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. 2024 Dec 5;(214):CS354963. doi: 10.15620/cdc/165797

Enrollment in High-deductible Health Plans Among People Younger Than Age 65 With Private Health Insurance: United States, 2019-2023.

Robin A Cohen, Elizabeth M Briones
PMCID: PMC11831409  PMID: 39937774

Abstract

OBJECTIVE

This report provides a comprehensive look at enrollment in high-deductible health plans (HDHP), including consumer-directed health plans (CDHP) among privately insured people younger than age 65.

METHODS

Data from the 2019 through 2023 National Health Interview Survey were used to examine enrollment in HDHPs and CDHPs among people younger than age 65 with private health insurance. CDHPs are HDHPs with an associated health savings account or health reimbursement account. All estimates are presented by sex, age group, race and Hispanic origin, family income, family educational attainment, level of urbanization, and source of private coverage.

RESULTS

In 2023, among privately insured people younger than age 65, 41.7% were enrolled in an HDHP. Enrollment increased from 40.3% in 2019 to 43.3% in 2021, followed by a decrease to 41.7% in 2023. Among people with employment-based coverage, enrollment in an HDHP increased from 40.2% in 2019 to 43.4% in 2021, followed by a decrease to 41.9% in 2023. For people with directly purchased coverage, enrollment in an HDHP increased from 44.3% in 2019 to 47.0% in 2020, followed by a decrease to 43.1% in 2023. Generally, White non-Hispanic people were the most likely to be enrolled in an HDHP. Black non-Hispanic and Hispanic people were the least likely to be enrolled in an HDHP. Enrollment in an HDHP increased with family income and family educational attainment. In 2023, 19.5% of people younger than age 65 with private health insurance were enrolled in a CDHP. Enrollment characteristics of people with CDHPs mirrored those of people with HDHPs overall. However, children were more likely to be enrolled in an CDHP plan than adults ages 18-64. People with employment-based coverage were nearly four times more likely to be enrolled in a CDHP than their counterparts with directly purchased coverage.

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References

  1. Healthcare.gov. High deductible health plan (HDHP). Available from: https://www.healthcare.gov/glossary/high-deductible-health-plan/.
  2. Baker L, Bundorf K, Royalty A, Galvin C,McDonald K.. Consumer-oriented strategies for improving health benefit design: An overview. Technical Review 15. AHRQ Publication No. 07-0067. Agency for Healthcare Research and Quality. 2007. [PubMed]
  3. U.S. Government Accountability Office. Consumer-directed health plans: Early enrollee experiences with health savings accounts and eligible health plans. GAO–06–798. 2006.
  4. Cohen RA, Martinez ME.. Consumer-directed health care for persons under 65 years of age with private health insurance: United States, 2007. NCHS data brief, no 15. Hyattsville, MD: National Center for Health Statistics. 2009. [PubMed]
  5. Cohen RA, Terlizzi EP, Martinez ME.. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2018. National Center for Health Statistics. 2019. Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201905.pdf.
  6. Employee Benefit Research Institute and Greenwald Research. 2023 consumer engagement in health care survey report. 2024. Available from: https://www.ebri.org/docs/default-source/cehcs/2023-cehcs-report.df?sfvrsn=3c78072f_2.
  7. for AgencyResearch Healthcare and Quality.. Medical expenditure panel survey insurance component 2022 chartbook. AHRQ Publication No. 23(24)-0077. 2023. Available from: https://meps.ahrq.gov/data_files/publications/cb27/cb27.pdf. [PubMed]
  8. Claxton G, Rae M, Winger A, Wager E.. Employer health benefits 2023 annual survey. Kaiser Family Foundation. 2023.
  9. Veilleux KA, Weissman JS.. Does being poor and sick modify the effect of individuals on high-deductible health plan (HDHP) reporting delayed/forgone care? J Health Care Poor and Underserved 34(2):673‒84. 2023. doi: 10.1353/hpu.2023.0057. [DOI] [PubMed]
  10. Kullgren JT, Cliff EQ, Krenz C, West BT, Levy H, Fendrick M, Fagerlin A.. Use of health savings accounts among US adults enrolled in high-deductible health plans. JAMA Netw Open 3(7):e2011014. 2020. DOI: 10.1001/jamanetworkopen.2020.11014. 10.1001/jamanetworkopen.2020.11014PMC7368175 [DOI] [PubMed]
  11. Maciejewski ML, Hung A.. High-deductible health plans and health savings accounts: A match made in heaven but not for this irrational world. JAMA Netw Open 3(7):e2011000. 2020. DOI: 10.1001/jamanetworkopen.2020.11000. 10.1001/jamanetworkopen.2020.11000PMC10103790 [DOI] [PubMed]
  12. National Center for Health Statistics. National Health Interview Survey: 2020 survey description. 2021.
  13. National Center for Health Statistics. National Health Interview Survey: 2021 survey description. 2022.
  14. National Center for Health Statistics. National Health Interview Survey: 2019 survey description. 2020.
  15. National Center for Health Statistics. National Health Interview Survey: 2022 survey description. 2023.
  16. National Center for Health Statistics. National Health Interview Survey: 2023 survey description. 2024.
  17. Cohen RA, Sohi IS. Long-term trends in health insurance: Estimates from the National Health Interview Survey, United States, 1968–2023. National Center for Health Statistics. 2024. Available from: https://www.cdc.gov/nchs/health_policy/coverage_and_access.htm.
  18. Parker JD, Talih M, Malec DJ, Beresovsky V, Carroll M, Gonzalez JF JrJr, et al. . National Center for Health Statistics data presentation standards for proportions. National Center for Health Statistics. Vital Health Stat 2(175). 2017. Available from: https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf. [PubMed]
  19. Korn EL, Graubard BI.. Confidence intervals for proportions with small expected number of positive counts estimated from survey data. Surv Methodol 24(2):193–201. 1998.
  20. Ellison J, Shafer P, Cole MB.. Racial/ethnic and income-based disparities in health savings account participation among privately insured adults. Health Aff (Millwood) 39(11):1917–25. 2020. DOI: 10.1377/hlthaff.2020.00222. doi: 10.1377/hlthaff.2020.00222. [DOI] [PubMed]
  21. Jetty A, Petterson S, Rabin DL, Liaw W.. Privately insured adults in HDHP with higher deductibles reduce rates of primary care and preventive services. Transl Behav Med 8(3):375–85. 2018. doi: 10.1093/tbm/ibx076. [DOI] [PubMed]
  22. Borah BJ, Burns ME, Shah ND.. Assessing the impact of high deductible health plans on health-care utilization and cost: A changes-in-changes approach. Health Econ 20(9):1025–42. 2011. DOI: 10.1002/hec.1757. doi: 10.1002/hec.1757. [DOI] [PubMed]
  23. Haviland AM, Eisenberg MD, Mehrotra A, Huckfeldt PJ, Sood N.. Do “consumer-directed” health plans bend the cost curve over time? J Health Econ 46:33–51. 2016. DOI: 10.1016/j.jhealeco.2016.01.001. doi: 10.1016/j.jhealeco.2016.01.001. [DOI] [PubMed]
  24. Rabin DL, Jetty A, Petterson S, Saqr Z, Froehlich A.. Among low-income respondents with diabetes, high-deductible versus no-deductible insurance sharply reduces medical service use. Diabetes Care 40(2):239–45. 2017. doi: 10.2337/dc16-1579. [DOI] [PubMed]
  25. Wharam JF, Landon BE, Galbraith AA, Kleinman KP, Soumerai SB, Ross-Degnan D.. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA 297(10):1093–102. DOI: 10.1001/jama.297.10.1093. doi: 10.1001/jama.297.10.1093. [DOI] [PubMed]
  26. Wharam JF, Zhang F, Wallace J, Lu C, Earle C, Soumerai SB, et al. . Vulnerable and less vulnerable women in high-deductible health plans experienced delayed breast cancer care. Health Aff (Millwood) 38(3):408–15. 2019.PMC7268048 [DOI] [PubMed]
  27. Adbus S, Selden TM, Keenan P.. The financial burdens of high-deductible plans. Health Aff (Millwood) 35(12): 2297–301. 2016. doi: 10.1377/hlthaff.2016.0842. [DOI] [PubMed]
  28. Agarwal R, Mazurenko O, Menachemi N.. High-deductible health plans reduce health care cost and utilization, including use of needed preventive services. Health Aff (Millwood) 36(10):1762–8. 2017. doi: 10.1377/hlthaff.2017.0610. [DOI] [PubMed]
  29. Cohen RA, Zammitti EP.. High-deductible health plans and financial barriers to medical care: Early release of estimates from the National Health Interview Survey, 2016. National Center for Health Statistics. 2017. Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERHDHP_Access_0617.pdf.
  30. Galbraith AA, Ross-Degnan D, Soumerai SB, Rosenthal MB, Gay C, Lieu TA.. Nearly half of families in high-deductible health plans whose members have chronic conditions face substantial financial burden. Health Aff (Millwood) 30(2):322–31. 2011.PMC4423400 [DOI] [PubMed]
  31. Gupta R, Yang L, Lewey J, Navathe AS, Groeneveld PW, Khatana SAM.. Association of high-deductible health plans with health care use and costs for patients with cardiovascular disease. J Am Heart Assoc 12:e030730. 2023. DOI: 10.1161/JAHA.123.030730. 10.1161/JAHA.123.030730PMC10727247 [DOI] [PubMed]
  32. McCoy RG, Swarna KS, Jiang DH, Van Houten HK, Chen J, DavisEM, Herrin J.. Enrollment in high-deductible health plans and incident diabetes complications. JAMA Netw Open 7(3)e:243394. 2024. DOI: 10.1001/jamanetworkopen.2024.3394. 10.1001/jamanetworkopen.2024.3394PMC10960199 [DOI] [PubMed]
  33. Segel JE, Kullgren JT.. Health insurance deductibles and their associations with out-of-pocket spending and affordability barriers among US adults with chronic conditions. JAMA Intern Med 177(3):433–6. 2017. doi: 10.1001/jamainternmed.2016.8419. [DOI] [PubMed]
  34. Park KE, Saluja S, Kaplan CM.. Alleviating financial hardships associated with high-deductible health plans for adults with chronic conditions through health savings accounts. J Gen Intern Med 38(7):1593–8. 2023.PMC10212892 [DOI] [PubMed]
  35. James TG, Sullivan MK, Dumeny L, Lindsey K, Cheong J, Nicolette G.. Health insurance literacy and health service utilization among college students. 2020.J Am Coll Health 68(2):200–6. 2020. DOI: 10.1080/07448481.2018.1538151. doi: 10.1080/07448481.2018.1538151. [DOI] [PubMed]
  36. Loewenstein G, Friedman JY, McGill B, Ahmad S, Linck S, Sinkula S, et al. . Consumers’ misunderstanding of health insurance. J Health Econ 32(5):850–62. 2013. DOI: 10.1016/j.jhealeco.2013.04.004. doi: 10.1016/j.jhealeco.2013.04.004. [DOI] [PubMed]
  37. Norton M, Hamel L, Brodie M.. Assessing Americans’ familiarity with health insurance terms and concepts. Kaiser Family Foundation. 2014. Available from: https://www.kff.org/affordable-care-act/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/.
  38. Affordable Care Act of 2010. Pub L No 111–148, Pub L No 111–152. 2010.
  39. Census U.S., Bureau. Poverty thresholds. Available from: https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html.
  40. National Center for Health Statistics. Multiple imputation of family income in 2019 National Health Interview Survey: Methods. 2020. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2019/NHIS2019-imputation-techdoc-508.pdf.
  41. National Center for Health Statistics. Multiple imputation of family income in 2020 National Health Interview Survey: Methods. 2021. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2020/NHIS2020-imputation-techdoc-508.pdf.
  42. National Center for Health Statistics. Multiple imputation of family income in 2021 National Health Interview Survey: Methods. 2022. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2021/NHIS2021-imputation-techdoc-508.pdf.
  43. National Center for Health Statistics. Multiple imputation of family income in 2022 National Health Interview Survey: Methods. 2023. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2022/NHIS2022-imputation-techdoc-508.pdf.
  44. National Center for Health Statistics. Multiple imputation of family income in 2023 National Health Interview Survey: Methods. 2024. Available from: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2023/NHIS2023-imputation-techdoc-508.pdf.
  45. National Center for Health Statistics. NCHS urban–rural classification scheme for counties. Available from: https://www.cdc.gov/nchs/data-analysis-tools/urban-rural.html. [PubMed]
  46. Office of Management and Budget. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. OMB Bulletin No. 13–01. 2013.
  47. Ingram DD, Franco SJ.. 2013. NCHS urban–rural classification scheme for counties. National Center for Health Statistics. Vital Health Stat 2(166). 2014. [PubMed]

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