Health care behaviors among enrollees in a state high-risk insurance pool

State high risk insurance pools are the coverage of last resort for individuals who do not have access to group plans and are medically uninsurable in the individual market. However, most pools require high out-of-pocket spending, which may discourage appropriate management of serious conditions and lead to preventable disability. As part of a demonstration project to prevent of forestall disability, we sought to better understand the relationship between health insurance coverage and health care behaviors of persons with potentially disabling conditions enrolled in a state high risk insurance pool.

We conducted six focus groups with 42 risk pool enrollees, who experienced a variety of mental and physical health conditions, including diabetes, heart disease, current and past cancers, depression, bipolar disorder, epilepsy, multiple sclerosis, spinal injuries, and hepatitis C. Analyses of transcripts indicate that high premiums and deductibles limit participants' ability to afford basic health services and access to prescription medications despite their middle-class socioeconomic status. Participants reported delaying or forgoing needed medical care due to lack of coverage and/or out-of-pocket costs and using numerous and potentially dangerous strategies to minimize costs, such as “saving up” needed procedures until their total costs will exceed that year's deductible.

Our study indicates that health promotion through educational outreach to increase preventive screening rates, improve medication compliance, or encourage monitoring of chronic conditions may be insufficient in some populations. Public health advocates must acknowledge that insurance requiring significant cost-sharing, particularly among those with chronic conditions, creates real barriers to preventive care.