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EBRI study: low-income workers in high-deductible health plans avoid some care

By Eric Reinhardt


Low-income workers who switch to high-deductible health plans with health savings-accounts (HSAs) are more likely than their higher-paid colleagues to avoid certain types of health care. That’s according to new research that the Employee Benefit Research Institute (EBRI) recently released.

Based in Washington, D.C., EBRI describes itself as a “private, nonpartisan, nonprofit research institute that focuses on health, savings, retirement, and economic-security issues.”

The EBRI analysis — which looked at actual health claims of one large, unnamed Midwestern employer by workers’ income levels — found significant differences for the use of some health services, but not for others.

For instance, switching to an HSA-eligible health plan caused a decline in (nonpreventive) outpatient office visits for workers at all income levels, but the decline was twice as large for workers and their dependents with incomes less than $50,000 as compared with those with incomes of at least $100,000.

The decline in specialist visits accounted for most of the decline in outpatient office visits among the group of workers with less than $50,000 in annual income, EBRI said.

Also, the HSA-eligible health plan was associated with a reduction in various preventive services by worker income. For example, lower-income workers reduced their use of influenza vaccinations more than higher-income colleagues.

Further, the HSA-eligible health plan was associated with an increase in emergency-department visits and inpatient hospital admissions among lower-income individuals.

The usage levels of certain health-care services — inpatient hospital days; “avoidable” emergency-department visits; pneumonia vaccinations; HPV vaccinations; and blood-sugar testing for individuals with diabetes — were unaffected by enrollment in the HSA-eligible health plan both overall and by worker income, EBRI found.

“A key question with high-deductible HSA-eligible health plans is how the income differences of workers affect the use of health-care services and spending: Do lower-paid workers defer health care more than higher-paid workers?” Paul Fronstin, director of EBRI’s health research and education program and co-author of the report, said in the EBRI news release.

“We found mixed results: For some health services, yes it does — but for others, it does not,” he added.

The data for the EBRI study came from a large employer that offered an HSA-eligible health plan alongside a preferred provider organization (PPO) and covers the use of health-care services and spending over the six-year period from 2009 to 2014.

The full report, “The Impact of an HSA-Eligible Health Plan on Health Care Services Use and Spending by Worker Income,” EBRI Issue Brief no. 425 (August 2016), is available online at

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