Understanding behavioral risk factors in high-deductible health plans

Jeffrey T. Kullgren, MD, MS, MPHa,b,c; Kevin G. Volpp, MD, PhDb,c,d,e; Daniel E. Polsky, PhDc,d,e

aRobert Wood Johnson Foundation Clinical Scholars; bPhiladelphia Veterans Affairs Medical Center; cLeonard Davis Institute of Health Economics Center for Health Incentives, University of Pennsylvania; dDivision of General Internal Medicine, University of Pennsylvania School of Medicine; eThe Wharton School, University of Pennsylvania

Cross-sectional analysis of nationally-representative data from the 2007 Health Tracking Household Survey

Analytic sample comprised of adults age 18 to 64 enrolled in one private health insurance plan

Individuals with an annual deductible of at least $1,100 per person or $2,200 per family classified as HDHP enrollees

All others classified as traditional plan enrollees Individuals analyzed in 3 coverage source

groups ranging from the least to the greatest potential for plan self-selection:

Univariate logistic regression to measure unadjusted associations between HDHP enrollment and smoking and obesity

Multivariate logistic regression to examine associations between HDHP enrollment and smoking and obesity within each coverage source while adjusting for individual, household and geographic characteristics

Methods Results

HDHP enrollment associated with lower overall rates of smoking and obesity, but these associations vary by potential for plan self-selection

No associations between HDHP enrollment and behavioral risk factors among individuals with no choice of health plans

Negative associations between HDHP enrollment and behavioral risk factors only among individuals with the potential to self-select into a plan

Associations between HDHP enrollment and behavioral risk factors appear driven by individuals who choose these plans

Conclusions

HDHP enrollment is increasing and may accelerate as health reform implemented

Greater evidence for a self-selection effect than for a health-promoting effect as an explanation for negative associations between HDHP enrollment and behavioral risk factors

Need for further research on alternative ways health insurance benefit design can effectively encourage behavioral risk factor modification

Policy implications

Smoking and obesity are leading causes of death in the United States

One policy tool promoted as a way to encourage modification of behavioral risk factors like smoking and obesity is a high-deductible health plan (HDHP)

Lower rates of behavioral risk factors among HDHP enrollees have been cited as evidence that these plans are responsible for encouraging healthy lifestyle behaviors

These analyses fail to account for important factors that may explain these associations Potential confounders Health plan self-selection

Unknown whether associations between HDHP enrollment and smoking and obesity are driven by individuals who choose these plans

Background

To identify associations between HDHP enrollment and smoking and obesity among privately insured US adults

To determine whether associations between HDHP enrollment and rates of smoking and obesity differ by the degree to which individuals can self-select into a health plan

Objectives

Associations between HDHP enrollment and smoking*

* Smoking defined as currently smoking cigarettes every day.** Obesity defined as a body mass index ≥ 30 kg/m2 calculated from self-reported weight and height. † Unadjusted odds of outcome relative to traditional plan enrollees.‡ Odds of outcome adjusted for gender, age, annual household income, race/ethnicity, education, risk tolerance, employment status, marital status, parenthood, county MSA category, and US Census region. Reference group is traditional plan enrollees in the same coverage source group.

Associations between HDHP enrollment and obesity**

1.04 (0.69-1.56)

OR (95% CI)

0.72 (0.55-0.95)

0.56 (0.34-0.92)

0.63 (0.33-1.20)

All privately insured†

ESI without plan choice‡

ESI with plan choice‡

Non-group coverage‡

.5 1 1.5

OR (95% CI)

Coverage source

0.82 (0.68-1.00)

1.01 (0.79-1.52)

0.95 (0.71-1.28)

0.65 (0.38-1.11)

OR (95% CI)

All privately insured†

ESI without plan choice‡

ESI with plan choice‡

Non-group coverage‡

.5 1 1.5

Coverage source

OR (95% CI)