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Health expenditures and job-based insurance premiums are outpacing economic growth and wages by substantial margins.(9) (10) Many employers are coping with rising premiums by offering new insurance products that shift more financial risk to employees. Rising responsibility for costs among working families raises concerns that: 1) patients with moderate and low incomes and/or chronic illness will forgo needed care; 2) family budgets and retirement savings will be placed under stress from climbing out-of-pocket medical costs; and 3) families will find it increasingly difficult to pay medical bills and thus incur mounting medical debt. Using the Commonwealth Fund's 2003 Biennial Health Insurance Survey, Karen Davis and colleagues found in an April 2005 Fund report that adults with deductibles of $1,000 or more have significantly greater difficulty accessing care due to cost compared with those with lower or no deductibles.(11)
In an article in the June 2005 Health Affairs, Cathy Schoen and colleagues developed a measure of "underinsurance" based on people's out-of-pocket costs and deductibles relative to their incomes.(12) Applying this measure to data from the Commonwealth Fund Biennial Health Insurance Survey, the authors found that at least 16 million adults were underinsured in 2003, in addition to the 46 million uninsured. The underinsured reported problems accessing needed care and problems with medical bills at rates similar to the uninsured.
The new Biennial Health Insurance Survey, to be published in 2006, will assess the stability and adequacy of insurance coverage, focusing on the effects of high deductibles and out-of-pocket spending on the health care of people with chronic illnesses and/or low incomes. In addition, with support from the Fund, the Employee Benefit Research Institute is fielding an online survey to examine adults' experiences with high-deductible plans, HSAs, and other medical savings accounts.
With Fund support, John Hsu, M.D., of Kaiser Permanente is evaluating the effects of high-deductible plans and HSAs, which Kaiser has offered since 2004. Hsu and colleagues are assessing the impact of these new products on health care use, costs, and health outcomes through analysis of plan data and interviews with enrollees. Findings will inform national policy as well as benefit design in the private sector.
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Percent of adults ages 19-64

* Did not fill a prescription; did not see a specialist when needed; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor because of costs.
Source: The Commonwealth Fund 2003 Biennial Health Insurance Survey.