Privately insured adults in HDHP with higher deductibles reduce rates of primary care and preventive services

Privately insured adults in HDHP with higher deductibles reduce rates of primary care and... Abstract Rates of insurance coverage in high deductible health plans (HDHP) and deductible size have been increasing. Over-time, financial barriers can lead to a substantial reduction in opportunities for health promotion and care coordination. We investigated the impact of different types of HDHPs on primary and specialty services utilization and receipt of preventive services among adult (18–64 years) privately insured respondents using pooled 2011–2014 Medical Expenditure Panel Survey (MEPS). The sample (n = 25,965) was divided into four insurance types (1) no deductible (ND) (2) low deductible (LD), (3) high deductible with health savings account (HD-HSA), and (4) high deductible without health savings account (HD-NoHSA). Multivariable regression models were estimated, adjusting for demographic characteristics and health status. Number of visits to primary care physicians and specialists were lowest for persons in the HD-NoHSA group (IRR 0.88 95% CI [0.81–0.96]). HD-NoHSA beneficiaries had lower rates of receiving hypertension screening (IRR 0.97 95% CI [0.94–0.99]) and flu vaccination (IRR 0.92 95% CI [0.86–1.00]) when compared to ND enrollees. Female respondents in the HD-NoHSA group were 7% less likely to receive mammograms (IRR 0.93 95% CI [0.89–0.98]) compared to the ND group. There was no significant association between insurance type and the other preventive service measures. Higher deductibles significantly decrease opportunities for early detection and management of chronic diseases, immunizations and care coordination. Fiscal barriers to essential medical care should be eliminated at least for those most vulnerable. Implications Practice: High deductible health plans (HDHPs) particularly with higher deductibles discourage physician office use. Reduced primary care visits, significantly reduced selected screening and immunizing services, imply that the out-of-pocket costs of higher deductibles compromise provision of health promotion and care-coordination services. Greater access to primary care and care coordination leads to increased uptake of preventive services. Policy: Rising deductibles of affordable lower premium HDHPs increasingly confound enrollee’s ability to access prevention services and provide opportunity to do care coordination. These trends are inconsistent with health promotion compromising the utility of health insurance and the social value of insurance. Research: The long-term effects of rising financial barriers to care lead to substantial reduction in opportunities for health promotion and care coordination. Future research could examine the relationship between care coordination and HDHP on receipt of preventive screening and health promotion services, and the impact of health insurance with high out-of-pocket costs on well-being and avoidable illness. INTRODUCTION Affordable health care is compromised for many Americans. The out-of-pocket costs of health insurance are increasing with increased enrollment in high deductible health plans (HDHPs). The proportion of US adults with high deductibles has increased since the Medicare Prescription and Modernization Act (MMA) of 2003, increasing six times between 2005 and 2015 (5%–29%) [1]. Deductible size also increased from 2006 to 2015; the average deductible under employer-based insurance increased from $1,070 to $1,954 [2]. HDHP enrollment further increased under the Affordable Care Act (ACA), as HDHPs have lower premiums and are attractive particularly to those of lower income who were previously uninsured [3]. Studies indicate that most of the enrollees who obtained coverage through health insurance exchanges have a deductible of at least $1,300 for individuals and $2,600 for families [4]. HDHPs were designed to reduce unnecessary medical care; however, research indicates that people with HDHP also avoid necessary care [5]. Rabin et al. reported that higher deductibles of HDHP severely limited primary care and specialist office visits and routine check-ups in lower income groups with diabetes [6]. Preventive care is necessary for early detection and slower progression of chronic disease, and to identify and modify disease risk factors [7]. The ACA improved access to certain recommended preventive services by mandating their coverage, even in HDHPs with no out-of-pocket charge. These include annual preventive visits, cholesterol screening, diabetes screening, blood pressure screening, colon cancer screening, cervical cancer screening, and breast cancer screening [8, 9]. Access to primary care and care coordination offer opportunities for health promotion and preventive care and are associated with higher rates of delivery of preventive services [9–11]. However, rising financial barriers to care reduce such occasions impeding the promotion of preventive services. Only 43 per cent of the individuals enrolled in high deductible plans were aware of cost-exemption for preventive services or had knowledge about specific details of their health insurance plan [9]. The literature shows mixed results in preventive care seeking behaviors of HDHP populations. In a survey of Kaiser Health Maintenance Organization (HMO) patients, almost 20 per cent of those with HDHPs avoided preventive visits and did not seek at least one of the preventive screening tests due to cost concerns [12]. A Research ANd Development (RAND) review of HDHP reported moderately lower rates of preventive services [5], whereas, in an HMO-based Massachusetts study, cancer screening rates in HDHP insured women of low income were similar to the control group with no HDHP [13]. Another study that compared HRA with PPO showed similar cancer screening rates in both cohorts [14]. Other researchers found constant rates of breast cancer and cervical cancer screening tests before and after eliminating preventive services from cost-sharing in HDHP enrollees [15, 16]. Prior studies used employee-based insurance HDHP enrollees that were limited to geographical locations or restricted to vulnerable populations. No study has determined the uptake of preventive services and primary care associated with HDHPs using a nationally representative U.S. sample. The purpose of this study is to investigate the impact of HDHPs by type of deductible on the receipt of preventive services among respondents having annual deductibles using pooled data from the 2011–2014 Medical Expenditure Panel Survey (MEPS). METHODS Data source and study sample MEPS is a nationally representative survey of civilian, noninstitutionalized populations with oversampling of Hispanics, Blacks, and Asians and is administered by the Agency for Healthcare Research and Quality (AHRQ). Data are collected across five rounds of interviews over 2 full years with overlapping panels. MEPS provides national estimates of the use of health services, medical expenditures, insurance coverage, and payment sources for all non-institutionalized civilian individuals residing in the USA. Each year a third of previous years’ National Health Interview Survey is subsampled to obtain the sampling frame for MEPS. MEPS uses a complex sample design that includes estimation weights, primary sampling units, and strata that reflect the complex survey design, and these variables must be used in analysis to obtain accurate estimates and unbiased standard errors [17]. We pooled 2011–2014 MEPS data to examine the association between HDHP and primary care and preventive service use. The study sample was restricted to privately insured adults under the age of 65. We divided the sample into four groups, based on annual deductible and health savings account (HSA) status: (a) no deductible (ND), (b) low deductible (LD) (less than $1,250 for an individual or less than $2,500 per family), (c) high deductible (greater than $1,250 or $2,500) with health savings account (HD-HSA), and (d) high deductible without health savings account (greater than $1,250 or $2,500; HD-NoHSA). The annual deductible and HSA were derived from the person-round plan datafiles, physician specialty was obtained from the office-based visit files, and all other variables were collected from the consolidated files. Outcome measures were the number of primary care visits per year and receipt of preventive services or screening tests recommended by the U.S. Preventive services Task Force (USPSTF): (a) routine check-up, (b) hypertension screening, (c) cholesterol screening, (d) breast cancer screening (mammogram), (e) colon cancer screening (colonoscopy), (f) cervical cancer screening (Papanicolaou) test, and (g) flu vaccination [18]. For each service, we restricted the sample, by gender and age, as specified in the USPSTF recommendations. Covariates included demographic characteristics: gender, census regions, race/ethnicity, education, income, and reported health status. The four census regions were (a) South, (b) Northeast, (c) Midwest, and (d) West. We created four race and ethnicity groups: (a) non-Hispanic Whites, (b) non-Hispanic Blacks, (c) Hispanics, and (d) Other. We combined Asians, Native Hawaiian or Pacific Islander, and American Indian or Alaskan Natives into an “Other” group. Three categories of education were created as follows: (a) less than 12 years of education, (b) obtaining high school diploma or GED high school equivalency, and (c) postsecondary education. We included five categories for income: (a) less than 100 per cent Federal Poverty Level (FPL), (b) 100%–124% FPL, (c) 125%–199% FPL, (d) 200%–399% FPL, and (e) greater than or equal to 400% FPL. Five categories of reported health status included as follows: (a) Excellent, (b) Very good, (c) Good, (d) Fair, and (e) Poor. Statistical analysis We analyzed the data using Stata 14.0 statistical software. We computed summary statistics and reported the number and percentages of the respondents in the entire sample by type of the physician seen (primary care physicians vs. specialist) and deductibles. We performed bivariate analyses on categorical variables using chi-squared tests and t-tests for continuous variables to compare demographic characteristics across deductible categories and by the physician type seen. To assess the significant differences between the mean number of primary care and specialist care visits, we used t-tests and adjusted-Wald tests. We used Poisson regressions for the number of primary care and specialist visits and for each of the preventive tests [19–21]. These models were estimated for the full sample as well as a sample restricted to those with at least one primary care visit. We reported incidence risk ratios and 95% confidence intervals (CIs). To obtain valid national estimates for the outcomes (preventive services and primary care visits), we included the MEPS complex survey poststratification, clustering variables and sampling weights in the analysis using Stata survey commands (Stata 14.0 Stata Corp., LP Texas Station). RESULTS Our total sample consisted of 49,874 respondents with data for annual deductibles. Restricting the sample to privately insured adults less than 65 years yielded 26,035 survey participants. Our final sample contained 25,965 privately insured adults (18–64 years), after adjusting for person weights and MEPS complex survey design and excluding those missing region (n = 1), education (n = 63), and reported health status (n = 6; Fig. 1). Fig 1 View largeDownload slide Flowchart—Recruitment of analysis sample. Fig 1 View largeDownload slide Flowchart—Recruitment of analysis sample. Table 1 compares the demographic characteristics of respondents across the four annual deductible categories. Of the total sample, 27 per cent of the respondents were enrolled in ND, 46 per cent in LD, 9 per cent in HD-HSA, and 17 per cent in HD-NoHSA. Individuals enrolled in HD-HSA were more likely to be non-Hispanic Whites (83.9%, p < .001), affluent (63.8%, p < .001), educated (77.5% with postsecondary education, p < .001), from the Northeast (33.5 %, p < .001), and reported very good-to-excellent health status (71.7%, p < .001) compared with respondents in other groups. Those with HD-NoHSA coverage were least likely to be affluent and most likely in poor-to-fair health. Table 1 Distribution of demographic characteristics of privately insured respondents (18–64 years) by annual deductible (N = 25,965) Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Chi-squared test of significance for categorical and adjusted-Wald test for continuous variables across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA. View Large Table 1 Distribution of demographic characteristics of privately insured respondents (18–64 years) by annual deductible (N = 25,965) Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Chi-squared test of significance for categorical and adjusted-Wald test for continuous variables across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA. View Large Our bivariate analyses contrasting primary care versus specialty care (Supplementary Table 1) showed that females were less likely to visit primary care physician than males (44.2% vs. 55.8%, p < .001). Adults with moderate income (200%–399% FPL) had higher proportion of primary care visits (34.1% vs. 30.6%, p = .004) than lower income respondents. Individuals seeking care from specialists were more likely to be affluent (≥200% FPL), have greater than 12 years of education, non-Hispanic Whites, HD-HSA enrollees, and to report good health status. Higher mean number of specialist visits were found in women (3.12, p < .001) compared with men, non-Hispanic Whites (2.84, p < .001) than non-Whites, and in those who reported poor health status (6.65, p < .001) in comparison to respondents in other health status categories (Supplementary Table 1). Table 2 displays the unadjusted percentage of preventive services: a higher proportion of women in HD-HSA group received cervical cancer and breast cancer screening tests compared with women enrolled in other deductible types. Likewise, hypertension screening rates were also higher for the individuals in HD-HSA than other categories. Table 2 Unadjusted percentage of preventive service use ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 Chi-squared test of significance across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA; CI confidence interval. View Large Table 2 Unadjusted percentage of preventive service use ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 Chi-squared test of significance across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA; CI confidence interval. View Large Poisson regression results demonstrate the mean number of primary care and specialist visits after adjusting for demographic characteristics and self-reported health status (Table 3). LD enrollees had 7 per cent and HD-NoHSA had 12 per cent lower than expected mean number of primary care visits compared with ND enrollees (p < .001). No statistically significant differences in number of specialty visits were observed across the insurance types. Table 3 Incidence risk ratios of primary care visits and specialty visits by annual deductible among privately insured adults (18–64 years) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA, IRR incidence risk ratio, CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Table 3 Incidence risk ratios of primary care visits and specialty visits by annual deductible among privately insured adults (18–64 years) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA, IRR incidence risk ratio, CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Women with HD-NoHSA had 7 per cent less likelihood of being screened for breast cancer compared with those with ND (incidence risk ratios [IRRs] 0.932, 95% CI [0.890–0.975]) after adjusting for race/ethnicity, region, poverty, education, and health status (Table 4). Similarly, those with HD-NoHSA were 4 per cent less likely to receive hypertension screening compared with those with ND. HD-NoHSA beneficiaries had 8 per cent lower rates of receiving flu vaccination in comparison to those with ND. Table 4 Incidence risk ratios of obtaining preventive screening tests/check-ups and vaccination by annual deductible among privately insured adults (18–64 years) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA; IRR incidence risk ratio; CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Table 4 Incidence risk ratios of obtaining preventive screening tests/check-ups and vaccination by annual deductible among privately insured adults (18–64 years) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA; IRR incidence risk ratio; CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large We conducted additional analysis to examine preventive care use among the respondents who had at least one primary care visit and found no statistically significant differences in preventive care rates between the ND and HD-NoHSA groups (Supplementary Table 2). DISCUSSION Using a nationally representative sample, we found that individuals with HDHPs without an HSA are less likely to access primary care and specialty services and receive preventive services than those with ND. These differences are minimized for those making at least one primary care visit during the last 12 months. Specifically, we found that rates of breast cancer and hypertension screening, and flu vaccination were lower among respondents in HD without HSA compared with those enrolled in ND insurance plans. Our findings on the uptake of preventive services are consistent with the Commonwealth Fund study that found one in five respondents with HD plans and one in ten individuals of those with LD plans skipped at least one preventive service [3]. Under the ACA, although uninsured rates have fallen, premiums and deductibles have increased, with more of the privately insured at risk of out-of-pocket costs when using services. HDHPs are intended as a cost containment measure to reduce the use of nonessential and more costly care while allowing use of essential health care services. According to the ACA, preventive care services are exempted from out-of-pocket charges including the deductible, so one would expect to see similar rates of receipt of preventive services and lower cost primary care visits. In contrast, we found reduction in the number of primary care visits among individuals with deductibles particularly higher deductibles (LD, HD-NoHSA), except for those with health savings accounts. The low percentage of women relative to men seeking care from primary care physicians may be because women of reproductive age see their obstetrician or gynecologists for all their care including regular care [22]. Studies show that a significantly higher proportion of affluent women of post-reproductive age seek routine medical care from their obstetrician or gynecologists [23]. Non-Hispanic Whites, young, affluent, and well-educated individuals reporting good-to-excellent health status would be expected to choose HDHPs [24, 25]. However, HD-NoHSA enrollees in our sample were less educated and less affluent and reported belonging to minority racial/ethnic groups with a higher need for medical care. Perhaps, low-income populations enroll in HDHPs with less costly premiums unaware of the benefits covered by their health insurance plans [3, 4]. Consistent with these demographic characteristics, HD-NoHSA enrollees reported slightly worse health status than other insured groups. Importantly, they visited primary care physician less often and used fewer prevention services than the individuals in no deductible plans. Unlike the ND respondents, HD-NoHSA beneficiaries must pay particularly high out-of-pocket costs obtaining care and are not protected by accumulated HSA savings for medical care like those in the HD-HSA group. These HD-NoHSA enrollees defer needed medical care and are at greatest risk of chronic diseases and their complications so could most benefit from the lower cost, more prevention counseling, and disease screening visits of primary care providers. High out-of-pocket costs compromise health promotion for both groups (HD-HSA and HD-NoHSA). Preventive care is an important aspect of primary care [26, 27] and studies show that patients benefit from preventive services integrated into primary care in community and clinical settings. Many HDHP insurance plan enrollees are unaware that the ACA covers preventive care office visits, screening tests, immunizations, and counseling with no out-of-pocket charges and thus do not benefit from preventive care services and recommendations [28]. According to a Kaiser Family Foundation study, nearly 20 per cent of the HDHP population including low income individuals with low health literacy is unaware of the ACA exemption of preventive services from the health insurance deductible [11]. Although survey respondents in a Commonwealth Fund study knew their deductible amount, they were not aware of their benefit package and the services that counted towards the deductible [29]. The perceptions of affordability affect health care decisions and health-seeking behaviors of those insured [30]. A Commonwealth Fund survey of privately insured individuals using an affordability index indicated that almost 50 per cent of survey participants with low–moderate income were unable to afford their deductibles; even those with high income (32%) reported difficulties in paying for annual deductibles [3]. Having an HDHP has been associated with a poor financial health [29]; low income populations have the highest financial burden [30]. The financial burden of out-of-pocket expenses from HDHP if one is chronically ill can result in difficulty paying medical bills and lead to accrual of medical debt over time. People experiencing medical debt further delay or avoid obtaining care when needed. Rabin et al. examined the relationship between medical debt and delayed or avoided care, finding that lower income diabetic respondents with a medical debt were twice as likely to delay or avoid needed care compared with their higher income counterparts [5]. Long-term consequences of not receiving preventive care services include failure to detect early stage chronic disease, avoidable progression of chronic disease, more absenteeism, and reduced productivity [31–34]. Individuals with HDHP and chronic diseases may also reduce ambulatory care visits due to cost concerns [35–37]. Non-adherence to medications due to HDHP may result in worsening of chronic disease and lead to higher emergency department (ED) utilization rates and hospitalizations. In a study by Wharam et al., individuals of low socioeconomic status (SES) enrolled in HDHPs had fewer ED visits and hospitalizations in year one when compared with those of high SES. However, higher rates of hospitalizations were reported in year two among low SES, indicating that deferred medical care may have further advanced their chronic disease [38]. Our study has several limitations; importantly, our observational cohort study design reveals associations and cannot determine whether a causal relationship exists between uptake of preventive care services and HDHPs. Respondents who value preventive care and health maintenance may be more inclined to get recommended preventive screening tests or immunizations. Individuals who tend to use one preventive service may be more likely to obtain other recommended screening tests, which may have biased our results. For example, those who have regular annual wellness exams may have higher likelihood of receiving multiple preventive care tests. As with any survey, the MEPS is subject to recall bias, though its validation methods should minimize these effects. Missing data were negligible in our sample, excluding the bias from missing data. These limitations do not detract from the innovative findings of the current study. This is the first study, using a nationally representative sample of the U.S. population to demonstrate lower frequency of visits to primary care and specialists and reduced uptake of preventive care tests among respondents with HD insurance plans and no HSA. CONCLUSIONS Given our finding that patients with HDs without HSA use primary care less frequently, it is not surprising that they also report lower rates of some preventive care tests. As the ACA reduced uninsurance, it promised downstream cost savings principally through the achievement of primary care’s promise to reduce high cost emergency and hospital care through continuous, comprehensive, and coordinated care [39]. It is only in these settings that care coordination flourishes enabling effective population health and panel management [40]. Minimizing financial access barriers to primary care is crucial to health maintenance and disease prevention. POLICY IMPLICATIONS Cost-sharing HDHP reduce both unnecessary and necessary care, including preventive care. To maximize essential medical care with no out-of-pocket costs, individuals with HDHPs should be identified and educated about the cost exemption of preventive care and the benefit of preventive care and primary care visits. Greater access to primary care means greater access to care coordination. Insurance should be regulated (a) so that there are income-related deductibles for needed services, to ensure low income populations can afford access to these health services. (b) As the ACA is modified or repealed, prevention benefits should remain cost free and primary care visits should be low cost to assure that those of lower SES can access primary care for prevention, early detection of chronic disease, and avoidable progression of chronic disease. Future studies should investigate the health consequences particularly for those with chronic diseases of limitations to care associated with HDHP. These may include as follows: limited access to preventive services, underutilization of all health care services, and the long-term medical debt of HDHP. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Compliance with Ethical Standards Conflict of Interest: None declared. Primary Data: Text and tables included in this report have not been published previously and this work is not under consideration elsewhere. Data reported in this manuscript have not been reported elsewhere. This study involved secondary data analysis of public-use Medical Expenditure Panel Survey (MEPS) data. The authors agree to allow the journal to review their data if requested. Authors’ Contributions: All the authors have agreed with the contents of the disclosure report and have approved the final manuscript. Ethical Approval: The study was conducted according to the Ethical Standards for the Protection of Human Participants and Animals in Research according to the Helsinki Declaration of 1975. IRB approval is not applicable to this study because (i) publicly available MEPS deidentified data were used in the study; (ii) as these data cannot be traced to individual respondents, there is no risk to the respondents and also this project involved data analysis of existing data; (iii) confidentiality of the MEPS respondents is protected by Sections 944 (c) and 308 (d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 299c-3(c) and 42 U.S.C.242m (d)]. Informed Consent: Informed consent does not apply to this study as it involved secondary data analysis of MEPS data, and there are no potential risks to the respondents as they are deidentified. Acknowledgments There was no funding available for development of the study or article nor was the article reviewed by a commercial or governmental source regarding its presentation or interpretation of the data. References 1. AHIP Center for Policy and Research . Census of Health Savings Account – High Deductible Health Plans . 2015 . 2. 2015 Employer Health Benefits Survey . The Kaiser Family Foundation and Health Research & Educational Trust . 2015 . 3. Collins SR , Gunja M , Doty MM , Buetel S . How high is America’s Health Care Cost Burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July-August 2015 . Issue Brief (Commonw Fund) . 2015 ; 32 : 1 – 15 . Google Scholar PubMed 4. Dolan R. Health policy brief: High-deductible health plans. Health Aff. 2016 . 5. Rand Corporation . Analysis of High Deductible Health Plans [Internet] . Technical Reports 2009 [cited 2016 June 7]. 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Health Aff (Millwood) . 2013 ; 32 ( 8 ): 1398 – 1406 . Google Scholar CrossRef Search ADS PubMed 39. Institute of Medicine . Primary Care: America’s Health in a New Era . Washington, DC : National Academy Press ; 1996 . 40. Bodenheim T Gorob A , Willard-Grace R , Grumbach K . The ten building blocks of primary care . Ann Fam Med . 2014 ; 12 ( 2 ): 166 – 171 . Google Scholar CrossRef Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Privately insured adults in HDHP with higher deductibles reduce rates of primary care and preventive services

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Abstract

Abstract Rates of insurance coverage in high deductible health plans (HDHP) and deductible size have been increasing. Over-time, financial barriers can lead to a substantial reduction in opportunities for health promotion and care coordination. We investigated the impact of different types of HDHPs on primary and specialty services utilization and receipt of preventive services among adult (18–64 years) privately insured respondents using pooled 2011–2014 Medical Expenditure Panel Survey (MEPS). The sample (n = 25,965) was divided into four insurance types (1) no deductible (ND) (2) low deductible (LD), (3) high deductible with health savings account (HD-HSA), and (4) high deductible without health savings account (HD-NoHSA). Multivariable regression models were estimated, adjusting for demographic characteristics and health status. Number of visits to primary care physicians and specialists were lowest for persons in the HD-NoHSA group (IRR 0.88 95% CI [0.81–0.96]). HD-NoHSA beneficiaries had lower rates of receiving hypertension screening (IRR 0.97 95% CI [0.94–0.99]) and flu vaccination (IRR 0.92 95% CI [0.86–1.00]) when compared to ND enrollees. Female respondents in the HD-NoHSA group were 7% less likely to receive mammograms (IRR 0.93 95% CI [0.89–0.98]) compared to the ND group. There was no significant association between insurance type and the other preventive service measures. Higher deductibles significantly decrease opportunities for early detection and management of chronic diseases, immunizations and care coordination. Fiscal barriers to essential medical care should be eliminated at least for those most vulnerable. Implications Practice: High deductible health plans (HDHPs) particularly with higher deductibles discourage physician office use. Reduced primary care visits, significantly reduced selected screening and immunizing services, imply that the out-of-pocket costs of higher deductibles compromise provision of health promotion and care-coordination services. Greater access to primary care and care coordination leads to increased uptake of preventive services. Policy: Rising deductibles of affordable lower premium HDHPs increasingly confound enrollee’s ability to access prevention services and provide opportunity to do care coordination. These trends are inconsistent with health promotion compromising the utility of health insurance and the social value of insurance. Research: The long-term effects of rising financial barriers to care lead to substantial reduction in opportunities for health promotion and care coordination. Future research could examine the relationship between care coordination and HDHP on receipt of preventive screening and health promotion services, and the impact of health insurance with high out-of-pocket costs on well-being and avoidable illness. INTRODUCTION Affordable health care is compromised for many Americans. The out-of-pocket costs of health insurance are increasing with increased enrollment in high deductible health plans (HDHPs). The proportion of US adults with high deductibles has increased since the Medicare Prescription and Modernization Act (MMA) of 2003, increasing six times between 2005 and 2015 (5%–29%) [1]. Deductible size also increased from 2006 to 2015; the average deductible under employer-based insurance increased from $1,070 to $1,954 [2]. HDHP enrollment further increased under the Affordable Care Act (ACA), as HDHPs have lower premiums and are attractive particularly to those of lower income who were previously uninsured [3]. Studies indicate that most of the enrollees who obtained coverage through health insurance exchanges have a deductible of at least $1,300 for individuals and $2,600 for families [4]. HDHPs were designed to reduce unnecessary medical care; however, research indicates that people with HDHP also avoid necessary care [5]. Rabin et al. reported that higher deductibles of HDHP severely limited primary care and specialist office visits and routine check-ups in lower income groups with diabetes [6]. Preventive care is necessary for early detection and slower progression of chronic disease, and to identify and modify disease risk factors [7]. The ACA improved access to certain recommended preventive services by mandating their coverage, even in HDHPs with no out-of-pocket charge. These include annual preventive visits, cholesterol screening, diabetes screening, blood pressure screening, colon cancer screening, cervical cancer screening, and breast cancer screening [8, 9]. Access to primary care and care coordination offer opportunities for health promotion and preventive care and are associated with higher rates of delivery of preventive services [9–11]. However, rising financial barriers to care reduce such occasions impeding the promotion of preventive services. Only 43 per cent of the individuals enrolled in high deductible plans were aware of cost-exemption for preventive services or had knowledge about specific details of their health insurance plan [9]. The literature shows mixed results in preventive care seeking behaviors of HDHP populations. In a survey of Kaiser Health Maintenance Organization (HMO) patients, almost 20 per cent of those with HDHPs avoided preventive visits and did not seek at least one of the preventive screening tests due to cost concerns [12]. A Research ANd Development (RAND) review of HDHP reported moderately lower rates of preventive services [5], whereas, in an HMO-based Massachusetts study, cancer screening rates in HDHP insured women of low income were similar to the control group with no HDHP [13]. Another study that compared HRA with PPO showed similar cancer screening rates in both cohorts [14]. Other researchers found constant rates of breast cancer and cervical cancer screening tests before and after eliminating preventive services from cost-sharing in HDHP enrollees [15, 16]. Prior studies used employee-based insurance HDHP enrollees that were limited to geographical locations or restricted to vulnerable populations. No study has determined the uptake of preventive services and primary care associated with HDHPs using a nationally representative U.S. sample. The purpose of this study is to investigate the impact of HDHPs by type of deductible on the receipt of preventive services among respondents having annual deductibles using pooled data from the 2011–2014 Medical Expenditure Panel Survey (MEPS). METHODS Data source and study sample MEPS is a nationally representative survey of civilian, noninstitutionalized populations with oversampling of Hispanics, Blacks, and Asians and is administered by the Agency for Healthcare Research and Quality (AHRQ). Data are collected across five rounds of interviews over 2 full years with overlapping panels. MEPS provides national estimates of the use of health services, medical expenditures, insurance coverage, and payment sources for all non-institutionalized civilian individuals residing in the USA. Each year a third of previous years’ National Health Interview Survey is subsampled to obtain the sampling frame for MEPS. MEPS uses a complex sample design that includes estimation weights, primary sampling units, and strata that reflect the complex survey design, and these variables must be used in analysis to obtain accurate estimates and unbiased standard errors [17]. We pooled 2011–2014 MEPS data to examine the association between HDHP and primary care and preventive service use. The study sample was restricted to privately insured adults under the age of 65. We divided the sample into four groups, based on annual deductible and health savings account (HSA) status: (a) no deductible (ND), (b) low deductible (LD) (less than $1,250 for an individual or less than $2,500 per family), (c) high deductible (greater than $1,250 or $2,500) with health savings account (HD-HSA), and (d) high deductible without health savings account (greater than $1,250 or $2,500; HD-NoHSA). The annual deductible and HSA were derived from the person-round plan datafiles, physician specialty was obtained from the office-based visit files, and all other variables were collected from the consolidated files. Outcome measures were the number of primary care visits per year and receipt of preventive services or screening tests recommended by the U.S. Preventive services Task Force (USPSTF): (a) routine check-up, (b) hypertension screening, (c) cholesterol screening, (d) breast cancer screening (mammogram), (e) colon cancer screening (colonoscopy), (f) cervical cancer screening (Papanicolaou) test, and (g) flu vaccination [18]. For each service, we restricted the sample, by gender and age, as specified in the USPSTF recommendations. Covariates included demographic characteristics: gender, census regions, race/ethnicity, education, income, and reported health status. The four census regions were (a) South, (b) Northeast, (c) Midwest, and (d) West. We created four race and ethnicity groups: (a) non-Hispanic Whites, (b) non-Hispanic Blacks, (c) Hispanics, and (d) Other. We combined Asians, Native Hawaiian or Pacific Islander, and American Indian or Alaskan Natives into an “Other” group. Three categories of education were created as follows: (a) less than 12 years of education, (b) obtaining high school diploma or GED high school equivalency, and (c) postsecondary education. We included five categories for income: (a) less than 100 per cent Federal Poverty Level (FPL), (b) 100%–124% FPL, (c) 125%–199% FPL, (d) 200%–399% FPL, and (e) greater than or equal to 400% FPL. Five categories of reported health status included as follows: (a) Excellent, (b) Very good, (c) Good, (d) Fair, and (e) Poor. Statistical analysis We analyzed the data using Stata 14.0 statistical software. We computed summary statistics and reported the number and percentages of the respondents in the entire sample by type of the physician seen (primary care physicians vs. specialist) and deductibles. We performed bivariate analyses on categorical variables using chi-squared tests and t-tests for continuous variables to compare demographic characteristics across deductible categories and by the physician type seen. To assess the significant differences between the mean number of primary care and specialist care visits, we used t-tests and adjusted-Wald tests. We used Poisson regressions for the number of primary care and specialist visits and for each of the preventive tests [19–21]. These models were estimated for the full sample as well as a sample restricted to those with at least one primary care visit. We reported incidence risk ratios and 95% confidence intervals (CIs). To obtain valid national estimates for the outcomes (preventive services and primary care visits), we included the MEPS complex survey poststratification, clustering variables and sampling weights in the analysis using Stata survey commands (Stata 14.0 Stata Corp., LP Texas Station). RESULTS Our total sample consisted of 49,874 respondents with data for annual deductibles. Restricting the sample to privately insured adults less than 65 years yielded 26,035 survey participants. Our final sample contained 25,965 privately insured adults (18–64 years), after adjusting for person weights and MEPS complex survey design and excluding those missing region (n = 1), education (n = 63), and reported health status (n = 6; Fig. 1). Fig 1 View largeDownload slide Flowchart—Recruitment of analysis sample. Fig 1 View largeDownload slide Flowchart—Recruitment of analysis sample. Table 1 compares the demographic characteristics of respondents across the four annual deductible categories. Of the total sample, 27 per cent of the respondents were enrolled in ND, 46 per cent in LD, 9 per cent in HD-HSA, and 17 per cent in HD-NoHSA. Individuals enrolled in HD-HSA were more likely to be non-Hispanic Whites (83.9%, p < .001), affluent (63.8%, p < .001), educated (77.5% with postsecondary education, p < .001), from the Northeast (33.5 %, p < .001), and reported very good-to-excellent health status (71.7%, p < .001) compared with respondents in other groups. Those with HD-NoHSA coverage were least likely to be affluent and most likely in poor-to-fair health. Table 1 Distribution of demographic characteristics of privately insured respondents (18–64 years) by annual deductible (N = 25,965) Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Chi-squared test of significance for categorical and adjusted-Wald test for continuous variables across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA. View Large Table 1 Distribution of demographic characteristics of privately insured respondents (18–64 years) by annual deductible (N = 25,965) Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Characteristics ND (N = 8,114 [27.1%]) LD (N = 11,609 [46.4%]) HD-HSA (N = 2,110 [9.4%]) HD-NoHSA (N = 4,132 [17.1%]) p n % n % n % n % Gender .913  Female 4,266 51.8 6,148 52.0 1,118 52.1 2,165 51.3  Male 3,848 48.2 5,461 48.0 992 47.9 1,967 48.7 Region <.001  South 1,906 29.7 1,518 14.9 269 14.0 539 13.9  North East 1,152 15.1 2,767 25.1 722 33.5 1,135 28.3  Midwest 1,967 26.1 4,645 39.4 653 32.6 1,570 38.8  West 3,089 29.2 2,679 20.6 466 20.0 888 19.0 Federal Poverty Level <.001  <100% 343 3.5 386 2.5 36 1.3 163 3.5  100%–124% 176 1.3 282 1.5 22 0.7 81 1.4  125%–199% 847 7.6 1,235 7.7 161 5.7 505 9.6  200%–399% 2,898 31.8 4,130 33.0 676 28.6 1,498 33.1  400+% 3,850 55.9 5,576 55.4 1,215 63.8 1,885 52.3 Race/ethnicity <.001  White, NH 3,262 62.7 6,585 75.7 1,516 83.9 2,546 78.7  Black, NH 1,594 11.9 1,917 8.6 204 4.9 537 6.8  Other, NH 1,433 12.2 1,055 6.1 198 6.3 442 7.0  Hispanic 1,825 13.2 2,052 9.5 192 4.9 607 7.5 Education <.001  <12 Years 838 7.5 1,010 6.5 116 5.3 327 6.4  HS/GED 1,942 21.4 3,016 23.8 380 17.2 1027 21.5  Post-secondary 5,334 71.1 7,583 69.7 1,614 77.5 2,778 72.1 Physician type  Primary care 2,015 24.1 2,752 23.3 462 22.5 966 22.8 .566  Specialist 1,187 16.0 1,930 18.2 420 20.1 672 16.9 .006 Health Status  Excellent 2,583 32.6 3,499 31.2 655 30.4 1,266 31.7 .004  Very good 2,850 35.8 4,176 37.4 821 41.3 1,430 35.3  Good 2,006 23.6 2,941 23.5 500 22.4 1,040 23.9  Fair 576 6.8 784 6.0 113 4.9 322 7.5  Poor 99 1.3 209 1.9 21 1.0 74 1.6 Primary care visits 1.2 1.16 1.23 1.1 .140 Specialist visits 1.96 1.88 2.06 1.82 .229 Chi-squared test of significance for categorical and adjusted-Wald test for continuous variables across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA. View Large Our bivariate analyses contrasting primary care versus specialty care (Supplementary Table 1) showed that females were less likely to visit primary care physician than males (44.2% vs. 55.8%, p < .001). Adults with moderate income (200%–399% FPL) had higher proportion of primary care visits (34.1% vs. 30.6%, p = .004) than lower income respondents. Individuals seeking care from specialists were more likely to be affluent (≥200% FPL), have greater than 12 years of education, non-Hispanic Whites, HD-HSA enrollees, and to report good health status. Higher mean number of specialist visits were found in women (3.12, p < .001) compared with men, non-Hispanic Whites (2.84, p < .001) than non-Whites, and in those who reported poor health status (6.65, p < .001) in comparison to respondents in other health status categories (Supplementary Table 1). Table 2 displays the unadjusted percentage of preventive services: a higher proportion of women in HD-HSA group received cervical cancer and breast cancer screening tests compared with women enrolled in other deductible types. Likewise, hypertension screening rates were also higher for the individuals in HD-HSA than other categories. Table 2 Unadjusted percentage of preventive service use ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 Chi-squared test of significance across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA; CI confidence interval. View Large Table 2 Unadjusted percentage of preventive service use ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 ND LD HD-HSA HD- NoHSA p Percent (95% CI) Percent (95% CI) Percent (95% CI) Percent (95% CI) Cervical cancer screening 80.9 (79.0–82.7) 79.8 (78.4–81.1) 83.5 (80.6–86.1) 78.0 (75.5–80.4) <.001 Breast cancer screening 82.9 (80.5–85.1) 78.6 (76.7–80.4) 81.8 (77.6–85.4) 75.8 (72.7–78.7) .020 Colon cancer screening 36.7 (34.1–39.4) 38.7 (36.8–40.6) 36.6 (33.0–40.3) 37.5 (34.4–40.8) .499 Cholesterol test 77.7 (76.1–79.2) 76.8 (75.6–78.0) 78.0 (75.2–80.5) 75.7 (73.6–77.7) .360 Hypertension screening 85.3 (84.0–86.5) 85.5 (84.5–86.5) 87.4 (85.5–89.1) 83.1 (81.2–84.9 .007 Routine check-up 69.5 (68.0–71.0) 69.4 (68.0–70.9) 69.7 (67.0–72.3) 67.2 (64.7–69.6) .369 Flu vaccination 43.4 (41.6–45.2) 42.0 (40.3–43.7) 45.0 (42.0–48.1) 40.5 (38.0–43.1) .073 Chi-squared test of significance across annual deductible categories. ND no deductible; LD low deductible; HD-HAS high deductible with HSA; HD-NoHSA high deductible NoHSA; CI confidence interval. View Large Poisson regression results demonstrate the mean number of primary care and specialist visits after adjusting for demographic characteristics and self-reported health status (Table 3). LD enrollees had 7 per cent and HD-NoHSA had 12 per cent lower than expected mean number of primary care visits compared with ND enrollees (p < .001). No statistically significant differences in number of specialty visits were observed across the insurance types. Table 3 Incidence risk ratios of primary care visits and specialty visits by annual deductible among privately insured adults (18–64 years) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA, IRR incidence risk ratio, CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Table 3 Incidence risk ratios of primary care visits and specialty visits by annual deductible among privately insured adults (18–64 years) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) Characteristics Primary care visits Specialist visits N 25,965 25,965 IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0−1.0) 1 (1.0−1.0) LD 0.93* 0.94 (0.87–1.00) (0.86–1.03) HD-HSA 1.00 1.01 (0.92–1.08) (0.90–1.14) HD-NoHSA 0.88*** 0.89* (0.81–0.96) (0.79–1.02) Gender Male 1 (1.0–1.0) 1 (1.0–1.0) Female 1.24*** 1.77*** (1.17–1.30) (1.63–1.93) Race/Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 0.90*** 0.69*** (0.84–0.97) (0.60–0.79) Other, NH 0.82*** 0.69*** (0.75–0.90) (0.60–0.80) Hispanic 0.84*** 0.78*** (0.78–0.89) (0.69–0.87) Region South 1 (1.0–1.0) 1 (1.0–1.0) North East 1.07 0.85** (0.96–1.19) (0.74–0.97) Midwest 1.08* 0.91 (0.99–1.19) (0.78–1.05) West 1.03 0.80*** (0.94–1.14) (0.70–0.92) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 0.92 0.66*** (0.75–1.14) (0.49–0.90) 125%–199% 1.00 0.92 (0.87–1.15) (0.73–1.14) 200%–399% 1.08 0.82** (0.96–1.22) (0.68–0.99) 400+% 1.18** 1.08 (1.04–1.35) (0.90–1.28) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) <12 Years 1.04 0.81** (0.95–1.14) (0.66–0.99) Post-Secondary 1.04 1.41*** (0.97–1.12) (1.29–1.54) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) Very good 0.66*** 0.66*** (0.55–0.79) (0.53–0.81) Good 0.46*** 0.36*** (0.39–0.54) (0.30–0.44) Fair 0.33*** 0.25*** (0.28–0.39) (0.21–0.30) Poor 0.24*** 0.19*** (0.20–0.29) (0.16–0.23) Constant 2.59*** 4.72*** (2.10–3.19) (3.53–6.30) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA, IRR incidence risk ratio, CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Women with HD-NoHSA had 7 per cent less likelihood of being screened for breast cancer compared with those with ND (incidence risk ratios [IRRs] 0.932, 95% CI [0.890–0.975]) after adjusting for race/ethnicity, region, poverty, education, and health status (Table 4). Similarly, those with HD-NoHSA were 4 per cent less likely to receive hypertension screening compared with those with ND. HD-NoHSA beneficiaries had 8 per cent lower rates of receiving flu vaccination in comparison to those with ND. Table 4 Incidence risk ratios of obtaining preventive screening tests/check-ups and vaccination by annual deductible among privately insured adults (18–64 years) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA; IRR incidence risk ratio; CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large Table 4 Incidence risk ratios of obtaining preventive screening tests/check-ups and vaccination by annual deductible among privately insured adults (18–64 years) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) Characteristics Cervical cancer screening Breast cancer screening Colon cancer screening Cholesterol screening Hypertension screening Routine Annual check-up Flu vaccination N 13,085 7,621 14,520 24,742 25,454 25,353 25,391 IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI) Annual deductible ND 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) LD 0.99 0.96** 1.06* 0.99 0.99 1.00 0.96 (0.97−1.02) (0.92−0.99) (0.99−1.15) (0.97−1.02) (0.98−1.01) (0.98−1.038) (0.91−1.01) HD-HSA 1.03 0.98 1.00 1.01 1.01 1.01 0.99 (0.99−1.07) (0.93−1.03) (0.89−1.12) (0.97−1.05) (0.99−1.04) (0.96−1.05) (0.92−1.07) HD-NoHSA 0.97 0.93*** 1.05 0.99 0.97** 0.98 0.92** (0.94−1.01) (0.89−0.98) (0.94−1.17) (0.96−1.02) (0.94−0.99) (0.93−1.02) (0.86−1.00) Gender Male 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) 1 (1.0−1.0) Female 1.00 1.06*** 1.13*** 1.18*** 1.28*** (0.94−1.06) (1.04−1.08) (1.12−1.15) (1.16−1.20) (1.23−1.34) Race/ Ethnicity White, NH 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Black, NH 1.08*** 1.07*** 1.09* 1.09*** 1.01 1.10*** 0.83*** (1.05–1.12) (1.04–1.11) (1.00–1.18) (1.07–1.12) (0.99–1.03) (1.06–1.14) (0.77–0.89) Other, NH 0.94** 0.93** 0.73*** 1.00 0.94*** 0.97 0.99 (0.90–0.99) (0.87–0.98) (0.63–0.85) (0.97–1.04) (0.92–0.97) (0.93–1.01) (0.92–1.08) Hispanic 1.07*** 1.017 0.81*** 1.05*** 0.95*** 0.97* 0.91*** (1.03–1.11) (0.91–1.07) (0.74–0.90) (1.02–1.08) (0.93–0.97) (0.93–1.01) (0.85–0.98) Region South 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) North East 0.97 0.97 0.85*** 0.93*** 1.00 0.93*** 0.96 (0.94–1.01) (0.92–1.012) (0.76–0.94) (0.90–0.97) (0.97–1.03) (0.89–0.97) (0.87–1.06) Midwest 0.98 0.99 0.86** 0.98 1.00 0.96** 1.01 (0.94–1.01) (0.94–1.04) (0.77–0.97) (0.97–1.01) (0.98–1.03) (0.92–0.99) (0.92–1.11) West 0.97* 0.96 0.78*** 0.95*** 0.97 0.89*** 0.92 (0.93–1.00) (0.91–1.02) (0.69–0.87) (0.91–0.98) (0.94–1.01) (0.86–0.93) (0.83–1.02) Federal Poverty Level <100% 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 100%–124% 1.06 0.87* 0.78 1.01 0.96 0.90** 0.90 (0.97–1.16) (0.73–1.02) (0.57–1.06) (0.92–1.12) (0.91–1.02) (0.82–0.99) (0.71–1.15) 125%–199% 0.99 0.87** 0.75*** 1.09** 0.97 0.96 1.08 (0.92–1.08) (0.77–0.98) (0.61–0.93) (1.01–1.18) (0.93–1.02) (0.90–1.03) (0.90–1.28) 200%–399% 1.04 0.99 0.81** 1.12*** 1.00 1.01 1.11 (0.97–1.11) (0.88–1.08) (0.68–0.96) (1.04–1.20) (0.96–1.04) (0.95–1.08) (0.95–1.29) 400+% 1.04 1.08 1.06 1.23*** 1.04* 1.10*** 1.34*** (0.97–1.11) (0.98–1.19) (0.89–1.25) (1.14–1.32) (1.00–1.08) (1.04–1.17) (1.16–1.56) Education HS/GED 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) <12 years 0.78*** 1.00 0.80** 0.78*** 0.96** 1.01 0.92 (0.72–0.85) (0.91–1.09) (0.66–0.98) (0.73–0.83) (0.93–1.00) (0.96–1.06) (0.82–1.02) Postsecondary 1.14*** 1.06*** 1.03 1.03** 1.02** 1.02 1.20*** (1.10–1.18) (1.02–1.11) (0.95–1.12) (1.01–1.06) (1.04–1.05) (0.99–1.05) (1.14–1.28) Health Status Excellent 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) 1 (1.0–1.0) Very good 1.16** 1.08 0.87 0.97 0.95*** 0.98 0.93 (1.02–1.32) (0.93–1.26) (0.74–1.03) (0.92–1.01) (0.93–0.98) (0.91–1.06) (0.80–1.08) Good 1.23*** 1.14 0.79*** 0.89*** 0.94*** 0.95* 0.84** (1.08–1.39) (0.97–1.34) (0.64–0.92) (0.84–0.93) (0.91–0.96) (0.88–1.01) (0.73–0.96) Fair 1.24*** 1.15* 0.75*** 0.82*** 0.88*** 0.87*** 0.75*** (1.09–1.41) (0.99–1.35) (0.64–0.88) (0.78–0.86) (0.86–0.91) (0.81–0.93) (0.65–0.86) Poor 1.23*** 1.16* 0.66*** 0.74*** 0.84*** 0.81*** 0.69*** (1.09–1.40) (0.99–1.36) (0.55–0.78) (0.70–0.78) (0.82–0.86) (0.75–0.86) (0.60–0.80) Constant 0.60*** 0.68*** 0.59*** 0.79*** 0.89*** 0.71*** 0.38*** (0.52–0.68) (0.57–0.82) (0.46–0.76) (0.72–0.87) (0.84–0.94) (0.65–0.78) (0.30–0.47) ND no deductible; LD low deductible; HD-HSA high deductible with HSA; HD-NoHSA high deductible NoHSA; IRR incidence risk ratio; CI confidence interval. ***p < .01; **p < .05; *p < .1. View Large We conducted additional analysis to examine preventive care use among the respondents who had at least one primary care visit and found no statistically significant differences in preventive care rates between the ND and HD-NoHSA groups (Supplementary Table 2). DISCUSSION Using a nationally representative sample, we found that individuals with HDHPs without an HSA are less likely to access primary care and specialty services and receive preventive services than those with ND. These differences are minimized for those making at least one primary care visit during the last 12 months. Specifically, we found that rates of breast cancer and hypertension screening, and flu vaccination were lower among respondents in HD without HSA compared with those enrolled in ND insurance plans. Our findings on the uptake of preventive services are consistent with the Commonwealth Fund study that found one in five respondents with HD plans and one in ten individuals of those with LD plans skipped at least one preventive service [3]. Under the ACA, although uninsured rates have fallen, premiums and deductibles have increased, with more of the privately insured at risk of out-of-pocket costs when using services. HDHPs are intended as a cost containment measure to reduce the use of nonessential and more costly care while allowing use of essential health care services. According to the ACA, preventive care services are exempted from out-of-pocket charges including the deductible, so one would expect to see similar rates of receipt of preventive services and lower cost primary care visits. In contrast, we found reduction in the number of primary care visits among individuals with deductibles particularly higher deductibles (LD, HD-NoHSA), except for those with health savings accounts. The low percentage of women relative to men seeking care from primary care physicians may be because women of reproductive age see their obstetrician or gynecologists for all their care including regular care [22]. Studies show that a significantly higher proportion of affluent women of post-reproductive age seek routine medical care from their obstetrician or gynecologists [23]. Non-Hispanic Whites, young, affluent, and well-educated individuals reporting good-to-excellent health status would be expected to choose HDHPs [24, 25]. However, HD-NoHSA enrollees in our sample were less educated and less affluent and reported belonging to minority racial/ethnic groups with a higher need for medical care. Perhaps, low-income populations enroll in HDHPs with less costly premiums unaware of the benefits covered by their health insurance plans [3, 4]. Consistent with these demographic characteristics, HD-NoHSA enrollees reported slightly worse health status than other insured groups. Importantly, they visited primary care physician less often and used fewer prevention services than the individuals in no deductible plans. Unlike the ND respondents, HD-NoHSA beneficiaries must pay particularly high out-of-pocket costs obtaining care and are not protected by accumulated HSA savings for medical care like those in the HD-HSA group. These HD-NoHSA enrollees defer needed medical care and are at greatest risk of chronic diseases and their complications so could most benefit from the lower cost, more prevention counseling, and disease screening visits of primary care providers. High out-of-pocket costs compromise health promotion for both groups (HD-HSA and HD-NoHSA). Preventive care is an important aspect of primary care [26, 27] and studies show that patients benefit from preventive services integrated into primary care in community and clinical settings. Many HDHP insurance plan enrollees are unaware that the ACA covers preventive care office visits, screening tests, immunizations, and counseling with no out-of-pocket charges and thus do not benefit from preventive care services and recommendations [28]. According to a Kaiser Family Foundation study, nearly 20 per cent of the HDHP population including low income individuals with low health literacy is unaware of the ACA exemption of preventive services from the health insurance deductible [11]. Although survey respondents in a Commonwealth Fund study knew their deductible amount, they were not aware of their benefit package and the services that counted towards the deductible [29]. The perceptions of affordability affect health care decisions and health-seeking behaviors of those insured [30]. A Commonwealth Fund survey of privately insured individuals using an affordability index indicated that almost 50 per cent of survey participants with low–moderate income were unable to afford their deductibles; even those with high income (32%) reported difficulties in paying for annual deductibles [3]. Having an HDHP has been associated with a poor financial health [29]; low income populations have the highest financial burden [30]. The financial burden of out-of-pocket expenses from HDHP if one is chronically ill can result in difficulty paying medical bills and lead to accrual of medical debt over time. People experiencing medical debt further delay or avoid obtaining care when needed. Rabin et al. examined the relationship between medical debt and delayed or avoided care, finding that lower income diabetic respondents with a medical debt were twice as likely to delay or avoid needed care compared with their higher income counterparts [5]. Long-term consequences of not receiving preventive care services include failure to detect early stage chronic disease, avoidable progression of chronic disease, more absenteeism, and reduced productivity [31–34]. Individuals with HDHP and chronic diseases may also reduce ambulatory care visits due to cost concerns [35–37]. Non-adherence to medications due to HDHP may result in worsening of chronic disease and lead to higher emergency department (ED) utilization rates and hospitalizations. In a study by Wharam et al., individuals of low socioeconomic status (SES) enrolled in HDHPs had fewer ED visits and hospitalizations in year one when compared with those of high SES. However, higher rates of hospitalizations were reported in year two among low SES, indicating that deferred medical care may have further advanced their chronic disease [38]. Our study has several limitations; importantly, our observational cohort study design reveals associations and cannot determine whether a causal relationship exists between uptake of preventive care services and HDHPs. Respondents who value preventive care and health maintenance may be more inclined to get recommended preventive screening tests or immunizations. Individuals who tend to use one preventive service may be more likely to obtain other recommended screening tests, which may have biased our results. For example, those who have regular annual wellness exams may have higher likelihood of receiving multiple preventive care tests. As with any survey, the MEPS is subject to recall bias, though its validation methods should minimize these effects. Missing data were negligible in our sample, excluding the bias from missing data. These limitations do not detract from the innovative findings of the current study. This is the first study, using a nationally representative sample of the U.S. population to demonstrate lower frequency of visits to primary care and specialists and reduced uptake of preventive care tests among respondents with HD insurance plans and no HSA. CONCLUSIONS Given our finding that patients with HDs without HSA use primary care less frequently, it is not surprising that they also report lower rates of some preventive care tests. As the ACA reduced uninsurance, it promised downstream cost savings principally through the achievement of primary care’s promise to reduce high cost emergency and hospital care through continuous, comprehensive, and coordinated care [39]. It is only in these settings that care coordination flourishes enabling effective population health and panel management [40]. Minimizing financial access barriers to primary care is crucial to health maintenance and disease prevention. POLICY IMPLICATIONS Cost-sharing HDHP reduce both unnecessary and necessary care, including preventive care. To maximize essential medical care with no out-of-pocket costs, individuals with HDHPs should be identified and educated about the cost exemption of preventive care and the benefit of preventive care and primary care visits. Greater access to primary care means greater access to care coordination. Insurance should be regulated (a) so that there are income-related deductibles for needed services, to ensure low income populations can afford access to these health services. (b) As the ACA is modified or repealed, prevention benefits should remain cost free and primary care visits should be low cost to assure that those of lower SES can access primary care for prevention, early detection of chronic disease, and avoidable progression of chronic disease. Future studies should investigate the health consequences particularly for those with chronic diseases of limitations to care associated with HDHP. These may include as follows: limited access to preventive services, underutilization of all health care services, and the long-term medical debt of HDHP. SUPPLEMENTARY MATERIAL Supplementary material is available at Translational Behavioral Medicine online. Compliance with Ethical Standards Conflict of Interest: None declared. Primary Data: Text and tables included in this report have not been published previously and this work is not under consideration elsewhere. Data reported in this manuscript have not been reported elsewhere. This study involved secondary data analysis of public-use Medical Expenditure Panel Survey (MEPS) data. The authors agree to allow the journal to review their data if requested. Authors’ Contributions: All the authors have agreed with the contents of the disclosure report and have approved the final manuscript. Ethical Approval: The study was conducted according to the Ethical Standards for the Protection of Human Participants and Animals in Research according to the Helsinki Declaration of 1975. IRB approval is not applicable to this study because (i) publicly available MEPS deidentified data were used in the study; (ii) as these data cannot be traced to individual respondents, there is no risk to the respondents and also this project involved data analysis of existing data; (iii) confidentiality of the MEPS respondents is protected by Sections 944 (c) and 308 (d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 299c-3(c) and 42 U.S.C.242m (d)]. Informed Consent: Informed consent does not apply to this study as it involved secondary data analysis of MEPS data, and there are no potential risks to the respondents as they are deidentified. 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Translational Behavioral MedicineOxford University Press

Published: May 23, 2018

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