with an HSA.2
The average aggregate deductibles for workers with family coverage are $4321 for HDHP/HRAs and $4364 for HSA-qualified HDHPs, yet there can be wide variation.3 HSA-qualified HDHPs are legally required to have a maximum annual out-of-pocket (OOP) liability of no more than $6550 for single coverage and $13,100 for family coverage in 2016. For a low-income family of 4 making $48,678 per year, meeting a high deductible that is a sizable portion of that income is a daunting task.
Under most healthcare plans, patients must satisfy their deductible before their coverage kicks in, making care more expensive for those with lower incomes or greater healthcare needs. As a result, lower-income families are getting less preventive care and putting off care they need. They had 4 times the rate of avoidable hospitalizations compared with higher-income workers and had 3 times the rate of emergency department visits, thus incurring higher costs for themselves and for the healthcare system.5