Low-socioeconomic patients with high-deductibles receive less high-severity emergency care

Low-Socioeconomic-Status Enrollees In High-Deductible Plans Reduced High-Severity Emergency Care

By J. Frank Wharam, Fang Zhang, Bruce E. Landon, Stephen B. Soumerai and Dennis Ross-Degnan
Health Affairs, August 2013


One-third of US workers now have high-deductible health plans, and those numbers are expected to grow in 2014 as implementation of the Affordable Care Act continues. There is concern that high-deductible health plans might cause enrollees of low socioeconomic status to forgo emergency care as a result of burdensome out-of-pocket costs. We analyzed emergency department (ED) visits and hospitalizations over two years among enrollees insured in high-deductible plans through small employers in Massachusetts. We found that plan members of low socioeconomic status experienced 25–30 percent reductions in high-severity ED visits over both years, while hospitalizations declined by 23 percent in year 1 but rose again in year 2. Similar trends were not found among high-deductible plan members of high socioeconomic status. Our findings suggest that plan members of low socioeconomic status at small firms responded inappropriately to high-deductible plans and that initial reductions in high-severity ED visits might have increased the need for subsequent hospitalizations. Policy makers and employers should consider proactive strategies to educate high-deductible plan members about their benefit structures or identify members at higher risk of avoiding needed care. They should also consider implementing means-based deductibles.


By Don McCanne, M.D.

People of low-socioeconomic status who have high-deductible health plans have 25 to 30 percent fewer emergency department visits for high-severity medical conditions - conditions with a high probability of needing ED-level care within twelve hours. That can't be good.

Since similar trends were not found in people of high-socioeconomic status, the authors suggest that deductibles should be means-based - lower deductibles for those of low-socioeconomic status. But that would add more administrative complexity to our system already overburdened with administrative excesses.

The purpose of the deductibles is to reduce health care spending, but we don't want to do that by not taking care of individuals with high-severity medical conditions. It would be far more efficient to simply eliminate deductibles for everyone and use better, patient-friendly methods of controlling spending. That's what single payer is all about - people getting the health care they need while making it affordable for everyone.