Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
Department of Health Care Policy, Harvard Medical School, Boston, MA, United States of America.
J Subst Use Addict Treat. 2023 Nov;154:209152. doi: 10.1016/j.josat.2023.209152. Epub 2023 Aug 31.
High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP.
Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level.
The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling.
Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.
高免赔额健康计划（HDHPs）使参保人在医疗费用方面承担更多的自付费用，这可能会加剧物质使用障碍（SUDs）的治疗不足。然而，影响 SUD 参保人是否选择 HDHP 的因素尚不清楚。在这项研究中，我们研究了与 SUD 参保人选择 HDHP 相关的因素。
我们使用 OptumLabs（2007-2017 年）的去标识化行政商业索赔和参保人登记数据，确定了在提供至少一种 HDHP 和一种非 HDHP 计划的雇主处参保的个人。我们使用计划和参保人人口统计学特征的线性回归来模拟参保人是否选择了 HDHP。关键计划特征包括计划是否有健康储蓄账户（HSA）或健康报销安排（HRA）。关键人口统计学变量包括年龄、种族/族裔、普查块收入范围、普查块最高教育程度和性别。我们分别调查了新参保人（即以前未参保 HDHP）和续保参保人的决定，以及单人参保人和不同规模家庭的决定。该研究还调整了模型，纳入了其他计划特征、雇主和年份固定效应以及普查分区。稳健标准误差按雇主级别聚类。
样本包括 30832 个计划和 318334 名参保人。在有新参保决定的参保人中，24.6%选择了 HDHP；93.8%的 HDHP 参保人选择续保 HDHP。研究发现，计划中存在 HRA 与新参保和续保 HDHP 的概率更高相关。我们发现，患有 SUD 的较年长参保人不太可能新参保 HDHP，而非白人、居住在低收入普查块和教育程度较低的普查块的参保人更有可能新参保 HDHP。前一年更高的医疗保健利用率与新参保 HDHP 的可能性降低相关，但与续保的可能性增加相关。
鉴于 HDHPs 可能会抑制 SUD 治疗的新证据，更多的 HDHP 参保可能会加剧健康差距。
