Are the Healthy Behaviors of US High-Deductible Health Plan Enrollees Driven by People Who Chose These Plans? Smoking as a Case Study

PURPOSE: 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. DESIGN: Cross-sectional analysis of nationally-representative data. SETTING: United States from 2007 to 2008. SUBJECTS: 6,941 privately insured non-elderly adult participants in the 2007 Health Tracking Household Survey. MEASURES: Self-reported smoking status. ANALYSIS: 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. RESULTS: 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). CONCLUSIONS: 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.