How health insurance deductibles negatively impact members with lower incomes:
A barrier-breaking strategy to boost health equity in health plans.

High-deductible health plans (HDHPs) can have bad consequences for people. Numerous studies document how HDHPs can reduce health care access and utilization ― contributing to health inequity and reduced health outcomes for people with lower incomes.

By striving to decrease health disparities, employers can boost employee well-being and create competitive advantages for employee retention and acquisition. And they’re recognizing this opportunity. Ninety-five percent of employers surveyed in the Business Group on Health 2024 Large Employer Health Care Strategy Survey plan to implement at least one diversity initiative to address health inequities in 2024.1

“Deductibles impact lower earners more than higher earners, they’re inherently regressive. They disparately affect communities residing in lower-income neighborhoods. There's a critical health equity and Social Determinants of Health (SDOH) overlay to that,” says Trevor Fast, Benefit Products Lead at Surest.

People with lower incomes or chronic conditions can be especially vulnerable to cost-related access barriers when enrolled in an HDHP, reports a national survey published in the Journal of the American Medical Association (JAMA).2

The landmark RAND Health Insurance Experiment showed that cost sharing, fundamental to HDHPs, reduces health care costs by lowering utilization. But patients reduced their use of both appropriate and inappropriate services. The demand for health care was particularly reduced in low-income and vulnerable populations. Over the years, these findings have been confirmed in multiple studies. Data extracted from a review of several studies suggested that HDHPs may be associated with a reduction in preventive care and medication adherence.3

How HDHPs can impact minority cancer patients

Another JAMA study examined the association between HDHP enrollment and access to care by race/ethnicity among cancer survivors, a population that often faces substantial cost-related barriers to care. Enrollment in an HDHP adversely affected Black versus white patients when assessing the use of medication to save money, delays in filling prescriptions to save money, and ability to afford a specialist.4

This study found the negative connection between HDHPs and cost-related barriers to care is larger among Black cancer survivors relative to their white counterparts, illuminating the potential for HDHPs to widen documented racial/ethnic disparities in cancer outcomes.5

How a health plan can improve health equity

“We wanted to improve members’ health by removing barriers to high-value care,” says Fast. Surest started by eliminating deductibles but didn’t stop there. The Surest plan implemented its “equity enhancement” that puts more subsidy into services used to treat conditions that especially burden underserved communities, making health care more inclusive and equitable.

“Because of the flexible structure of the Surest benefit, we had an opportunity to do something unique around Diversity, Equity, and Inclusion (DEI) principles ― embedded in the subsidy,” emphasizes Fast. “Where we identify conditions that are borne by underserved communities, we can lower prices (copays) on services, procedures, and treatments used to treat those conditions. We can go beyond simply eliminating the deductible and have further impact on reducing barriers to high-value care, which increases access and affordability for everyone.”

How does Surest identify conditions for an equity enhancement/lower copay?

Surest analyzes members’ data across geographies, health conditions, and race/ethnicity. “It helps us understand whether we have any unintentional bias in the benefit and where we have opportunities to improve,” says Fast. This information identifies conditions that underserved populations deal with disproportionately. The data allow Surest to subsidize medical treatments for these conditions at a higher rate, resulting in lower copays. Examples of this include allergy treatment, cardiac rehab therapy, dialysis, and glaucoma surgery.

An annual evaluation determines if additional conditions should be added to the equity enhancement. “Hundreds of specifically defined services and benefits are included with clear, precise copays in the Surest plan. So, we had to create a science around subsidizing each one ― which no other insurance company does,” stresses Fast.

Is the enhancement improving health care utilization for the underserved?

Early results of the equity enhancement are encouraging. In a study comparing a large employer group’s utilization across the BIPOC (Black, Indigenous, and people of color) and non-BIPOC populations, pre- and post-enhancement, the share of services the BIPOC population accounted for increased post-enhancement across several enhancement service categories. Specifically:

How Surest can increase access and affordability outside of the equity enhancement

The Surest plan is specifically designed to make health care more accessible and affordable with no deductible and clear, upfront pricing. Members can search on the app or website in advance to find care options and pricing that meet their needs. Prices are lower for services, providers, and locations evaluated as high-value based on quality, efficiency, and overall effectiveness of care ― which can remove financial barriers to care.

“Surest members can dramatically lower their total cost of care when they use high-value treatments at high-value providers,” says Fast.

Members have access to a broad, national network of providers. And to further boost access and affordability, there are virtual care options with copays as low as $0.

Data show increased preventive care among members who migrated from a deductible plan to Surest

A comparison of members having 12 months on a deductible plan in 2021 and 12 months on the
no deductible Surest plan in 2022 shows they boosted preventive care utilization after moving to the Surest plan, which may improve health outcomes.

How employers’ health plan choices may impact members’ health

Fast says employers only offering plans with deductibles, especially HDHPs, have no ability to lower employees’ costs when they seek high-value care. He says that care is frequently restricted and avoided as a function of HDHPs. “You just can't address it if the only medical benefit you offer your employees is a high-deductible plan,” emphasizes Fast. “The Surest benefit structure gives you an opportunity to spend every dollar you're subsidizing on health benefits in a much more precise and directed way that generates value.”

The Surest plan offers employers an actionable way to incorporate health equity principles into the heart of their benefit. It goes beyond what's legally required regarding non-discrimination in the workplace and demonstrates a commitment to actionable subsidies within the benefit. A win for employers looking to increase well-being for their diverse workforce.

1Business Group on Health 2024 Large Employer Health Care Strategy Survey

2Use of Health Savings Accounts Among US Adults Enrolled in High-Deductible Health Plans | Health Policy | JAMA Network Open | JAMA Network

3High-Deductible Health Plans Reduce Health Care Cost And Utilization, Including Use Of Needed Preventive Services | Health Affairs

4,5Association Between High-Deductible Health Plans and Disparities in Access to Care Among Cancer Survivors | Health Policy | JAMA Network Open | JAMA Network

6Comparison of members identified as having 12 months enrollment in a UHC plan in 2021, and 12-months enrollment in a Surest plan in 2022. 167_V01.

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