Are Adults With Diabetes Who Switch to High-Deductible Health Plans at Greater Risk for Complications?

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Diabetes—which impacts how the body uses blood sugar—can cause a variety of different problems, including blindness, cardiovascular disease (CVD), and end-stage kidney disease (ESKD).1

Aside from early detection, preventing these complications often requires controlling CVD risk factors, such as dyslipidemia, hypertension, and hyperglycemia. Tackling these challenges is no simple task, especially financially. People living with diabetes reportedly incur more than 25% of total healthcare costs in the United States; approximately $12,000 in excess is spent per person with diabetes compared to those who don’t have diabetes. One must also keep in mind that each person’s financial burden surrounding diabetes depends on that specific patient’s health insurance.

A retrospective cohort study published in JAMA Network Open1 sought to determine whether switching to a high-deductible health plan (HDHP)—when an employer requires it do so—is related to the rise in risk of experiencing both macrovascular and microvascular complications of diabetes.

With the help of deidentified administrative claims data that linked medical benefit information of enrollees in employer-sponsored health plans, the study dove into annual cohorts of adults with diabetes (≥18 years of age) who were enrolled in employer-sponsored non-HDHPs for one year and then were either required by their employer to switch to an HDHP, or stayed in a non-HDHP instead between Jan. 1, 2010, and Dec. 31, 2018. Diabetes status was determined with the help of healthcare effectiveness data and information set standards.

The study featured a total sample size of 42,326 adults who had switched to an HDHP (mean [SD] age, 52 [10] years; 19,752 [46.7%] female) and 202,729 adults who did not switch (mean [SD] age, 53 [10] years; 89, 828 [44.3%] female).

Those who changed over to an HDHP had more of a chance of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% confidence interval (CI), 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment).

The study did also present its share of limitations, including the fact that this was a retrospective, observational study. Due to its nature, the authors were unable to establish any sort of causal relationship between the high out-of-pocket (OOP) costs incurred by enrollees in the HDHPs and any consequential microvascular and macrovascular complications.

As a result, the authors concluded that, “ … enrollment in an HDHP was associated with higher risk of chronic diabetes complications, with evidence of a cumulative financial burden the longer individuals are enrolled in the HDHP. The financial burden of, and morbidity associated with, HDHPs can be minimized if HDHPs were to cover evidence-based chronic disease care in addition to preventive services. Additional investment in and funding for HSAs can also mitigate the OOP costs HDHP enrollees incur managing their disease. Nevertheless, although HDHPs are cost-saving to employers and payers, this study’s findings suggest that they may impede access to care and increase the risk of adverse health outcomes for people living with diabetes. As such, they may not be an optimal solution for the high and increasing costs of health care in the US.”


1. McCoy RG, Swarna KS, Jiang DH, et al. Enrollment in High-Deductible Health Plans and Incident Diabetes Complications. JAMA Netw Open. 2024;7(3):e243394. doi:10.1001/jamanetworkopen.2024.3394

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