Out-of-Pocket Costs for Chronic Illness Management in High-Deductible Health Plans

Importance: High-deductible health plans (HDHPs) enroll a substantial share of privately insured Americans and are associated with reduced use of care, even care that is considered medically necessary. However, the magnitude of patient out-of-pocket (OOP) costs required to obtain evidence-based medical care when enrolled in HDHPs remains poorly understood.

Objective

To estimate patient OOP costs required to receive guideline-concordant care for common chronic conditions when enrolled in an HDHP vs a non-HDHP. Design, setting, and participants: This retrospective cohort study used 2022 to 2023 national commercial insurance claims data. Participants included adults aged 18 to 64 years with employer-sponsored insurance and previously diagnosed diabetes, hypertension, or both. To enter the cohort, persons had to have received guideline-concordant care for their chronic illnesses. Data were analyzed from July 2025 to April 2026. Exposure: Enrollment in an HDHP vs a non-HDHP. Main outcomes and measures: The primary outcome was annual patient OOP costs to receive evidence-based care. Entropy balancing and generalized linear models with geographic fixed effects estimated the mean OOP costs of receiving minimum recommended medical care for diabetes, hypertension, or both in HDHPs and non-HDHPs. Estimates were weighted to ensure that observed costs were representative of the full sample of chronically ill persons.