title: Health care use and decision making among lower-income families in high-deductible health plans.
abstract: BACKGROUND
  Lower-income families may face unique challenges in high-deductible health plans (HDHPs).
  
  
  METHODS
  We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's HDHP with at least $500 in annualized out-of-pocket expenditures. Lower-income families were defined as having incomes that were less than 300% of the federal poverty level. Primary outcomes were cost-related delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of families asking their physician about hypothetical recommended services subject to the plan deductible. Multivariate logistic regression was used to control for potential confounders of associations between income group and primary outcomes.
  
  
  RESULTS
  Lower-income families (n = 141) were more likely than higher-income families (n = 273) to report cost-related delayed or foregone care (57% vs 42%; adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible.
  
  
  CONCLUSIONS
  Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.
authors.affiliation: VA Medical Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, 19104-6021, USA. kullgren@mail.med.upenn.edu
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Kullgren
authors.forename: Alison A
authors.initials: AA
authors.lastname: Galbraith
authors.forename: Virginia L
authors.initials: VL
authors.lastname: Hinrichsen
authors.forename: Irina
authors.initials: I
authors.lastname: Miroshnik
authors.forename: Robert B
authors.initials: RB
authors.lastname: Penfold
authors.forename: Meredith B
authors.initials: MB
authors.lastname: Rosenthal
authors.forename: Bruce E
authors.initials: BE
authors.lastname: Landon
authors.forename: Tracy A
authors.initials: TA
authors.lastname: Lieu
mesh_terms: D000328:Adult; D002648:Child; D003256:Community Participation; D003430:Cross-Sectional Studies; D003657:Decision Making; D003669:Deductibles and Coinsurance; D019937:Diagnostic Techniques and Procedures / Q000191:economics* / Q000706:statistics & numerical data; D015438:Health Behavior; D057220:Health Literacy; D006801:Humans; D007182:Income; D057226:Information Seeking Behavior; D019458:Insurance Coverage / Q000191:economics; D007348:Insurance, Health / Q000191:economics*; D009511:New England; D010817:Physician-Patient Relations; D011795:Surveys and Questionnaires