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Delayed and Forgone Care for Families with Chronic Conditions in High-Deductible Health Plans



High-deductible health plans (HDHPs) are an increasingly common strategy to contain health care costs. Individuals with chronic conditions are at particular risk for increased out-of-pocket costs in HDHPs and resulting cost-related underuse of essential health care.


To evaluate whether families with chronic conditions in HDHPs have higher rates of delayed or forgone care due to cost, compared with those in traditional health insurance plans.


This mail and phone survey used multiple logistic regression to compare family-level rates of reporting delayed/forgone care in HDHPs vs. traditional plans.


We selected families with children that had at least one member with a chronic condition. Families had employer-sponsored insurance in a Massachusetts health plan and >12 months of enrollment in an HDHP or a traditional plan.

Main Measures

The primary outcome was report of any delayed or forgone care due to cost (acute care, emergency department visits, chronic care, checkups, or tests) for adults or children during the prior 12 months.


Respondents included 208 families in HDHPs and 370 in traditional plans. Membership in an HDHP and lower income were each independently associated with higher probability of delayed/forgone care due to cost. For adult family members, the predicted probability of delayed/forgone care due to cost was higher in HDHPs than in traditional plans [40.0% vs 15.1% among families with incomes <400% of the federal poverty level (FPL) and 16.0% vs 4.8% among those with incomes ≥400% FPL]. Similar associations were observed for children.


Among families with chronic conditions, reporting of delayed/forgone care due to cost is higher for both adults and children in HDHPs than in traditional plans. Families with lower incomes are also at higher risk for delayed/forgone care.

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The authors thank Christopher Forrest, Bruce Landon, and Carol Cosenza for guidance in the design of the survey instrument; Christopher Forrest and Linda Dunbar for making the Chronic Condition Checklist available and assisting with its use; Irina Miroshnik for help with data collection and interpretation; and the team of research assistants for their help in conducting the survey.


This study was supported by the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative. Additional support for the survey was provided by the Center for Child Health Care Studies, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School. Dr Galbraith’s effort was supported in part by a K23 Mentored Career Development Award from NICHD (HD052742). Drs. Soumerai and Ross-Degnan are investigators in the HMO Research Network Center for Education and Research in Therapeutics and are supported by the Agency for Healthcare Research and Quality (grant no. U18HS010391). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Prior Presentations

An abstract based on this research was presented at the 2010 Pediatric Academic Societies Meeting in Vancouver, British Columbia, and at the 2010 AcademyHealth Annual Research Meeting in Boston, MA, as a poster.

Conflict of Interest

Dr. Galbraith has received support for a separate research project from the Harvard Pilgrim Health Care Foundation through a Faculty Grant.

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Corresponding author

Correspondence to Alison A. Galbraith MD, MPH.

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Galbraith, A.A., Soumerai, S.B., Ross-Degnan, D. et al. Delayed and Forgone Care for Families with Chronic Conditions in High-Deductible Health Plans. J GEN INTERN MED 27, 1105–1111 (2012).

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  • health insurance
  • deductible
  • cost sharing
  • utilization
  • health policy