Do High Deductibles Reduce the Use of ‘Free’ Preventive Services Under the Affordable Care Act?

The Patient Protection and Affordable Care Act of 2010 (ACA) sought to increase use of preventive services by eliminating cost sharing to consumers, making eligible services exempt from plan deductibles, copayments, and coinsurance. However, consumer understanding of health insurance terminology and benefit design is poor, and thus this incentive to increase use of preventive services could get lost in more salient plan features. We also know that those enrolled in high deductible health plans use fewer preventive services, and medical care in general, but it is unclear if this changed after the ACA. In this study, we address whether high deductible health plan enrollment is associated with a differential response in the use of preventive services after this policy change using a quasi-experimental approach, employing both parametric and semi-parametric difference-in-differences. We also examine whether the policy was effective in reducing the out-of-pocket costs realized by consumers for eligible services. Prior studies have tended to focus on a single or narrow set of preventive services that were subject to the elimination of cost sharing under this ACA provision, but we sought to include the full set of services covered to the extent possible. We use a national multi-payer set of commercially enrolled individuals (IBM® MarketScan® Commercial Database) to describe trends in preventive service use and out-of-pocket costs, then focusing on a cohort of continuously insured adults in 2010 and 2011 to identify whether there was any differential response to the policy change by high deductible health plan enrollment. Our results suggest that the elimination of cost sharing for preventive services did not result in a differential response by high deductible health plan status. We do, however, find that the policy was seemingly ineffective at reducing out-of-pocket costs associated with use of eligible preventive services, likely due to implementation issues with this benefit. If use of preventive services is less than optimal and costs continue to be a barrier, then examination of coding requirements and insurer practices is needed to ensure the policy is meeting its intended goal.