Are the healthy behaviors of US high-deductible health plan enrollees driven by people who chose these plans? Smoking as a case study.

Abstract

To determine whether negative associations between enrollment in a high-deductible health plan (HDHP) and one exemplar unhealthy behavior--daily smoking--are found only among people who chose these plans.Cross-sectional analysis of nationally-representative data.United States from 2007 to 2008.6,941 privately insured non-elderly adult participants in the 2007 Health Tracking Household Survey.Self-reported smoking status.We classified subjects as HDHP or traditional health plan enrollees with employer-sponsored insurance (ESI) and no choice of plans, ESI with a choice of plans, or coverage through the non-group market. We used multivariate logistic regression to measure associations between HDHP enrollment and daily smoking within each of the 3 coverage source groups while controlling for potential confounders.HDHP enrollment was associated with lower odds of smoking among individuals with ESI and a choice of plans (AOR 0.55, 95% CI 0.33-0.90) and those with non-group coverage (AOR 0.64, 95% CI 0.34-1.22), though the latter association was not statistically significant. HDHP enrollment was not associated with lower odds of smoking among individuals with ESI and no choice of plans (AOR 1.04, 95% CI 0.69-1.56).HDHP enrollment is associated with lower odds of smoking only among individuals who chose to enroll in an HDHP. Lower rates of unhealthy behaviors among HDHP enrollees may be a reflection of individuals who choose these plans.