Rising out-of-pocket costs cause more people to postpone or skip needed care

Cost-sharing mechanisms such as deductibles, copays and coinsurance are intended to slow rising healthcare costs by discouraging people from seeking unneeded medical care. But as out-of-pocket costs increase and family incomes stagnate, such measures instead are causing many people-especially those with low and moderate incomes-to postpone needed care or not get it at all, according to a new study.

The study by The Commonwealth Fund-part of its ongoing Health Care Affordability Tracking Survey-looks at how much adults with private insurance pay in deductibles and copays, and how those expenses affect their healthcare decisions.

Thirteen percent of those surveyed had deductibles equal to 5% or more of their incomes. Among those, 40% said they had not seen a doctor when they were sick, did not get a preventive care test, skipped a recommended follow-up test, or did not get needed care from a specialist. Results were similar even among the 23% of respondents whose deductibles were less than 5% of their income.

Overall, 43% of survey respondents said it was either somewhat or very difficult or impossible to afford their deductible, with the proportion rising to 58% among those earning less than 100% of the federal poverty level, and 64% for those earning between 100% and 199%.

The report cites a study by the Kaiser Family Foundation showing that 80% of workers covered by employer-based insurance now have deductibles, compared with 55% in 2006. The average deductible for an individual policy is $1,217, up from $584 in 2006.

Especially troubling is a finding that 27% of adults with deductibles comprising at least 5% of their income did not see a doctor for a medical

Sara Collins, Ph.D.problem, says Sara Collins, Ph.D., a Commonwealth Fund vice president and the study’s lead author. “Avoiding preventive care tests could result in development of more serious and costly conditions that may be treated early at lower cost,” Collins says. “But what is also concerning is that deductibles by law exclude preventive tests. So this shows that the complexities of cost sharing create confusion for consumers and may lead to delays or avoidance of needed care.” 

Copays and coinsurance are less of a burden but still affect healthcare decisions, the survey found. Just under one-fourth of respondents said it was very or somewhat difficult or impossible to afford copays for medical treatment or prescriptions, but the proportion was higher (40%) for those with incomes less than the federal poverty level.

“Overall, lower-income adults delayed or avoided care because of their copayments at twice the rate of adults with higher incomes,” the report finds. “Nearly half (46%) of insured adults with incomes under 200% of poverty said that because of copayments or coinsurance, they had either not filled a prescription, not gone to the doctor when they were sick, skipped a medical test or follow-up visit…or not seen a specialist when they or their doctor thought they needed one.”

The report notes that the Affordable Care Act could reduce the number of underinsured Americans by making coverage in the individual and small-group market more comprehensive. “But the underlying rate of growth in health care costs relative to income growth also will have an impact on the number of underinsured people in the coming years,” the authors say. “A systemwide effort to reduce health care cost growth will be needed to ensure the affordability of both insurance and health care for working Americans over time.”