High-deductible health plan (HDHP) effects on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from low-deductible health plans to HDHPs between 2004-2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible (≤$500) plans for a year then up to 4 years in HDHPs (≥$1000). Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident breast cancer, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ statistically from low-income counterparts. HDHP members living in metropolitan, non-metropolitan, predominantly white, and predominantly non-white areas also experienced delayed breast cancer care. Policies might be needed to reduce out-of-pocket costs for breast cancer care. Forty-six percent of US adults under age 65 have high-deductible health plans (HDHPs). 1 These arrangements require potential out-of-pocket spending each year of approximately $1000-$7000 per person for most non-preventive care. In 2018, 58% of workers with individual plans had deductibles of ≥$1000 and 26% had deductibles of ≥$2000. 2 Very few studies have examined whether HDHPs act as a barrier to receipt of essential, life-sustaining care. In the early 2000s, a confluence of factors including rising health care costs, the managed care backlash, incentives in the Medicare Modernization Act, and advocacy from political and consumerist proponents helped stimulate the rise of HDHPs. This major payment policy change created a natural experiment with uncertain effects on consumer health. Our study seeks to understand one aspect of this natural experiment, namely, whether both vulnerable and non-vulnerable HDHP members delay potentially life-saving care.

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. Design: Observational longitudinal comparison of matched groups. Setting: A large national health insurer during 2003 to 2012. Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. Intervention: Employer-mandated transition to a high-deductible plan. Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. Limitation: Health outcomes were not examined. Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment.

IMPORTANCE There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures. OBJECTIVE To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG). DESIGN, SETTING, AND PARTICIPANTS This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG. EXPOSURES Bariatric surgery procedure type (RYGB vs VSG). MAIN OUTCOMES AND MEASURES The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling.RESULTS Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80). (continued) Key Points Question Do patients have greater risk of subsequent operative intervention after Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG)? Findings Among 13 027 patients in this cohort study, compared with matched counterparts undergoing RYGB, patients undergoing VSG had lower overall risk of subsequent operative and nonoperative interventions, including biliary procedures, abdominal wall hernia repair, other abdominal operations, and endoscopy, up to 4 years after surgery. Meaning Patients deciding between RYGB and VSG should consider not only the clinical effectiveness of these 2 procedures but al...