How deductibles contribute to health care inequity and discrimination
Systemic bias and lack of access to care are not the only factors preventing minorities and socioeconomically disadvantaged groups from realizing health equity.
COVID-19 has forced our society to confront a number of uncomfortable truths, including the fact that minorities who contract the coronavirus are far more likely to die than white Americans. There are many factors that lead to unacceptable health care outcomes like the coronavirus death rate disparity, including the fact that people of color are less likely to be insured, that doctors treat and manage pain experienced by people of color differently, and that people of color are less likely to have reliable access to high-quality care in their neighborhoods.
Unfortunately, systemic bias and lack of access to care are not the only factors preventing minorities and socioeconomically disadvantaged groups from realizing health equity. Some barriers include the fact that socioeconomically disadvantaged groups often delay or avoid care because they work jobs that don’t offer sick leave or they miss medical appointments because of family obligations.
Related: COVID-19 and social determinants of health: Considerations for employers
Other obstacles are the prevalence of health insurance that is cheap but fails to cover basic health care costs. For example, high-deductible plans have become increasingly popular as a result of rapid increases in the cost of monthly health plan premiums over the past 20 years. These plans—with their relatively low premiums—are popular with lower-income Americans because they help make their monthly budgets work.
High-deductible plans have become so common that in 49 states, at least 25% of residents who received employer-sponsored insurance were enrolled in one as of 2016. In New York, where I live, nearly 40% were enrolled in a high-deductible plan four years ago. Other high-population states had similar numbers: Florida was at 40% and California at 28%.
Many high-deductible plans are inexpensive in terms of premium costs, but the deductible is flatly unaffordable, which leads to health care avoidance and medical homelessness. Of the nearly 160 million Americans with health insurance through their employer, more than 40% have plans with deductibles over $1,500 for individuals, or more than $3,000 for a family.
However, nearly half of Americans don’t even have $400 available for an emergency, making the health care finance arithmetic completely upside down for most of America.
One survey found that 40% of privately insured adults with deductibles that comprise 5% or more of their income put off or entirely avoided essential health care due to their deductible. And a new study published in JAMA Open Network found that 22.8% of Black cancer survivors on high-deductible plans skipped medication in order to save money, while only 8% of white cancer survivors with high deductible plans did the same. By contrast, among cancer survivors on other kinds of plans, just 7.7% of Black and 5.4% of white patients skipped medication.
Additionally, 14.9% of Black patients on high-deductible plans were unable to afford to see a specialist, compared to 6.2% of white patients. For patients with other types of health plans, only 4.9% of Black and 2.9% of white patients could not afford to see a specialist.
To address these systemic issues, we must create health plan solutions that are affordable for both businesses and their employees, and ensure those plans offer greater access to care than traditional health plans.
We can accomplish this by building optimized networks with high-quality providers that practice cost-effective care, giving us a better chance of directing patients toward high-value care, which not only lowers costs, but also improves outcomes.
We must ensure individuals have access to care where and when they need it, so they can juggle work and childcare with their medical needs. Networks need to have providers who are located in underserved neighborhoods, and who have availability for new patients and can provide care after business hours and telephonically.
We cannot, however, stop there. Primary care should be free, with simple, predictable copays for all other care, eliminating concerns individuals have about their ability to afford their care. Under this model, individuals are also more likely to receive preventive care, which is another area in which Black people tend to receive less care than whites.
Lastly, we need to promote and value innovation that targets health care affordability and social determinants of health. For every dollar that has gone into supporting new apps and tools that are well-intended but target well-heeled millennials and/or Medicare populations, only a fraction is devoted to basic needs—patient access and affordability. Where we spend our money is a reflection of the values of our society and, currently, it’s simply not aligned with what matters most.
We have the ability to make a real difference in helping socioeconomically disadvantaged groups gain access to the kind of care they need to reduce the sort of disparities in mortality that we’re seeing during COVID-19. We simply need the creativity and the will to bring about change.
Ashok Subramanian is the CEO of Centivo, which he founded in 2017 after observing the inefficiency in the health care system and the pain that has resulted for employers and employees.
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