Back in 2009, before high-deductible health plans were all the rage and a standard part of the ACA health exchanges, the investment firm Fidelity surveyed employees at various companies that opted for a high-deductible plan tied to a health savings account. The Fidelity research found that about half of those workers said they or a family member went without care for minor ailments as many as four times a year to avoid paying out-of-pocket expenses.
One might have considered this a clue that HSAs and catastrophic coverage were no way to maintain health—at least not for those who couldn't afford the deductible. But this evidence was roundly ignored.
A few years later, in 2011, a RAND Corp. study of high-deductible health plans reaching out to more than 800,000 families across the US found that key types of preventive care including mammography, cervical cancer screening and colorectal cancer screening fell among those with HDPs.
This might have sounded an alarm bell, but it seems this too was passed over by those making employee benefits decisions.
Then, in 2013, a study in the noted journal Health Affairs found that among people of lower socioeconomic status, high deductible plans reduced emergency department use for serious conditions like asthma flare-ups or congestive heart disease by 25% to 30%. But that's only half of the story. While hospitalizations among this group declined during the first year of the study by 23%, hospitalizations jumped in the second year, suggesting that delays in care lead to even more serious illness later.
What about alternatives?
And here we are in 2014, seemingly unable to come up with any workable method for reducing health spending other than high deductible plans which, it seems obvious to me at least, are nothing more than an attempt to reduce access to care for those in lower socioeconomic tiers.
Sure, we all heard the cant spouted by the fans of HDPs arguing that requiring consumers to pick up a large percentage of their episodic health costs would make them better shoppers. In this fairy tale, the "consumer directed" policies would shift the entire healthcare system to a more efficient mode, with smart consumer choices remaking the system practically on their own.
Well, what evidence do we have that savagely high deductibles force consumers to make good healthcare choices? None that I could find. Rather, it appears that consumers—at the present at least—are not equipped to sort through price and quality data and reward good providers en masse. They want the expertise that those who create networks bring to the table. And those who can't pay high deductibles in the first place, a meaningful percentage of consumers, get no say at all.
Bottom line, it looks like HDPs largely accomplish just three things: They pressure consumers to avoid needed care, force providers to pick up a progressively larger percent of the bill for nearly-uninsured patients with HDPs and allow payers to issue (presumably profitable) policies that offer very little coverage.
After years of pretending that high deductibles would magically improve the healthcare system, it's long past time to find another way to shape patient behavior. HDPs aren't just cruel, they don't work.