High-deductible Health Plans, Surgical Conditions, and a Different Moral Hazard

Abstract

health care system, namely access to health care and cost of care to both patients and the public sector. More than 10 years later, there has been a considerable decrease in the number of uninsured Americans, largely through expansion of Medicaid eligibility, implementation of the dependent coverage expansion, and establishment of nongroup marketplaces. However, increasingly common high-deductible health plans (HDHP) create new barriers to financial access to care for the 50% to 60% of Americans with employer-sponsored insurance coverage. A recent report found that over half of American private-sector workers were enrolled in HDHP with an average annual deductible for single-coverage plans approaching $3000 USD. 1 At the same time, public surveys found that 43% of working-age adults were inadequately insured, and 49% of individuals reported being unable to pay an unexpected $1000 USD medical bill within 30 days. 2 Well, over 50% of low-income, non-Hispanic Black, and Hispanic adults surveyed shared that they would be unable to pay such an unexpected medical bill. These financial barriers are impacting not only the overall affordability of care received but are increasingly demonstrating an influence on patient delays in seeking care, including for common emergency general surgical (EGS) conditions.In this edition of Annals of Surgery, Scott and colleagues evaluate the influence of HDHP on severity of EGS conditions at the time of presentation as well as the associated rates of catastrophic health expenditures (CHE), defined as out-of-pocket expenses exceeding 10% of annual income. 3 The study used national data of commercially insured patients aged 18 to 64 years old admitted from 2016 to 2019 with acute appendicitis, acute cholecystitis, intestinal obstruction, or acute diverticulitis. Patient coverage through an HDHP was associated with increased odds of presentation with severe disease [odds ratio (OR) = 1.23]. This increased risk of severe disease at presentation held true even when authors controlled for patient education, income, and insurance subtype. More than 20% of patients with HDHPs who were admitted with these EGS conditions experienced out-of-pocket spending > 10% of their income compared with 6.4% of patients with standard insurance plans. Even after controlling for confounding factors, including a presentation with severe disease, coverage through an HDHP was associated with markedly increased odds of experiencing a CHE (OR = 3.93). This association is significantly greater than the impact of presenting with a more severe, complex disease at the time of presentation (OR = 1.20). The role of HDHPs as both a result and driver of structural inequities was also well demonstrated in this work. The study population had a mean annual household income that was nearly 50% lower for non-Hispanic Black patients and 30% lower for Hispanic compared with non-Hispanic White patients. Non-Hispanic Black and Hispanic patients both also had markedly higher odds of CHE as compared with non-Hispanic White patients (O...