The healthcare business is full of painful ironies. Here's a new one: The insurance plans that now dominate the Affordable Care Act's exchanges may be bad medicine for keeping people healthy.
These high-deductible plans' low premiums do make health insurance more affordable for employers and consumers. But in practice they also appear to be discouraging people from getting care. Ultimately, they could leave families, employers and the nation no healthier, no more present at work, and no better cared-for than before these plans began taking us toward a more market-driven healthcare system.
These plans, which offer low monthly payments in exchange for paying a higher share of the ultimate price of care, are increasingly popular. Modern Healthcare says they represent 60 to 80 percent of the plans offered on health insurance exchanges during the open enrollment period that started Nov. 15. Some 45 million Americans were in such plans in 2013, a 15 percent increase from 2012, according to the American Association of Preferred Provider Organizations. The National Business Group on Health predicts almost a third of the nation's large employers will offer only high-deductible plans next year for some 7.5 million workers.
The premiums vary by state, type of plan and more, but the lowest-cost individual premiums on the federal exchange, according to the U.S. Department of Health and Human Services, are $69 a month. Although individuals may pay thousands in deductibles and out-of-pocket expenses before their plan starts to share the cost of care, that $69 price tag is very attractive.
It's great news for policy wonks, employers and insurers wanting Americans to share more – and be more aware – of their healthcare expenses. They're also wonderful relief to employers laboring under the relentless rise in employee premiums (up a relatively modest 3.9% for employers nationwide, according to Mercer, although more than twice that in some states). Not least, they are a valuable step toward a truly market-driven healthcare system in which people can choose their provider by quality and price.
It is said of markets that a rising tide lifts all boats. Less discussed is what happens to those who aren't in boats. And what about those who, in the case of these plans, have bought a ticket but refuse to get onboard?
Some providers and insurers already report their efforts to engage high-deductible plan patients are struggling. The reason: People fear it will cost them part of their deductible every time they return the call or even log on to a website.
Patients are skipping necessary treatments. In 2010, even before the spike in people with high-deductible plans, 58 percent of Americans said cost had forced them either to delay or forego medical care during the prior year. These plans, of course, are partially designed to make those costs even plainer. Ironically, they've also made the cost intimidating.
Almost half the "moderate income" buyers of the high-deductible plans already say their out-of-pocket bills are "difficult to impossible to afford," according to a new survey by the Commonwealth Fund. Sixty percent of the low-income buyers of these plans find their out-of-pocket expenses have become "difficult." Many physician groups, hospitals and health plans report having increasing trouble collecting the out-of-pocket payments owed to them.
It's happening, moreover, just as health policy pins its hopes for reducing the cost of care on "wellness." The logic: We can best lower our enormous healthcare bill by making citizens healthier, less likely to fall victim to diabetes, heart disease and the other expensive maladies. There are many ways to make citizens healthier; all of them are difficult. Physician groups, health plans and hospitals hope to do it with preventative medicine that intervenes in patients' lives before they get sick; catching and treating illnesses before they become serious – and expensive – medical conditions.
The pursuit of wellness often takes the form of building "medical homes" designed to diagnose and treat wider, medically important social and emotional contributors to ill health. It's also called "population management" – screening masses of employees or plan members for signs of conditions that can be treated short of hospitalization.
But if high-deductible plans really are a disincentive for people to use professionals to manage their health, these wellness efforts are pretty much stopped in their tracks.
Until and unless policy changes and actual health prices (as opposed to health insurance prices) conform to consumer earnings, encouraging people with high-deductible plans to engage in professionally managed preventative care is going to require different kinds of intervention.
Employers, physicians and plans clearly need to be better at communicating consistently, creatively and far more effectively than what passes for patient outreach today. The way to make copays marginally less of an issue is to make other qualities – the values that patients really care about – as important as the genuinely daunting financial obstacles to preventative care.
Otherwise, all we will be doing is creating an even larger mass of Americans who don't take care of themselves until it's too late.
Bill Sonn is the senior strategist for the healthcare practice at SE2, a Denver-based integrated communications firm. He can be reached at Bill@PublicPersuasion.com.
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