Instructor in Pediatrics Boston Children's Hospital Melrose, Massachusetts, United States
Background: High deductible health plan (HDHP) offerings by employers have increased following the Affordable Care Act. HDHP design can lead to large out of pocket expenditures and result in care avoidance by members as a cost saving strategy. Cystic Fibrosis (CF) is a complex, multi-system, chronic health condition. Healthcare for people with CF (PwCF) is expensive due to high-cost medications, need for specialized equipment, and frequent clinical assessments. The impact of having a HDHP on financial burden in PwCF is unknown. Objective: We evaluated the prevalence of HDHP use in PwCF and its association with self reported financial outcomes. Design/Methods: The CF Health Insurance Study was a national cross-sectional survey conducted from July-December 2019 assessing characteristics of health insurance, financial burden, and unmet medical needs. For this analysis, HDHP were defined as those with private health plans reporting an annual deductible of >$1500. Unmet medical needs were defined by a positive response to questions addressing delayed or forgone care. Financial burden was defined by a positive response to questions addressing problems paying medical bills. Modified poisson regression with robust error variance was performed to calculate adjusted prevalence ratios (aRR). Results: The study included 1284 PwCF or their caregivers. The mean age of PwCF was 26 years and 52% had household income >400% federal poverty level. The distribution of primary insurance reported was 32% HDHP, 22% low deductible health plan (LDHP), and 21% Medicaid. In adjusted analyses, those on HDHP had greater prevalence of reported financial burden (aRR 1.57, p< 0.001), medical debt (aRR 1.27 p=0.004), and trouble paying for medical treatments (aRR 1.42, p< 0.001) compared to those on LDHP. Those with HDHP had greater prevalence of increasing credit card debt (aRR 1.27, p=0.009) and using up all or most of savings (aRR 1.30, p=0.011) in response to medical bills. PwCF on HDHP also reported a higher rate of delaying filling prescriptions (aRR LDHP 1.47, p=0.013) and skipping routine visits (aRR 1.73, p=0.038).
Conclusion(s): HDHP impart greater financial risk and avoidance of recommended care for PwCF who are faced with high cost of care due to the complexity of their health condition. These outcomes are problematic and suggest an adverse consequence of HDHP benefit design. PwCF may not have access to alternative insurance plans, but may be better served when alternatives are available. CF is a model for high cost conditions and these outcomes are likely applicable in other chronic diseases.
