At the peak of the coronavirus crisis in 2020, American policymakers were faced with the critical challenge of how to encourage as many Americans as possible to be tested for and vaccinated against the COVID-19 virus. Fortunately, Congress rose to this challenge by passing legislation that, in addition to providing these services to the uninsured, required private insurance plans to eliminate all out-of-pocket costs associated with getting vaccinated or tested. Following this change, vaccination and testing soared among privately insured people.
While Congress’s prompt legislative action in the face of an unanticipated acute health care crisis should be applauded, one might ask why lowering out-of-pocket costs for privately insured patients with chronic medical conditions has not become a priority for policymakers. These conditions, such as diabetes and hypertension, often require even more frequent medical visits, have higher costs for medical treatments, and are associated with more morbidity and mortality than COVID-19. A prime target for action to reduce financial barriers to care for people with chronic conditions is high-deductible health plans.
These plans typically offer lower insurance premiums but require enrolled people to pay a larger sum of money out-of-pocket each year (the deductible) before the insurance kicks in. In a typical high-deductible plan, this is about $7,000. These plans entice many employers who seek to save money on insurance plans they offer employees, as they know that high deductibles discourage the use of health care. These plans also entice patients, especially those with lower incomes, with the incentive of lower monthly premiums. However, while the lower premiums help the enrollee’s monthly budget, the high deductibles often prevent the use of care when needed, especially for those with chronic medical conditions that require long-term medication use.
In our recently published study in the Journal of General Internal Medicine, we analyzed data from a national survey of Americans from 2011 to 2018 to understand the care of privately insured adults with diabetes enrolled in traditional insurance plans compared with those enrolled in high-deductible health plans.
We found that patients with diabetes enrolled in high-deductible health plans are more likely to not fill their prescription medicines, skip medication doses, take less medication, and delay filling their prescription due to financial constraints.
Given the known complications of poorly controlled diabetes, these patients were then likely at greater risk of vision problems, kidney disease, increased risk of amputations, heart attack, and stroke. Skipping medications to save costs was especially prevalent in diabetic patients taking insulin, which confers a greater risk of death due to a dreaded complication of diabetes, diabetic ketoacidosis, which occurs when blood sugar levels become dangerously elevated. This is especially important, given the large increases in the cost of insulin, which rose 200 percent over the last two decades.
As a primary care provider, I must admit that I do not always ask about what type of insurance coverage my patients have when prescribing diabetes medications and in finding out why my patients may not take the medications I prescribe. It is sad that this should be a consideration for patients who have insurance coverage, but it is clear that I and all physicians need to consider insurance type when treating diabetic patients.
However, our action should extend beyond the special communication between doctor and patient. We should defend our patients against the limitations imposed by high-deductible insurance plans coupled with the high prices of essential medication. The Inflation Reduction Act passed in 2022 limited out-of-pocket insulin costs for seniors on Medicare at $35 per month, which was a promising start to reform, but did not extend to those younger than 65. In March 2023, Eli Lilly, Novo Nordisk, and most recently Sanofi will collectively place a $35 out-of-pocket cap on prescriptions for many types of insulin. However, even with this price cap, it will still pose a life-risking obstacle to those who resort to medication rationing when they cannot afford their medication due to high deductibles.
These insulin price caps do not change the fundamental equation: high deductibles discourage people from seeking and using needed care. Therefore, we need legislation that would eliminate high-deductible plans and further lower out-of-pocket costs for insulin to a fairer price, like that seen in most other countries. Another needed intervention is to educate people about the risks of signing up for high-deductible plans for patients with chronic medical conditions before enrolling in these restrictive plans.
Let us agree that just as patients with COVID-19 deserve to avoid financial barriers that obstruct their necessary care, patients with chronic medical conditions should not be subjected to the risk of financial devastation created by their health plans.
Shirin Hund is an internal medicine physician.
