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  • Posted June 29, 2020

How Insurance Plans Keep Black Patients From Cancer Care

Health insurance plans with high deductibles may be taking a financial toll on Black patients, according to a new study of cancer survivors.

The researchers said the findings point to yet another reason for racial health disparities in the United States: High deductibles may make it harder for Black patients, in particular, to afford medications or see a doctor.

"Just because we've expanded health insurance coverage doesn't mean people have access to the care they need," said lead researcher Megan Cole, an assistant professor at Boston University School of Public Health.

And for Black patients, she said, high deductibles may only compound the structural inequities that they already face.

Deductibles are the set amount of money a person has to pay for health care before the insurance coverage kicks in. Plans with a bigger deductible generally have a lower monthly premium.

And over the years, U.S. employers have grown fonder of them as the costs of health care steadily rise, Cole said. Between 2009 and 2019, the percentage of employees in high-deductible plans rose from 8% to 30%, according to a Kaiser Family Foundation study.

But it has not been clear whether high deductibles could be adding to longstanding racial inequities in health care and health, Cole said. To study the question, her team looked at national data on over 3,700 cancer survivors who were surveyed between 2013 and 2018.

Overall, 44% were enrolled in a high-deductible plan. In that group, Black patients were more likely than white patients to have skipped medications, skipped doses, or put off filling a prescription in order to save money, the findings showed.

Just over 28% delayed a prescription, for example, versus about 8% of their white counterparts.

High deductibles were also a barrier to seeing a specialist, the study found: 15% of Black patients said they could not afford it, compared with 6% of white patients.

Such wide racial gaps were generally not seen among cancer survivors on health plans with lower deductibles.

What constitutes a "high" deductible? It's not just subjective. There are health plans that are formally defined (by the Internal Revenue Service) as high-deductible, explained Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, in Washington, D.C.

For 2020, the IRS said a high deductible is at least $1,400 for individuals, and $2,800 for families.

Young said that high deductibles and other forms of "cost-sharing" may discourage people from opting for medical procedures that are "low value" -- like an elective surgery with little evidence of benefits.

The problem comes when patients cannot afford needed care.

In recent years, Young said, some high-deductible plans have been designed to be "more nuanced." They may, for example, cover necessary medications for chronic health conditions right away, and not apply the deductible.

But ultimately, Young said, the root issue is the high price of health care.

Based on the new findings, those price tags -- and the cost-sharing that comes with them -- may be disproportionately affecting Black patients.

The full extent of the harm is not clear. Cole said the data did not reveal the kinds of medications that cancer survivors skipped, or how it might have affected their health.

But, she said, the fact that they had to make that choice is concerning.

Limits on the types of services that are subject to deductibles might help, Cole said. But other measures are also needed, she added -- from caps on deductible sizes to broader measures to tackle the "institutional racism" at the heart of health disparities.

The concept of higher costs leading people to bypass things they don't need might work in some other areas. "But health care just doesn't work that way," Cole said.

The findings were published online June 24 in JAMA Network Open.

More information

The U.S. National Library of Medicine has resources on paying for medical care.

SOURCES: Megan Cole, PhD, MPH, assistant professor, health law, policy and management, Boston University School of Public Health; Christen Linke Young, JD, fellow, USC-Brookings Schaeffer Initiative for Health Policy, Washington, D.C.; JAMA Network Open, June 24, 2020, online
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