July 27, 2017
In
November 2015, Tina Heck was in her garage lifting 40-pound bags of wood
pellets to fuel her heating stove, when something went very wrong with her
back.
“The
next day, I could barely walk,” said the 55-year-old who lives on an acre of
land in Nevada City, Calif., 60 miles northeast of Sacramento. The cause: a
bulging disc in her lower spine, which shoots pain down her leg and makes her
back stiff.
The
injury wasn’t Heck’s only setback. The initial MRI, cortisone shot and doctor
visit cost her $3,000 because her health plan requires her to shell out $5,000
before insurer payments kick in. She doesn’t want to explore other treatment
options because of that high deductible. Heck, who makes $68,000 a year in
marketing for a nonprofit, is not willing to add more debt on top of her
credit-card and mortgage payments.
“I’m in
pain every day,” she said, but “it’s not bad enough to go into debt.”
The
concept behind high-deductible plans was to lower premiums and reduce overall
health costs by ensuring that consumers shared the financial burden of their
own health care decisions. But evidence is mounting: High deductibles have
actually forced people to delay care that could prevent health emergencies
later or improve their quality of life.
Regardless
of what happens to the Affordable Care Act, such plans are likely to become
more widespread as health care costs continue to rise. Just over half of people
with health plans from their employers now have a deductible of $1,000 or more,
up from 10% in 2006, according to the Kaiser Family Foundation. (Kaiser Health
News, which produces California Healthline, is an editorially independent
program of the foundation.)
“People
who have medical problems that can be put off tend to do so much more now
because of the high deductible,” said Dr. Ted Mazer, a San-Diego based head and
neck surgeon who is president-elect of the California Medical Association.
Annual
deductibles can amount to many thousands of dollars on some plans. Covered
California bronze plans, with the lowest premiums available on the exchange,
carry deductibles of $6,300 for an individual and $12,600 for a family.
A
Kaiser Family Foundation survey released
this year showed that 43% of insured people reported having trouble paying
their deductible, up from 34% in 2015. (Kaiser Health News, which produces
California Healthline, is an editorially independent part of the foundation.)
In
one study by the
liberal advocacy group Families USA, more than a quarter of people in
high-deductible plans delayed some type of medical service such as a doctor
visit or diagnostic test. And 44% of adults with high out-of-pocket expenses
put off medical care, according to a nonpartisan Commonwealth Fund study.
Another
recent study by
researchers at the University of California-Berkeley and Harvard University
found that people with high-deductible plans spent 42% less on health care
before meeting their deductibles, primarily by reducing the amount of health
care they received, not by shopping around for a better price.
Jonathan
Kolstad, associate professor of economics at UC-Berkeley’s business school and
co-author of the study, said patients dropped both needed care, such as
diabetes medication, and potentially unnecessary care, such as imaging for
headaches.
“Left
to their own devices, people [in high-deductible plans] seem ill-equipped to
make their own decisions” about what care they need, and what care they don’t,
Kolstad said.
Mazer
said that, in his practice, people have delayed all kinds of treatment that may
not save “life or limb” but involved medical conditions that interfered with
breathing or sleeping.
He said
he’s had patients who needed a biopsy to determine if an abnormal vocal cord
was cancerous, and they put it off because of the cost.
“I have
to make the phone call and say, ‘We’re looking at a mass that may be malignant
and if you put it off you’re putting yourself at risk,’ ” Mazer said. “And I’ll
tell you, we’ve had people take that risk.”
Recent
Republican proposals to repeal Obamacare have promoted the use of
high-deductible plans by allowing people to put away more tax-free dollars into
the health savings accounts that
consumers use in conjunction with those plans. And experts said the proposals
would also spur the growth of
these plans — by cutting the subsidies available through exchanges, inducing
customers to look for cheaper plans with higher deductibles.
Conservatives
say insurance that promotes personal financial responsibility helps tamp down
overall health costs. Hoover Institution analysts, for example, argue that high
deductibles encourage patients to “choose wisely.”
But new
evidence suggests that putting off care can be dangerous and, eventually, more
costly to patients.
A March
2017 Harvard study found that low-income
patients with diabetes who had high-deductible plans delayed visits for
complications such as skin infections and pneumonia. They wound up getting more
expensive care later on.
Patients
may try to treat their conditions at home, or hope they go away — but if that
approach fails, “they then have to seek care at the emergency department,” said
Frank Wharam, a health policy researcher at Harvard Medical School and lead
author of the study.
Wharam
said the middle-income earners he studied didn’t suffer any adverse effects
from health care choices they made in high-deductible plans, adding that more
studies are needed on that group.
Sabrina
Corlette, from the Georgetown University Center on Health Insurance Reforms,
said that until national health policy addresses the “underlying costs of
care,” patients in high-deductible plans will likely be stuck with the
difficult task of figuring out what medical attention they need or can afford.
Heck
said the symptoms from her back injury have changed — the pain is in a
different part of the body than it was right after the injury. But she’s not
even considering a trip to a nearby clinic for a new assessment. That would
require another MRI, she said, which could cost at least $1,500, and it might
not even help her. If her deductible weren’t as high, she’d feel “freer” to
explore other health care options, she said.
For
now, she’s taking a lot of ibuprofen and seeing a chiropractor.
“A lot
of people get stuck in this place,” she said.
Pauline
Bartolone: pbartolone@kff.org,
@pbartolone
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