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High Out-of-Pockets and Deductibles

RESEARCH And News

The latest studies and documentation that out-of-pocket costs are harming working families, hurting American competitiveness, and worsening physician practice. 

High-deductible and skinny health insurance plans drive medical debt

A recent Urban Institute report highlights the issue of medical debt but fails to examine two of the chief driving forces of this debt: inadequate enrollment in comprehensive health care coverage and high-deductible health plans that intentionally push more costs onto patients. It also fails to appreciate the looming crisis when the public health emergency ends and Medicaid enrollment could plummet. As the extent of medical debt shows, both the government and the private market is failing too many patients, leaving too many either uninsured or with subpar plans that expose too many people to bills they cannot afford to pay. While hospital financial assistance is crucial to helping many individuals of limited means access care, it is no substitute for a solution that gets to the root causes of medical debt.

American Hospital Association | March 2023

 

Prior authorization nightmares prompt Kansas lawmakers to consider new regulations

A debate is raging nationally regarding prior authorization. You’re probably familiar with it. It’s a common practice in medicine today. Your doctor says you need a particular medicine, or diagnostic test, but your insurance company has to approve it first. Getting it approved can take weeks—or even longer. The process impacts large health systems and private practices. “It has really deep-reaching impacts to healthcare, and most importantly to the patients,” said Dr. Timothy Williamson with the University of Kansas Health System. “There’s really has been negative impact to patients.” Prior authorization is a requirement by most health plans. Its purpose is to contain costs and confirm the service or medication is “medically necessary.” But many doctors believe it has gotten out of hand. The first submission is routinely denied.

KCTV | March 2023

Prescription drug middlemen are jacking up prices

The rising cost of prescription drugs continues to be a top concern for many Americans. One of the leading culprits in pushing those costs even higher are pharmacy benefit managers (PBMs) — companies whose behavior is so egregious that Democrats and Republicans are united in trying to reform them. Yet, in a recent piece for the Washington Examiner, Ashley Herzog, a freelancer for the Heartland Institute, defended PBMs and argued against the PBM Transparency Act, a bipartisan bill that would hold PBMs accountable. To understand why the PBM Transparency Act is so important, and why Herzog’s argument is misplaced, it’s important to consider the role PBMs play in the healthcare industry, specifically when it comes to drug pricing. The three largest PBMs control 80% of all prescriptions in the U.S. In fact, they own, or are owned by, some of the largest insurance companies in the world. They extract “rebates” from drug companies in exchange for preferential placement on insurance companies’ lists of covered drugs. In other words, it’s pay-to-play. In 2021, they collected $200 billion in rebates from drugmakers. That’s 40% of every dollar spent on pharmaceuticals. Whether or how much any of that is passed on to patients is a mystery.

Washington Examiner | March 2023

'Patients should flee from UnitedHealthcare' amid changes to prior authorization, says 1 gastroenterologist

UnitedHealthcare, an insurer of 45 million patients worldwide, has announced changes to its prior authorization requirements for gastroenterology care, set to take effect June 1. New requirements will require patients on a United commercial plan to seek prior authorization for gastroenterology endoscopy services. Practicing gastroenterologists are not happy about the change, warning that it could have potentially dire consequences for GI patients. Already, physicians report prior authorization challenges causing delays to necessary medical care for patients up to 94 percent of the time, according to a survey from the American Medical Association.

Becker's ASC | March 2023

Pharmacy Benefit Managers Are An Unsung Source of High Drug Prices

The high cost of prescription drugs has been an issue on the minds of many Americans for years. Now, Congress is beginning to investigate a previously under-the-radar culprit behind the sky-high prices, Pharmacy benefit managers (PBMs)…They have a set of underhanded tactics at their disposal to pad their bottom line, while keeping drug costs higher for employers, health plans, and – ultimately – patients.The first way this is done is through rebates. A PBM could negotiate to purchase prescriptions from a pharmaceutical company for $500 per month, but agree to a $100 per month rebate every time a purchase comes in. So, the true cost is $400 per month. However, the PBM can – and often does – pocket a large portion of that rebate. In this instance, PBMs could keep $80 of the $100 rebate and only pass along the other $20 to employers. Employers, meanwhile, think they get a nice discount to $480 per month from $500. However, the pharmaceutical company could have just sold it for $400. The difference is that the PBM could not have pocketed a nice rebate for itself. In this way, PBMs are incentivized to keep prescription prices higher, so they have the opportunity to negotiate higher rebates. If drug costs went down, or employers paid closer to face value, PBM profits would plummet. The second way this is accomplished is through what’s called “spread pricing.”

RealClear Markets | March 2023

 

Here's how much diabetes costs employers each year

Diabetes costs employers billions every year in both direct costs and indirect costs, as the disease impacts productivity and absenteeism, according to new data from Nomi Health. The direct healthcare provider analyzed the costs associated with diabetes as part of its Trends in Spend Tracker, which uses claims data to identify shifts in healthcare spending. Nomi Health examined about 500,000 employer claims, and estimated that diabetes costs them $245 billion per year. Of that, about $175 billion in annual spending is direct costs, such as medication and treatment. The remaining $70 billion is related to indirect costs, such as absenteeism, lost productivity and disability, according to the report.

Fierce Health Care | March 2023

Surveyed physicians say prior authorization harms patient outcomes, burns healthcare resources

Current prior authorization practices drive worse patient outcomes and increased utilization of healthcare resources due to unnecessary encounters or ineffective care, a majority of physicians said in a survey conducted by the American Medical Association. Released this week, the December poll of 1,001 practicing physicians outlined unintended outcomes resulting from treatment approval processes required by payers in a bid to control costs. Specifically, 86% of respondents told the professional organization that prior authorization “sometimes, often or always” leads to higher overall utilization of healthcare resources. Just under two-thirds said that prior authorization has led to ineffective initial treatments, while 62% pointed to additional office visits and 46% to immediate care and/or emergency room visits resulting from the practice.

Fierce Healthcare | March 2023

EBRI, Commonwealth study finds that support for employer-based health benefits remains strong

When the Affordable Care Act (ACA) was passed in 2010, one of the main concerns — which was often used to argue against passage of the health care reform bill — was that Americans would stop enrolling in employer-based plans and instead jump to the government-controlled ACA marketplace. More than ten years later, that prediction has not come true. In fact, companies and employees alike seem to see health benefits as an important feature of employment, with companies often competing to offer the best health plans at the most affordable price. A new report, “What Employers Say About the Future of Employer-Sponsored Health Insurance,” found that employers see health benefits as a valuable recruitment and retention tool and have worked hard to keep such benefits as an expected part of the relationship between employer and employee. As a result, more than 70% of working Americans get their health insurance through their employer.

BenefitsPro | March 2023

Democrats search for the next big thing on health care

First it was passing the ACA. Then it was defending the ACA. Then it was allowing Medicare to negotiate drug prices.     But when we asked lawmakers and outside groups what the Democrats' next major health care goal will be, we did not get one clear answer. Instead, we got lots of smaller, wonkier answers. Why it matters: It's a sign that the Democrats don't yet agree on the next big thing — and that could leave their health care agenda scattered in Congress over the next two years. What they're saying: "There's a lot of good ideas out there, but this often happens, once you get a big victory you often need a little time to form consensus on what's next," Sen. Chris Murphy told Axios.

Axios | March 2023

Millions May See Lower Out-of-Pocket Costs for Heart Medications. Inflation Reduction Act may make cardiovascular therapy more affordable for Medicare beneficiaries

Cardiovascular disease is the leading cause of death worldwide, including in the United States, where about 20 percent of all deaths are caused by heart disease. Highly effective medications can lower the rates of death and disability related to cardiovascular diseases. However, the expense of long-term prescription medications represents a significant barrier to care for many patients with chronic cardiovascular conditions. The Inflation Reduction Act — signed into law in August 2022 — includes several clauses related to drug benefits that are expected to lower prescription medication costs for Medicare Part D beneficiaries over time and expand low-income subsidies.

Harvard Medical School | March 2023

How major retailers are trying to change how America consumes health care

Amazon, Walmart, CVS, Dollar General and other big retailers are elbowing their way into health care delivery, pushing a customized consumer experience driven by digital health products. What's happening: At its core, these companies are pulling together different tech-enabled services — urgent, primary, home and specialty care, pharmacy, and, in some cases, full integration with an insurer. Why it matters: A more user-friendly portal to the health system could lead to more engaged patients and better access to care in underserved areas. But the retailers' forays are prompting growing anti-trust and privacy concerns, as well as fears of further erosion of the doctor-patient relationship once considered central to coordinated care. 

Axios | March 2023

Many Americans Are Likely to Skip Preventive Care if ACA Coverage Falls Through

At least 2 in 5 U.S. adults said they would not pay out of pocket for 11 of 12 preventive services currently covered by the Affordable Care Act.

Morning Consult | March 2023

Even with lawsuits and copay caps, will insulin ever be affordable?

In an attempt to tackle the root causes of the inflated cost of insulin, the state of California filed a lawsuit last week accusing drug manufacturers and pharmacy benefit managers of artificially and illegally jacking up the price of insulin. The sausage-making of how insulin is priced is not for the faint of heart. It’s a complex tangle of drug manufacturers who’ve been resisting generics, health insurance companies trying to keep up impressive profits, plus the wholesalers who distribute medicines to pharmacies and the pharmacies that provide them to patients. Slithered into this midst are the pharmacy benefit managers, companies that negotiate the prices for medications on behalf of insurance companies and administer the prescription drug aspect of individuals’ health insurance.

STAT | January 2023

Upcoding: one reason Medicare Advantage companies pay clinicians to make home health checkups

At the start of 2023, an estimated 2.5 million Americans age 65 and older began using Medicare Advantage programs. Some made this choice in response to aggressive marketing campaigns. This brings the total enrollment of Medicare Advantage plans to nearly 31 million. One unexpected “benefit” of these plans is an offer by the insurance company sponsoring the plan to send a nurse or physician’s assistant, often from a startup company, to an individual’s home. There is no charge for the visit, and the insurance company may even pay the beneficiary for agreeing to do this. Some companies call relentlessly to get the offer accepted. Before explaining whose interests these visits serve, it helps to tease out the roles of the players. Health insurance companies do not deliver health care. That’s what medical providers and groups do. The primary role of insurance companies is to pay the bills; they profit by taking in more money from beneficiaries than they pay for the medical care they need. To be sure, this distinction is getting murky: some health insurers have bought medical provider groups, and some health systems offer health insurance.

STAT | January 2023

Record High in U.S. Put Off Medical Care Due to Cost in 2022

The percentage of Americans reporting they or a family member postponed medical treatment in 2022 due to cost rose 12 points in one year, to 38%, the highest in Gallup’s 22-year trend. Each year since 2001, Gallup has tracked Americans’ self-reports of delaying medical care in the past 12 months due to cost. The latest reading, from Gallup’s annual Health and Healthcare poll conducted Nov. 9-Dec. 2, is the highest by five points and marks the sharpest year-over-year increase to date. Story highlights: 38% say they put off treatment, up 12 percentage points from 2021.  27% say medical treatment was for a very or somewhat serious condition. Lower-income, younger adults, women most likely to report delaying care.

Gallup | January 2023

Toledo's passage of medical debt relief having ripple effect across country 

Now that Toledo has decided to funnel a portion of federal relief money to a proposal that calls for relieving medical debt for several thousand residents, other municipalities are following suit. In November, Toledo City Council joined with the Lucas County commissioners to allocate $1.6 million in American Rescue Plan Act funds to RIP Medical Debt. In turn, the New York-based nonprofit organization will purchase medical debt from hospitals, health systems, and collection agencies at steep discounts. Once the debt is acquired, any collection efforts associated with that debt are wiped out with no imposed tax consequences, or penalties to the recipient. Officials in New Orleans are finalizing a $1.3 million contract with RIP Medical Debt, and Pittsburgh City Council recently approved a budget that includes $1 million for medical debt relief. The idea that relieving medical debt for citizens is good public policy seems to be catching on, RIP Medical Debt CEO Allison Sesso said. 

Toledo's Blade | January 2023

Pharmacy Benefit Managers and the Federal Trade CommissionA Relationship Gone Sour 

On June 7, 2022, the Federal Trade Commission (FTC) announced its decision to launch an inquiry into the business practices of pharmacy benefit managers (PBMs).1 Although it is premature to presume that the investigation will lead to changes in the PBM market, the initiative was nonetheless cheered by the many policy experts that fault PBMs for increasing prescription drug prices. This is not, however, the first time that the FTC crossed paths with the PBMs. Earlier encounters offer a useful window into the evolving PBM market and the associated policy challenges. This Viewpoint offers a reminder of why PBMs emerged in the first place, why they have amassed such alarming influence, and how they positioned themselves as powerful actors within the prescription drug distribution system. 

JAMA | January 2023

Colorado lawmakers want to make EpiPens cheaper for most residents 

A bill in the Colorado legislature would cap the out-of-pocket cost of epinephrine auto-injectors at $60 for a pack of two. They are used to treat severe allergic reactions. House Bill 23-1002 would cap patients’ out-of-pocket cost for epinephrine auto-injectors at $60 for a pack of two, which is how they’re typically sold, starting in January 2024. The bill also would create a program for people whose out-of-pocket costs for EpiPens or their generic equivalents weren’t limited by the cap, and who aren’t covered by Medicare or Medicaid. Eligible people could receive two-packs of auto-injectors for $60, as needed, for one year. Manufacturers would have to either reimburse a pharmacy for the difference between what it paid for the auto-injector and the $60 it collected from a patient, or send the pharmacy a replacement pack. 

Denver Post | January 2023

CVS explores a $10B acquisition of Oak Street Health 

CVS Health Corp. is exploring an acquisition of Oak Street Health Inc., which runs primary care centers for Medicare recipients, according to people familiar with the matter. A deal could be reached within weeks that would value Oak Street at more than $10 billion, including debt, said the people, who asked to not be identified because the matter isn’t public. Talks between the companies are ongoing and could end without an agreement, the people said. Oak Street, which went public in 2020, aims to reinvent care for Medicare patients with low incomes and chronic health problems. The company says its high-touch approach — frequent checkups, preventive screenings and meetings with social workers — can reduce patients’ medical costs. 

BenefitsPro/Bloomberg | January 2023

More Patients Cite Out-of-Pocket Costs as Care Access Barrier
The number of patients saying out-of-pocket healthcare costs are a care access barrier is the highest it’s been since the start of the COVID-19 pandemic. Three in 10 Americans are citing high out-of-pocket patient costs as a care access barrier, with those patients telling a West Health and Gallup poll that they skipped necessary medical care in the past three months because of financial challenges. The survey of over 6,500 respondents, obtained via email, showed out-of-pocket healthcare costs are a problem even for the richest people. Among those households making more than $120,000 annually, 20 percent said they did not access healthcare in the past three months due to high costs. These figures represent a peak for the nation. The overall rate of cost-related delayed care is the highest it’s been since the start of the COVID-19 pandemic. For the richest households, the rate of cost-related delayed care is 3 percent higher than it was between March and October of 2021.

The Patient Engagement HIT | December 2021

More Patients Cite Out-of-Pocket Costs as Care Access Barrier
The number of patients saying out-of-pocket healthcare costs are a care access barrier is the highest it’s been since the start of the COVID-19 pandemic. Three in 10 Americans are citing high out-of-pocket patient costs as a care access barrier, with those patients telling a West Health and Gallup poll that they skipped necessary medical care in the past three months because of financial challenges. The survey of over 6,500 respondents, obtained via email, showed out-of-pocket healthcare costs are a problem even for the richest people. Among those households making more than $120,000 annually, 20 percent said they did not access healthcare in the past three months due to high costs. These figures represent a peak for the nation. The overall rate of cost-related delayed care is the highest it’s been since the start of the COVID-19 pandemic. For the richest households, the rate of cost-related delayed care is 3 percent higher than it was between March and October of 2021.

The Patient Engagement HIT | December 2021

How a Minnesota man who died from soaring insulin prices could change US diabetes care forever
Alec Smith died alone in his room at age 26 because he couldn’t afford life-saving insulin. But the tragedy has sparked a movement that is rattling Big Pharma and forcing politicians to take action. When Nicole Smith-Holt went to confront the bosses of Eli Lilly in May 2018, she had not been an activist for long. 

The Independent | December 2021

44% of Americans Put Off Medical Checkups Because of Cost

The average American spent over $5,000 on medical care in 2021 — a figure that would be much higher if patients pursued all of the care that’s necessary for them. According to a new survey from financial services company Discover, many people are skipping out on fundamental medical care needs (including medication and regular checkups) for fear of the bill. Americans have been shouldering both physical and mental health challenges that have been exacerbated by the pandemic, according to benefits provider LifeWorks' most recent Mental Health Index. According to the Discover survey, 58% of respondents said they've had to cover an unexpected expense as a result of the pandemic. In addition, respondents said they used their emergency savings (29%) and credit cards (13%), paid bills later (16%) or borrowed from loved ones (19%) to cover the costs of emergency expenses. A previous report from HSA platform Lively also showed that the majority have also reduced their health savings contributions in 2021.

Value Penguin | December 2021

Americans with Medical Debt Are More Worried about Making Payments than Getting Better
An annual survey from Discover Personal Loans also finds six in 10 Americans took steps to cover an unexpected expense amid the pandemic. A new survey from Discover Personal Loans revealed 58% of Americans took steps to address an unexpected expense since the beginning of the COVID-19 pandemic.

Stockhouse | December 2021

A Third of U.S. Kids Lack Good and Consistent Health Insurance

The number of underinsured children grew by 2.4 million during the three-year period, bringing the number of kids with inadequate coverage to 23.7 million, according to a paper published in the journal Pediatrics Monday. Researchers from the University of Pittsburgh School of Medicine analyzed data from the annual National Survey of Children's Health and found the increase was mainly driven by increased rates of inadequate private insurance. The authors define "inadequate" insurance as coverage not meeting children's' needs, not allowing patients to see their providers and leaving families with high out-of-pocket expenses.

University of Pittsburgh School of Medicine | December 2021

It shouldn't be this hard to grow old in America
The idea of growing old in America today is becoming more uncertain and even scary, and it shouldn’t be. This is one of the wealthiest nations on earth. While many seniors are fortunate to have adequate retirement income, affordable health care, and the means to live independently after decades of working, millions of others do not. They live on fixed incomes – some near or below poverty level – and struggle to maintain basic retirement and health security.  Many find themselves contending with chronic illnesses and need help with the tasks of daily living, but can’t afford proper care.  Or they are housed in nursing homes which recent history has proven can be substandard, if not outright dangerous.

The Hill | December 2021

In the Years Before the COVID-19 Pandemic, Nearly 13 Million Adults Delayed or Did Not Get Needed Prescription Drugs Because of Costs
More than one-quarter of adults with Medicare (25.4%) and 5.3% of privately insured adults spent more than 1% of their family income on their individual out-of-pocket prescription drug costs. More than 3% of Medicare beneficiaries—and nearly 7% of beneficiaries with unmet prescription drug needs—spent over more than 10% of their family income on prescription drugs. About one-in-ten adults who were uninsured all year (9.5%) or part of the year (11.6%) reported unmet prescription drug needs, compared with 4.9% of Medicare beneficiaries, 3.0% of privately insured adults, and 5.6% of nonelderly adults with Medicaid. For Medicare beneficiaries and privately insured adults, unmet prescription drug needs were most common among women, people with low incomes, and people with multiple chronic health conditions.

Urban Institute | December 2021

Coverage That Kills – Breast Cancer Care Is Undermined By High Deductible Health Plans
There are so many awful things about breast cancer. Here are two of them. (1) Receiving a diagnosis when your cancer is already advanced; (2) Not having enough money to pay for your treatment. Here is an awful thing about high deductible health plans: They delay breast cancer diagnosis and get in the way of proper breast cancer care.  We should all be bothered by high deductible health plans. For starters, the deductibles are often too high. For individual coverage, it’s increasingly common for people to face deductibles of $2,000 or more. For families, deductibles can exceed $6,000. To make matters worse, high deductible plans often burden people with other out-of-pocket. Add in these copays, and a family could face more than $13,000 of out of pocket expenses on top of their insurance premiums.  

Forbes | December 2021

Out-of-pocket costs may play larger role in telehealth visits than in-person care: survey
Out-of-pocket costs may play a larger role in choosing telehealth over in-person visits for those who would otherwise prefer virtual care, a new survey by the RAND Corporation suggests. In a study conducted in March by the nonprofit research organization and published in JAMA Network Open, researchers assessed post-pandemic patient preferences for telehealth versus in-person care. Nearly 67% of respondents said they wanted at least some of their care to be conducted virtually. But when the hypothetical cost of the virtual visit jumped from $10 to $30, nearly 62% of respondents who initially preferred video visits said they’d rather have an in-person visit instead. 

Fierce Healthcare | December 2021

13M people delayed or didn't fill prescription drugs pre-pandemic
An estimated 13 million adults delayed getting or didn't fill prescription drugs prior to the COVID-19 pandemic due to cost, according to a new survey. More than one-quarter of Medicare beneficiaries and 5.3% of privately insured adults spent more than 1% of their household income on their out-of-pocket prescription drug costs, according to the Urban Institute's estimated annual averages of 2018 and 2019 Medicare Expenditure Panel Survey data from nearly 30,000 Americans. 

Modern Healthcare | December 2021

Out-of-Pocket Costs Common With Colonoscopy After Fecal Screen— Study details cost-sharing in the face of legal mandate for screening coverage

Patients needing colonoscopy after a non-invasive, stool-based test (SBT) often paid out of pocket for it, a study showed. One in six older adults who had a colonoscopy in the 6 months after some form of SBT ended up with cost-sharing, including 48% of commercially insured and 78% of Medicare patients in the insurance database claims analysis. Those out-of-pocket costs ranged from $99 to $231, reported Nicole Princic, MS, of IBM Watson Health in Cambridge, Massachusetts, and colleagues in a research letter in JAMA Network Open. 

MedPage Today | December 2021

High-Deductible Health Plans Make the Chronically Ill Pay More for Less
High-deductible health plans (HDHPs) incentivize patients, particularly those with low incomes, to avoid care, because doing so subjects them to the financial burdens insurance was supposed to prevent. However, forgoing care could worsen their disease control and lead to higher expenditures from emergency department visits and hospitalizations. 

University of Chicago Medicine / University of Arizona | January 2020

Many Americans Face Choices: Pay Medical Bills Or Maintain Holiday Cheer

Many American households struggle to pay for medical expenses, forcing some to make difficult decisions. According to the 2021 Aflac Health Care Issues Survey released today, these choices include working more, forgoing medical care, cutting back on holiday spending and more. Even with health insurance, families that experienced COVID-19 and those with children are especially hard hit. With the latest Centers for Disease Control and Prevention data indicating more than 45 million Americans tested positive for COVID-19 since the pandemic began, millions of households may be facing similar financial challenges, especially as the holiday season approaches.

Insurance NewsNet | December 2021

Study: Hospital prices for radiology services 2 to 6 times higher than Medicare rates

A new study indicates that the median commercial negotiated prices for 13 common shoppable hospital radiology services were about two to six times higher than the rates set by Medicare. Researchers at Johns Hopkins University and Michigan State University reviewed data this year from approximately 2,000 U.S. hospitals that disclosed pricing information. Price differences ranged from 2.2 times higher for mammography of both breasts ($289 median commercial price vs. $129 Medicare rate) to 5.9 times higher for a CT scan of the head or brain without contrast ($813 median commercial price vs. $137 Medicare rate).

BenefitsPro | December 2021

5 Tips for Avoiding Surprise Virus Test Bills

Experts worry the Omicron variant could seed a new coronavirus wave. That would probably mean a lot more tests — and, in the U.S., a lot more surprise bills. 

The New York Times | December 2021

Most Consumers’ Healthcare costs exceeded $400 during at least one month for more than a quarter of Americans in 2017, ballooning far above the amount Federal Reserve estimates that most U.S. consumers have saved for surprise expenses
Of the 18 million people studied using the 2017 IBM MarketScan Commercial Claims and Encounters database, researchers found that 83 percent of enrollees paid an average of $954 in out-of-pocket healthcare costs, while 17 percent reported no out-of-pocket healthcare costs.

Modern Healthcare | February 2021

Deductibles for traditional health plans are climbing as the average for single coverage workers increased from $460 in 2007 to $1,153 in 2018 (a 124 percent increase).

Some patients (17 percent of commercially insured patients) can even pay a separate pharmacy deductible for prescription medications in addition to their regular deductible.

Cover My Meds | 2020

Catastrophic Out-of-Pocket Health Care Costs: A Problem Mainly for Middle-Income Americans with Employer Coverage

High deductibles and out-of-pocket maximums in private insurance, combined with exposure to out-of-network bills for physician services, leave many Americans facing very high out-of-pocket costs.

The Commonwealth Fund | April 2020

Annual Out-Of-Pocket Spending Clusters Within Short Time Intervals: Implications For Health Care Affordability

Nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day. 

Health Affairs | February 2021

Enrollment of large-company workers in high-deductible plans reaches a historic high.

Nearly half of large-company workers have moved into high-deductible plans.

Healthcare Financial Management Association | August 2019

Employers Are Scaling Back Their Dependence On High-Deductible Health Plans.

Some employers say that, in a tight labor market, offering a more generous plan with a deductible that’s less than four figures can be an attractive recruitment tool.

Kaiser Health News | October 2019

The cost burden of blood cancer care.

A blood cancer diagnosis means high spending, both by payers and patients. These costs are driven by many factors across the healthcare system including service utilization, insurance coverage, and the use of in-network or out-of-network providers.

The Leukemia & Lymphoma Society / Milliman | October 2018

Kaiser Family Foundation/LA Times Survey Of Adults With Employer-Sponsored Insurance
The survey takes a special look at those in high deductible plans (including those paired with a health savings account or HSA), those with chronic health conditions, and those with lower incomes. 

Kaiser Family Foundation / LA Times | May 2019

Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health CareEnrollees With Skin in the Game

The rapid growth of high-deductible health plans (HDHP) has been driven in part owing to a belief that consumers must share the costs of health care to make good  decisions.

JAMA Internal Medicine | March 2016

Consumers have no money to put any more “skin in the game” of health care.

"[W]hen you look back over the past decade, the cumulative increase is startling. Out-of-pocket costs have increased 100 percent or more in most states since 2003, according to The Commonwealth Fund."

Center for Public Integrity | March 2015

Premium contributions and deductibles in employer plans accounted for 11.5 percent of median household income in 2019, up from 9.1 percent a decade earlier.

Premium contributions and deductibles were 10 percent or more of median income in 37 states in 2019, up from 10 states in 2010. If premiums and deductibles do not fall in 2021, household income lost during the pandemic economic crisis will increase cost burdens for middle-income families.

Commonwealth Fund | November 2020

72-Year-Old Cancer Survivor Has Vaccine Cancelled Over $244 Medical Debt.

Michael Rogan, a 72-year-old cancer patient and resident of Longmont, Colorado said his scheduled appointment to receive his first dose of COVID-19 vaccine was canceled because of his outstanding medical debt of $244.

Newsweek | February 2021

Pennsylvania residents are more worried than ever about health care costs, survey finds.

Half of Pennsylvania residents in a new survey by Pennsylvania Health Access Network and Altarum Healthcare Value Hub struggled with health-care costs in the last year and nearly two-thirds were worried about how they will pay for care in the future.

The Philadelphia Inquirer | February 2021

High out-of-pocket costs contribute to poor access to care and financial hardships for California workers

28 percent of U.S. adults under age 65 with job-based coverage are underinsured, meaning they have insurance, but are subject to high out-of-pocket costs such as deductibles and co-payments.

UC Berkeley Labor Center | December 2019

How Much U.S. Households with Employer Insurance Spend on Premiums and Out-of-Pocket Costs: A State-by-State Look
Faced with rising premiums, U.S. employers are sharing more of their costs with their workers, particularly through higher deductibles, copayments, and coinsurance. Recent research indicates that employer plan premium contributions and out-of-pocket costs, like those for prescription drugs, are eating up an increasing portion of household budgets.

The Commonwealth Fund | May 2019

How Much Do Medicare Beneficiaries Spend Out of Pocket on Health Care?

In 2016, the average person with Medicare coverage spent $5,460 out of their own pocket for health care. This average includes spending by community residents and beneficiaries residing in long-term care facilities who's average out-of-pocket spending on premiums and health care services was $4,519 in 2016. But some groups of beneficiaries spent substantially more than others. 

Kaiser Family Foundation | November 2019

Hospitals’ Covid-19 heroics have them poised for power in the new Washington

In 2016, the average person with Medicare coverage spent $5,460 out of their own pocket for health care. This average includes spending by community residents and beneficiaries residing in long-term care facilities who's average out-of-pocket spending on premiums and health care services was $4,519 in 2016. But some groups of beneficiaries spent substantially more than others. 

Kaiser Family Foundation | November 2019

Comparing Health Care Financial Burden With an Alternative Measure of Unaffordability.

For patients with COPD, enrollment in an HDHP was associated with cost-related barriers to care, financial strain, and more frequent emergency room visits and hospitalizations.

Harvard Medical School / Cambridge Health Alliance | January 2020

Comparing Health Care Financial Burden With an Alternative Measure of Unaffordability.

Health insurance plans with high deductibles increase exposure to health care costs, raising concerns about how the growth in these plans may be impacting both the financial burden of health care expenditures on families and their access to health care.

Journal of Health Care | October 2017

Black Americans in the South carry the largest share of medical debt. Advocates say Medicaid expansion can help
A new report reveals that Black Americans in the South carry the heftiest medical debt burden in the US. The Bloomberg study shows a myriad of ways medical and health care institutions pursue collecting more than $140 billion in US medical debt, which is the leading cause of bankruptcy in the country. According to Bloomberg, Black Americans in the South hold an average of $532 in medical debt. Black Americans are also more than twice as likely to be uninsured than their white counterparts, leading to higher mortality rates. Experts say this is largely due to Republican governors and state legislatures in southern states who continue to block the passing of Medicaid expansion. 

Insider | December 2021

Black Men Die Of Prostate Cancer At Double The Rate Of All Other Races
Thousands of Black men per year – from every socio-economic walk of life and every part of the U. S. – are disparately diagnosed with prostate cancer. Not only is the rate of prostate cancer among Black men higher than Whites, but the chances of Black men dying from it are more than double that of White men and men of other races, according to the National Cancer Institute. Doctors and medical administrators across the nation believe these grossly disparate numbers can be minimized or at least equalized by a therapy called Proton Beam. This is the reason that a list of insurance agencies are currently under fire by cancer advocates across the nation for refusing to cover the cost of proton beam therapy.

The Seattle Medium | December 2021

Health care disparities prevalent among employees at large companies
Employees of large U.S. companies — even those earning high salaries — face health care disparities, while women of color and LGBTQ+ employees face a higher share of unmet basic needs. Those are two key findings from first-of-its-kind research by management consulting firm McKinsey & Company that explored how employers across multiple industries can meet unmet needs and bolster health equity among employees.

BenefitsPro | December 2021

One State’s History of Hospital Debt Lawsuits Reveals Racial Gap
Hospitals sued patients to collect medical bills at an escalating pace over the past two decades in Wisconsin, according to a new analysis, and the suits disproportionately affected Black people. The rate of medical debt collection lawsuits in the state increased by more than a third from 2001 to 2018, researchers from Yale University and Stanford University reported in the journal Health Affairs. Lawsuits that led to wage garnishments also rose. The authors called it the first study of long-term trends in such suits by hospitals. Lawmakers in some states are scrutinizing the methods that health systems use to collect Americans’ estimated $140 billion in past-due medical debt. The analysis found that Wisconsin nonprofit hospitals were more likely to sue than for-profit medical centers. At the same time, hospital systems often benefit from tax breaks for nonprofit status and additional public funds meant to support treatment for patients who struggle to pay. Under pressure from consumer advocates, several states have passed laws to strengthen protections for patients.

Bloomberg | December 2021

Racial and Ethnic Health Disparities Exist in Every State, Report Finds
While racial and ethnic health disparities have and continue to exist, the scope has not been well documented or quantified. Now, a new Commonwealth Fund report is demonstrating just how deep some of these health inequities run. “There’s a historical perspective that plays into why we want to do the report… We know that in every state and nationally, people of color tend to have worse [health] outcomes than White people,” David C. Radley, PhD, MPH, senior scientist at the Commonwealth Fund, told Verywell. “They face experience low quality of care and access barriers that many White people don’t have. It was important to be able to quantify that.”  The report found that racial and ethnic disparities in the healthcare system exist in every U.S. state. How dramatic those disparities are varied. For example, Minnesota ranked third as having the largest disparities between White and Black, Latinx, Hispanic, Asian American and Native Hawaiian/Pacific Islander, and Native American communities (AANHPI). Meanwhile, Mississippi demonstrated the lowest performance for all groups.

Very Well Health | December 2021

As Biden Pushes for Racial Equity in Vaccination, Data Is Lagging

Federal health officials are struggling to gather accurate data on the race and ethnicity of people being vaccinated against the coronavirus, hampering President Biden’s push for racial equity in a pandemic that has taken a disproportionate toll on communities of color. Mr. Biden has repeatedly said racial equity will be at the core of his administration’s coronavirus response. White House officials announced a program to ship doses of vaccine directly to a network of federally funded clinics in underserved areas. “Equity is our North Star here,” Dr. Marcella Nunez-Smith, a Yale professor who has been appointed by Mr. Biden to lead a Covid-19 equity task force, said during a White House virus team briefing. So far, the federal government has gathered race and ethnicity data for just 52 percent of all vaccine recipients, according to a report issued last week by the Centers for Disease Control and Prevention.

The New York Times | February 2021

Pandemic Highlights Vulnerability of California’s Latinx Community

In 2019, patients spent $82 billion out-of-pocket for their medications.  Even with assistance from Medicare, the average 65-year-old couple faces $275,000 in medical bills throughout retirement. Seventeen percent of commercially insured patients pay a separate pharmacy deductible for prescription medications in addition to their regular deductible.  Despite coverage through Medicare, 19 percent of older Americans admit to skipping doses or medical care due to cost. Evidence suggests that prescription abandonment tracks with out-of-pocket costs; as costs escalate beyond $250, up to 69 percent of patients leave their medications at the

California Health Care Foundation | February 2021

High-deductible health plans may increase racial inequities, study finds 

There is also evidence that patients of color face greater barriers to care than others because of high-deductible health plan costs.  For example, in a recent study in JAMA Network Open, Black cancer survivors with a high-deductible plan were more likely to skip medications to save money than white cancer survivors with the same plans (22.8% versus 8%, respectively).

Becker's Hospital Review | June 2020

Among Low-Income Respondents With Diabetes, High-Deductible Versus No-Deductible Insurance Sharply Reduces Medical Service Use
Private insurance with a deductible substantially and problematically reduces medical service use for lower-income insured respondents with diabetes who have an HD; these patients are more likely to report forgoing needed medical services.

American Diabetes Association | February 2017

Vulnerable and Less Vulnerable Women in High-Deductible Health Plans Experienced Delayed Breast Cancer Care

The effects of high-deductible health plans (HDHPs) 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 health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment.

Health Affairs | March 2019

Racial/Ethnic And Income-Based Disparities In Health Savings Account Participation Among Privately Insured Adults"

Our findings show a substantial increase in HDHP enrollment across all racial/ethnic and income groups from 2007 to 2018. However, Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs, and these gaps increased over time. This means that the HDHP enrollees most likely to benefit from the potential financial protection of HSAs were the least likely to have them. If these trends persist, racial/ethnic and income-based disparities in cost-related barriers to care may widen."

Health Affairs | November 2020

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