The Impact of High-deductible Health Plans on Men and Women: An Analysis of Emergency Department Care

By Kozhimannil, Katy B. PhD, MPA; Law, Michael R. PhD, MSc; Blauer-Peterson, Cori MPH; Zhang, Fang PhD; Wharam, James Frank MB, BCh, BAO, MPH
Medical Care (APHA), August 2013


Background: Prior studies show that men are more likely than women to defer essential care. Enrollment in high-deductible health plans (HDHPs) could exacerbate this tendency, but sex-specific responses to HDHPs have not been assessed. We measured the impact of an HDHP separately for men and women.

Methods: Controlled longitudinal difference-in-differences analysis of low, intermediate, and high severity emergency department (ED) visits and hospitalizations among 6007 men and 6530 women for 1 year before and up to 2 years after their employers mandated a switch from a traditional health maintenance organization plan to an HDHP, compared with contemporaneous controls (18,433 men and 19,178 women) who remained in an health maintenance organization plan.

Results: In the year following transition to an HDHP, men substantially reduced ED visits at all severity levels relative to controls (changes in low, intermediate, and high severity visits of −21.5% [−37.9 to −5.2], −21.6% [−37.4 to −5.7], and −34.4% [−62.1 to −6.7], respectively). Female HDHP members selectively reduced low severity emergency visits (−26.9% [−40.8 to −13.0]) while preserving intermediate and high severity visits. Male HDHP members also experienced a 24.2% [−45.3 to −3.1] relative decline in hospitalizations in year 1, followed by a 30.1% [2.1 to 58.1] relative increase in hospitalizations between years 1 and 2.

Conclusions: Initial across-the-board reductions in ED and hospital care followed by increased hospitalizations imply that men may have foregone needed care following an HDHP transition. Clinicians caring for patients with HDHPs should be aware of sex differences in response to benefit design.…

One of the most important changes in health care financing taking place today is the tremendous surge in the use of high-deductible health plans. This is yet one more study that shows that we should question the wisdom of this policy intervention.

Males whose employers switched them from a traditional HMO to a high-deductible health plan reduced their use of emergency department high-severity visits by 34 percent. That is, they did not go to the emergency department when the severity of their condition clearly warranted it. That was followed a year later by a 30 percent increase in hospitalizations. Lead author Katy Kozhimannil stated, “The trends suggest that men might have put off needed care after their deductible went up, leading to more severe illness requiring hospital care later on” (American Medical News, Aug. 26).

High-deductible health plans not only cause financial hardship, they also maim and kill people. And they aren’t even necessary as a means to control spending. We can control costs more effectively and far more humanely through a publicly-administered single payer program that provides first-dollar coverage.