High-deductible health plans are increasingly common — and research shows they may lead patients to delay or skip needed care.
The percentage of Americans under age 65 enrolled in high-deductible health plans ranges from about 42%, according to CDC data, to as high as 58%, according to a study published last year in JAMA Network Open.
In the study, Risha Gidwani, DrPH, and colleagues analyzed data from 343,137 Americans with chronic conditions who were enrolled in high-deductible health plans. They found that HDHP enrollment was associated with significantly lower use of recommended, evidence-based clinic, laboratory, and prescription drug care across a range of common chronic illnesses, including, asthma, diabetes, hypertension, coronary artery disease, heart failure and major depressive disorder.
For journalists, high-deductible health plans are an important story because these patterns suggest that cost-sharing may be discouraging patients from seeking recommended care, with potential consequences for both health outcomes and long-term costs.
High costs and skipped care
Journalists should note that this trend is often driven by cost: patients must pay the full price of care until they meet their deductible. In 2023, the mean deductible was $2,418 for an individual and $4,674 for families.
About half of all American households of people younger than 65 cannot afford the average high-deductible health plan deductible, researchers said. And nearly 40% of Americans could not cover a $400 emergency expense, a cost that can easily be incurred in a single day of health care use.
This financial pressure can lead patients toskip prescriptions or avoid care, reduce medication doses or avoid doctor visits, tests and follow-up care, according to a December study in JAMA Internal Medicine.
In that analysis, Adam Gaffney, M.D., and colleagues measured the financial burden consumers with high-deductible health plans incurred over four years. Most studies examine these costs over a single year, but a related commentary, “Taking the Long View on Health Care-Related Financial Hardship,” emphasized the importance of longer-term analysis.
The value of a longer view
Studying the cost burden of high-deductible health plans over one year captures only part of the problem, wrote John W. Scott, M.D., of the University of Washington in Seattle.
By analyzing the financial harm over four years, he identified three key findings:
- About 11% of consumers with high-deductible health plans had financial strain over one year, but nearly 26% of adults reported health care cost burdens or foregone care over four years.
- Even brief coverage lapses increased the risk of financial hardship, underscoring the harms of being underinsured.
- More than half of the patients who died during the study period had health care-related financial hardship.
The stress on household budgets
The Gaffney study examined plans with maximum payment out-of-pocket costs of $8,500 for individuals and $17,000 for families — levels that would strain most households.
Their research was published two months before the U.S. Department of Health and Human Services proposed deductibles that, if approved, would be almost twice as high for catastrophic plans sold on the Affordable Care Act marketplaces, as we reported previously.
Among the 12,645 people in the Gaffney study, the risk of burdensome out-of-pocket costs rose every year: 6.5% of adults had cost burdens after one year, compared with 17.4% after four years.
Most studies assess high-deductible health plan-related costs over a single year, which can underestimate the cumulative risk over time, the researchers explained.
Over four years, a larger share of the population faced higher out-of-pocket costs than one-year analyses suggest. Those with the greatest cost burdens were more likely to have lower incomes, be uninsured or hospitalized and have a chronic disease.
A rising burden over time
Out-of-pocket costs don’t just strain finances — they can also lead to foregone care and force families to delay or cut back on essential spending, researchers noted. If these consumers take on debt or file for bankruptcy, those factors can harm health and lead to premature death.
In the study, the primary outcomes were cost burden or the catastrophic cost burden, measured over four years.
The researchers defined the primary outcomes using four cost-related factors:
- Cost burden: defined as out-of-pocket medical costs that were more than 10% of a family’s annual income or more than 5% in out-of-pocket costs of an individual’s annual income.
- Catastrophic cost burden: defined as out-of-pocket spending more than 40% of post-subsistence income, which is income minus food costs.
- Foregone care due to costs.
- Family-level cost burden: Spending 10% or more on out-of-pocket costs on drugs, health and dental care and on health insurance premiums.
For individuals with incomes below 200% of the federal poverty level that year, they wrote. This year, 200% of the federal poverty level for an individual is $31,920. For families, cost burden was defined as health care costs (excluding premiums) exceeding 10% of annual family income. Catastrophic cost burden was defined as out-of-pocket health spending (excluding premiums) exceeding 40% of post subsistence family income.
Resources
- How does cost affect access to healthcare?, Peterson-KFF Health System Tracker, March 10, 2026
- Marketplace Affordability: The Hazards of High Deductibles, Health Care Value Hub, Nov. 20, 2024
- Half of Patients With High-Deductible Health Plans Have Received a Surprise Medical Bill, Todd Shryock, Medical Economics, Jan. 23, 2023
- Measuring the Burden of Health Care Costs for Working Families, Health Affairs, April 2, 2019
- Measuring the Burden of Health Care Costs on US Families. The Affordability Index, JAMA, Nov. 21, 2017
