Enrollment in high-deductible health insurance plans has exploded over the past five years. I’m learning the hard way how these plans do — and do not — work.
About one-third of American workers covered by health insurance are now in high-deductible health plans, in which the policy holder pays a substantial portion of the cost of health care services out of pocket before insurance coverage kicks in. Many economists and health policy experts believe that these plans are a promising way to reduce health care spending.
So when a high-deductible plan became available through my employer, Harvard University, a couple years ago, I decided to enroll my family in it. If this is going to be a big national experiment, I thought that I, as a physician and a health policy scholar, ought to know what it’s like to live with this kind of health insurance. Debra, my wife, was not convinced.
While I am a proponent of experiments and evidence, Deb wasn’t interested in including our kids in this one. The notion of having to think about shopping for health care if any of us got sick wasn’t attractive to her. But if we stay healthy all year, I argued, we would actually come out financially ahead.
She reminded me that we have plenty of other reasons to stay healthy all year, and the potential financial savings didn’t feel like a particularly compelling additional reason. Defeated by her logic, I turned to pleading.
I made the point that we had a lot of advantages in navigating the health care system effectively and that she and I should go about making the same health care decisions that we would have otherwise. She relented.
My family is now in its second year under a high-deductible plan. That means we are responsible for paying the first $6,000 of our health expenses for the year, for everything from a doctor visit for a flu shot to surgery.
It has been an educational enterprise.
Our experiment is showing me again and again that it’s extremely hard to be a health care consumer in Massachusetts — just as I’m sure it is in other states. Want to know how much a particular type of health care costs, like a visit to a specialist or getting a minor surgery? Good luck figuring it out. My insurance company’s online tool was hard to use and, even as a physician, I could almost never guess what sets of services a visit to the doctor might generate. What’s more, there was no useful information about the quality of care. Price information without quality information is not particularly helpful when shopping for medical care.
The second lesson was that being a health care consumer is stressful, at least the way the system is currently set up. Here’s an example. Our son had surgery last year. We got a call saying it was time for his one-year follow-up. Deb stressed for nearly two months over whether or not to make the appointment. Of course she wants our son to get the care he needs, but did he truly need this follow-up? That’s both the promise and the peril of high-deductible plans — they are supposed to make you think twice about consuming health care.
She eventually went with our son for his one-year follow-up — they spent two minutes with the surgeon — and paid $465 for the visit. I’m not sure my son, or my spouse, felt any better afterward. There were many examples like this sprinkled throughout the year, but the most profound one was the one I experienced for myself.
I have supraventricular tachycardia, a common heart rhythm problem. When it hits, my heart races at about 180 beats per minute. It comes on a couple of times a year, lasts a few minutes, and usually isn’t a big deal. But one morning I woke up with my heart racing. After 30 minutes, I wondered if I should go to the emergency department, knowing that I’d probably get stuck with a multi-thousand-dollar bill. So I kept waiting. After an hour, during which my heart kept beating furiously, my chest started to hurt. I knew what that meant — I was at risk of having a heart attack.
Deb asked me what I would tell a patient in this situation. That was easy: I’d tell him or her to call 911. But I kept waiting. Finally, about 15 minutes later, the abnormal rhythm finally broke and I felt my heart calm down. I was lucky — I had rolled the dice and things had worked out.
That brings me to the third lesson of high-deductible health plans, the lesson of what didn’t happen — I didn’t really have a choice of where to go for treatment.
Imagine that for dinner on any given night, your two choices were eating at a very expensive gourmet restaurant or not eating at all. I bet that more of us would forgo dinner a lot. (Thank goodness we have a range of options.)
The US health system is something like that. During my heart rhythm problem, I realistically had only one choice — going to the emergency department. Knowing that they are usually the only option, hospital administrators make emergency departments super expensive.
One promise of high-deductible plans is that if we have a real market for health care, we will see lots of innovation, including different types and levels of urgent care centers. But that hasn’t happened.
During my heart episode, all I really needed was a place that had a heart monitor and that stocked common, inexpensive rhythm-restoring heart medicines. The real cost should have been $200 to $300. If I had known that such a place existed, I would have gone there. But this mid-price range of options is rarely available in health care. So I skipped it. And that’s what people are doing under high-deductible plans — skipping needed care.
Here’s my major takeaway so far from this ongoing experiment: Simply asking people to pay out of pocket for their health care doesn’t create a health care marketplace. If we are going to be serious about creating one, we have to generate much more innovation in care delivery models, including much more leeway on the scope of practice regulations, such as letting nurses do a lot of the things that only doctors can do today.
We must be much more aggressive about price transparency and make quality data ubiquitous. The way we’re doing it now, even I as a doctor and a health policy expert can’t figure out when I or my family’s needs are worth the expense.
If we continue with high-deductible health plans the way they exist today, more and more people will experience what my family did — the stress of having to make medical decisions with little information and few choices. At best, we’ll have a health care system that might save a little money — but at the risk of harming the health of our citizens.
Ashish Jha, MD, is an internist at the VA Boston Healthcare System, a professor of health policy at the Harvard T.H. Chan School of Public Health, and director of the Harvard Global Health Institute.