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A basic assumption of the classic reinsurance model is that the distribution of the loss is precisely known. In practice, only partial information is available for the loss distribution due to the lack of data and estimation error. We study a distributionally robust reinsurance problem by minimizing the maximum Value-at-Risk (or the worst-case VaR) of the total retained loss of the insurer for all loss distributions with known mean and variance. Our model handles typical stop-loss reinsurance contracts. We show that a three-point distribution achieves the worst-case VaR of the total retained loss of the insurer, from which the closed-form solutions of the worst-case distribution and optimal deductible are obtained. Moreover, we show that the worst-case Conditional Value-at-Risk of the total retained loss of the insurer is equal to the worst-case VaR, and thus the optimal deductible is the same in both cases.

High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population with high levels of unmet treatment need, often because of financial barriers. Enrollees with a co-occurring substance use disorder have greater treatment needs and unique barriers to care, perhaps changing their response to an HDHP.Commercial health insurance claims data in a difference-in-differences design was used to evaluate the effect of an employer's offer of an HDHP on 6,627,128 enrollee-years among enrollees with mental health conditions, stratified by having a co-occurring substance use disorder or not.Among enrollees without a co-occurring substance use disorder, an HDHP offer was associated with a 4.8% (95% confidence interval [CI]=2.4%-7.2%) reduction in overall spending on mental health care, despite an 11.3% (95% CI=1.0%-21.6%) increase in spending on mental health-related emergency department visits. Among enrollees with a co-occurring substance use disorder, no significant changes attributable to an HDHP offer were found in most categories of spending on combined mental health and substance use disorder care, apart from a 4.5% (95% CI=1.9%-7.2%) reduction in spending on psychotropic medications.HDHPs may reduce use of necessary care among enrollees with mental health conditions, which could exacerbate undertreatment in this population and result in adverse health outcomes.

The decision to transfer or share an insurable risk is critical for the decision maker’s economy. This paper deals with this decision, starting with the definition of a function that represents the difference between the expected utility of insuring, with or without deductibles, and the expected utility of not insuring. Considering a constant relative risk aversion (CRRA) utility function, we provide a decision pattern for the potential policyholders as a function of their wealth level. The obtained rule applies to any premium principle, any per-claim deductible and any risk distribution. Furthermore, numerical results are presented based on the mean principle, a per-claim absolute deductible and a Poisson-exponential model, and a sensitivity analysis regarding the deductible parameter and the insurer security loading was performed. One of the main conclusions of the paper is that the initial level of wealth is the main variable that determines the decision to insure or not to insure; thus, for high levels of wealth, the decision is always not to insure regardless of the risk aversion of the decision maker. Moreover, the parameters defining the deductible and the premium only have an influence at low levels of wealth.

Medical insurance that pays for the medical expenses of the insured is regarded as being maximally fair, but often leads to the excessive use of medical services, medical expenses rising too rapidly, and the waste of health resources. The deductible and reimbursement ratio defines the part of the cost to be borne by the patient to reduce moral hazard, preventing adverse selection and easing the burden of medical expenses. But will improving the deductible or reducing the reimbursement ratio reduce medical expenses and reduce the medical burden of the insured? By using panel data from 2011 to 2019, this paper examines the effect of the deductible and reimbursement ratio on reducing medical expenses. The following conclusions were obtained: First, the impact of the deductible on medical costs and the medical burden is significant and negative. Specifically, lowering the deductible can reduce medical costs and reduce the medical burden of patients. Second, the impact of the reimbursement ratio on medical expenses and the medical burden is significant and negative, that is, with all other factors remaining equal, an increase in reimbursement ratio will result in a reduction in medical expenses and medical burden. Third, the combined effect of the deductible and reimbursement ratio has a significant impact on both medical expenses and medical burdens. Specifically, changes in the deductible and reimbursement ratio in the same direction can reduce both the medical expenses and the burden on patients. Fourth, based on an analysis in which 31 provinces were divided into economically developed and less developed areas, it was found that the deductible and reimbursement ratio have a certain impact on medical expenses and medical burden; in relatively less developed areas, with increasing per capita GDP, the flow of patients in large hospitals will inevitably increase, and the overall medical expenses will rise.

In this paper, we investigate an optimal insurance design problem in which the insured's risk preference is of the regret-theoretical expected utility type and admissible insurance contracts are set to satisfy both the principle of indemnity and the incentive-compatible condition. When the insurance premium is calculated by the expected value principle, we show that the optimal solution for a regret-averse insured can be in the form of no insurance or partial insurance above a deductible. We obtain a necessary and sufficient condition for the optimality of no insurance and provide a numerical algorithm to derive the optimal partial insurance above a deductible. Notably, the deductible disappears if and only if the insurance premium is actuarially fair. Finally, we carry out a comparative statics analysis to examine the effect of the insured's regret coefficient on the insured's final wealth and insurance demand. When the insurance pricing is actuarially fair, we find that the increase of the regret coefficient incentivizes the insured to purchase less insurance coverage and leads to an increase in risk of the insured's final wealth. However, our numerical analysis indicates that this finding is not always true for unfair insurance pricing.

We consider a reinsurance problem for a mean-variance Stackelberg game with a random time horizon, in which an insurer and a reinsurer are the two players. The reinsurer computes its premium according to the mean-variance premium principle with parameters ( θ , η ) ∈ R + 2 . First, for any pair ( θ , η ) ∈ R + 2 , we compute the per-loss reinsurance strategy that maximizes a mean-variance functional of the insurer's surplus at the end of the random horizon. This reinsurance strategy is excess-of-loss reinsurance with constant proportional reinsurance for losses above the deductible. Then, given the information of what the insurer will choose when offered any mean-variance premium principle, we determine the optimal pair ( θ ⁎ , η ⁎ ) ∈ R + 2 that maximizes the reinsurer's expected surplus at the end of the random horizon. We show that the equilibrium deductible and coinsurance are both independent of the risk aversion parameter of the insurer. We also show that if the claim severity is light-tailed, in the sense that its hazard rate function is non-decreasing, then the equilibrium reinsurance is pure excess-of-loss reinsurance with no loading for the variance of the loss. Moreover, we show that if the claim severity is heavy-tailed, in the sense that its hazard rate function is decreasing, then the equilibrium reinsurance has a non-trivial coinsurance, with a positive loading for the variance of the loss. Finally, we solve four examples to illustrate these latter two, important results.

El presente trabajo plantea como objetivo general determinar la relación que tiene el planeamiento tributario con la determinación del impuesto a la renta en las empresas textiles de la ciudad de Arequipa, caso Artexsurle E.I.R.L., periodo 2020. El estudio corresponde a una investigación básica, de enfoque cuantitativo, de diseño no experimental, transversal, de tipo correlacional, y como instrumento se utilizó un cuestionario con preguntas cerradas, cuyas dimensiones para la variable 1 son: obligaciones, metas y objetivos, pronósticos; y para la variable 2 son: gastos deducibles y gastos no deducibles, el cuestionario fue aplicado al personal del área gerencial, administrativo y contable de la empresa. En los resultados se obtuvieron una fiabilidad estadística del 98.8%. Adicionalmente se tiene los datos siguientes: r=0.863 y el valor de p=0.000 es menor a 0.05. Concluyendo que existe una relación positiva, buena, fuerte y perfecta entre las variables de estudio, y al ser positiva el incremento de la variable planeamiento tributario redundará en la correcta determinación del impuesto a la renta. Recomendando mantener su aplicación la misma que promoverá seguridad tributaria, favoreciendo el pronóstico financiero y los flujos de caja positivos

Background and objectives High-deductible health plans (HDHPs) as a type of consumer-directed health insurance plan aim to control unnecessary service utilization and share the responsibility in payments and care with the patient. Our objective was to systematically pool the medical and non-medical impacts of HDHPs on patients with diabetes. Methods We searched databases, including PubMed, Scopus, Embase, and Wiley, to identify relevant published studies. We outlined the eligibility criteria based on the study population, intervention, comparison, outcome, and types of studies (PICOT). We included peer-reviewed quantitative studies published in English, including quasi-experimental, observational, and cross-sectional studies in this review. We used the narrative data synthesis method to categorize and interpret the results. Results Initial search yielded 149 results. After removing duplicates and screening for relevant titles and abstracts, and reviewing full texts, 11 studies met eligibility criteria. Overall, diabetic patients with HDHP were less likely to adhere to treatment and prescription refills, utilize fewer healthcare services and medications, and more likely to have acute emergency visits than their counterparts enrolled in low-deductible plans. However, the results on overall healthcare costs and the final health outcome were unclear. Conclusions It appears that HDHPs negatively impact low-income diabetic patients by leading them to forgo preventive and primary care services and experience excessive preventable emergency department visits. The socioeconomic characteristics of patients must be considered when developing HDHP policies, and adjustments should be made to HDHPs accordingly.

Objective Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. Methods Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. Results The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). Conclusions Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.

A risk-averse insurance company controls its reserve, modeled as a perturbed Cramer-Lundberg process, by choice of both the premium p and the deductible K offered to potential customers. The surplus is allocated to financial investment in a riskless and a basket of risky assets potentially correlating with the insurance risks and thus serving as a partial hedge against these. Assuming customers differ in riskiness, increasing p or K reduces the number of customers n ( p , K ) and increases the arrival rate of claims per customer λ ( p , K ) through adverse selection, with a combined negative effect on the aggregate arrival rate n ( p , K ) λ ( p , K ) . We derive the optimal premium rate, deductible, investment strategy, and dividend payout rate (consumption by the owner-manager) maximizing expected discounted lifetime utility of intermediate consumption under the assumption of constant absolute risk aversion. Closed-form solutions are provided under specific assumptions on the distributions of size and frequency of claims.

Objective We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs. Summary background data Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. Methods We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A two-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month out-of-pocket costs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure after injury. Results Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1,703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to HDHP enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE. Conclusions Privately insured trauma patients face substantial out-of-pocket costs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.

BACKGROUND: Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. OBJECTIVE: To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. DESIGN: Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). PARTICIPANTS: Enrollees with OUD from a national sample of commercial health insurance plans during 2007–2017 who initiate buprenorphine treatment. MAIN MEASURES: Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. KEY RESULTS: HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. CONCLUSIONS: HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-07094-9.

The purpose of this research is to analyze the influence of marketing strategies on farmers’ catastrophe insurance preferences and willingness to pay (WTP) in rural areas in China. A choice experiment was conducted with 234 rural households in Jiangsu Province, China. A mixed logit model is used. The results show that marketing strategies significantly affect farmers’ preferences and willingness to pay for catastrophe insurance. Farmers prefer village cadres’ marketing, and their willingness to pay is 11.62 yuan/mu higher than that of insurance companies. In addition, the deductible rate has the greatest impact on farmers’ demand for catastrophe insurance and willingness to pay. When the deductible rate is increased, farmers’ willingness to pay is reduced. Farmers’ preferences are heterogeneous. Females, older farmers, families with fewer members, farmers who rarely pay attention to weather forecasts and have less knowledge of catastrophe insurance prefer village cadre marketing. In the promotion of catastrophe insurance, local government should cooperate with insurance companies.

Background: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. Results: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, –5.9 to –2.7; absolute change, –4.5 [95% CI, –6.3 to –2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, –14.0 to –8.6) decrease (absolute change, –1.7 per 10 000 person-years [95% CI, –2.1 to –1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, –1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, –0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. Conclusions: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Knowing how small a violation of stochastic dominance rules would be accepted by most individuals is a prerequisite to applying almost stochastic dominance criteria. Unlike previous laboratory-experimental studies, this paper estimates an acceptable violation of stochastic dominance rules with 939,690 real world data observations on a choice of deductibles in automobile theft insurance. We find that, for all policyholders in the sample who optimally chose a low deductible, the upper bound estimate of the acceptable violation ratio is 0.0014, which is close to zero. On the other hand, considering that most decision makers, such as 99% (95%) of the policyholders in the sample, optimally chose the low deductible, the upper bound estimate of the acceptable violation ratio is 0.0405 (0.0732). Our results provide reference values for the acceptable violation ratio for applying almost stochastic dominance rules. This paper was accepted by Manel Baucells, decision analysis.

High-deductible health plans (HDHPs) require substantial out-of-pocket spending for most services, although medications may be subject to traditional copayment arrangements. This study examined effects of HDHPs on medication out-of-pocket spending and use and quality of care among individuals with bipolar disorder.This quasi-experimental study used claims data (2003-2014) for a national sample of 3,532 members with bipolar disorder, ages 12-64, continuously enrolled for 1 year in a low-deductible plan (≤$500) and then for 1 year in an HDHP (≥$1,000) after an employer-mandated switch. HDHP members were matched to 18,923 contemporaneous individuals in low-deductible plans (control group). Outcome measures were out-of-pocket spending and use of bipolar disorder medications, psychotropics for other disorders, and all other medications and appropriate laboratory monitoring for psychotropics.Relative to the control group, annual out-of-pocket spending per person for bipolar disorder medications increased 20.8% among HDHP members (95% confidence interval [CI]=14.9%-26.7%), and the absolute increase was $36 (95% CI=$25.9-$45.2). Specifically, out-of-pocket spending increased for antipsychotics (27.1%; 95% CI=17.4%-36.7%) and anticonvulsants (19.2%; 95% CI=11.9%-26.6%) but remained stable for lithium (-3.7%; 95% CI=-12.2% to 4.8%). No statistically significant changes were detected in use of bipolar disorder medications, other psychotropics, or all other medications or in appropriate laboratory monitoring for bipolar disorder medications.HDHP members with bipolar disorder experienced a moderate increase in out-of-pocket spending for medications but preserved bipolar disorder medication use. Findings may reflect individuals' perceptions of the importance of these medications for their functioning and well-being.

BACKGROUND: For people with diabetes, adherence to prescribed medications is essential. However, the rising prevalence of high-deductible health plans (HDHPs), and prices of diabetes medications such as insulin, could deter adherence. OBJECTIVE: To assess the impact of HDHP on cost-related medication non-adherence (CRN) among non-elderly adults with diabetes in the US. DESIGN: Repeated cross-sectional survey. SETTING: National Health Interview Survey, 2011–2018. PARTICIPANTS: A total of 7469 privately insured adults ages 18–64 with diabetes who were prescribed medications and enrolled in a HDHP or a traditional commercial health plan (TCP). MAIN MEASURES: Self-reported measures of CRN were compared between enrollees in HDHPs and TCPs overall and among the subset using insulin. Analyses were adjusted for demographic and clinical characteristics using multivariable linear regression models. KEY RESULTS: HDHP enrollees were more likely than TCP enrollees to not fill a prescription (13.4% vs 9.9%; adjusted percentage point difference (AD) 3.4 [95% CI 1.5 to 5.4]); skip medication doses (11.4% vs 8.5%; AD 2.8 [CI 1.0 to 4.7]); take less medication (11.1% vs 8.8%; AD 2.3 [CI 0.5 to 4.0]); delay filling a prescription to save money (14.4% vs 10.8%; AD 3.0 [CI 1.1 to 4.9]); and to have any form of CRN (20.4% vs 15.5%; AD 4.4 [CI 2.2 to 6.7]). Among those taking insulin, HDHP enrollees were more likely to have any CRN (25.1% vs 18.9%; AD 5.9 [CI 1.1 to 10.8]). CONCLUSION: HDHPs are associated with greater CRN among people with diabetes, particularly those prescribed insulin. For people with diabetes, enrollment in non-HDHPs might reduce CRN to prescribed medications. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06937-9.

OBJECTIVE: To test whether out‐of‐pocket costs and negotiated hospital prices for childbirth change after enrollment in high‐deductible health plans (HDHPs) and whether price effects differ in markets with more hospitals. DATA SOURCES: Administrative medical claims data from 2010 to 2014 from three large commercial insurers with plans in all U.S. states provided by the Health Care Cost Institute (HCCI). STUDY DESIGN: I identify employer groups that switched from non‐HDHPs in 1 year to HDHPs in a subsequent year. I estimate enrollees' change in out‐of‐pocket costs and negotiated hospital prices for childbirth after HDHP switch, relative to a comparison group of employers that do not switch plans. I use a triple‐difference design to estimate price changes for enrollees in markets with more hospital choices. Finally, I re‐estimate models with hospital‐fixed effects. DATA COLLECTION: From the HCCI sample, childbearing women enrolled in an employer‐sponsored plan with at least 10 people. PRINCIPAL FINDINGS: Switching to an HDHP increases out‐of‐pocket cost $227 (p

Mandatory health insurance in Switzerland operates on a community-based premium scheme. This can lead to a high financial burden on lower income individuals. Until 2014, premium subsidies were paid as cash transfer or in-kind transfer, providing different incentives to individuals for choosing their health plans. Using a difference-in-differences strategy, the impact of in-kind subsidy transfers on deductible choice and the choice of a cost-saving health plan was evaluated to understand effect heterogeneity based on individual background characteristics. The results indicate that eligible individuals from in-kind transfer cantons in general are incentivized to choose a low deductible plan compared to eligible individuals from cash transfer cantons. This effect is found strongest among female, middle-aged and healthy individuals who have most flexibility in adjusting their health plan choices in response to the financial incentives. Additionally, eligible individuals are less likely to choose a cost-saving health plan compared to a cash transfer canton.

On November 2020, the Law No. 239/2020 for amending and supplementing Law No. 227/2015 on the Fiscal Code introduced an incentive regarding early education. Thus, according to the law mentioned, expenses with early education are not deductible when the income tax is calculated, but taxpayers that incur this type of expenses subside them from the income tax owned, but not exceeding 1,500 RON/month for each child. If the amount exceeded the income tax owed, according to the law for the amendment of the Fiscal Code, the difference could have been subsided, in order, from the payroll tax retained by the taxpayer for the employees, from the VAT owed or from the excise duties owed. Currently, on the basis of the questions related to the way of interpretation and application of the regulations regarding the incentives provided for early education, the government decided to suspend the incentive till the end of 2021. In order to consider the fact that in the first quarter of 2021 there were taxpayers that incurred expenses with early education for which they could have benefited from incentives, the Government Ordinance No. 19/2021 regarding certain fiscal measure, as well as on amending and supplementing certain pronouncements in the fiscal field and, based on this, the Order of the President of the National Agency for Fiscal Administration No. 653/2021 for the approval of the model and of the way of filling and managing the 711 form “Statement of adjustment for the early education expenses”, which states the use of a new form only for those who applied the incentive for early education and had to deduct the amounts spent from other taxes owed as well, not only from the income tax.

In this article, we aim to present accounting and fiscal aspects regarding valuation allowances for tangible fixed assets and intangible assets, for inventories and receivables. All accounting principles must be followed in order to present a true and fair image of the financial statements. Valuation allowances play an important part in outlining the impairment losses incurred by assets, regardless if they are deductible or not.

Background Many cancer survivors face financial difficulties that prevent them from receiving appropriate health care. Racial/ethnic disparities in receipt of health care have been reported among cancer survivors, but recent data for important racial/ethnic subgroups of the US population are lacking. Methods To learn more about barriers to healthcare access faced by cancer survivors, we analyzed data from the NIH “All of Us” Research Program. Data were analyzed about demographic factors and other personal characteristics, personal medical history of cancer, healthcare utilization, and access to care. Results As of November 2020, a total of 5426 participants had a history of cancer (excluding skin cancer). About 88.2% were non‐Hispanic White; 3.9% were Black, African American, or African; 1.3% were Asian; 4.1% were Hispanic, Latino, or Spanish; and 1.2% reported more than one race. Just over one‐half had an annual income of $75,000 or greater. The majority of the participants (71.7%) were college graduates or had an advanced degree. About 47.0%% had private health insurance, 41.0% had Medicare, 6.0% had Medicaid, and the remainder had military, Veterans Affairs, other insurance, or no health insurance. Frequently cited reasons for delayed care in the past 12 months were “had to pay out of pocket for some or all of the procedures,” “deductible was too high/or could not afford the deductible,” “couldn't afford the copay,” “couldn't get time off work,” and “were nervous about seeing a health care provider.” Discussion A minority of cancer survivors who participated in the NIH “All of Us” Program had difficulty paying for health care in the past 12 months. Of particular concern are minorities such as African American and Hispanic cancer survivors along with those who are low income., Many cancer survivors face financial problems that prevent them from receiving timely and recommended health care. A minority of cancer survivors who participated in the NIH “All of Us” Research Program had difficulty paying for health care in the past 12 months. Of particular concern are minorities such as African American and Hispanic cancer survivors along with those who are low income.

The objective of this study is to evaluate the impact of high-deductible health plans on elective surgery (tonsillectomy) in the pediatric population.Cross-sectional study.Health claims database from a third-party payer.Data were reviewed for children up to 18 years of age who underwent tonsillectomy or arm fracture repair (nonelective control) from 2016 to 2019. Incidence of surgery by health plan deductible (high, low, or government insured) and met or unmet status of deductibles were compared.A total of 10,047 tonsillectomy claims and 9903 arm fracture repair claims met inclusion and exclusion criteria. The incidence of tonsillectomy was significantly different across deductible plan types. Patients with met deductibles were more likely to undergo tonsillectomy. In patients with deductibles ≥$4000, a 1.75-fold increase in tonsillectomy was observed in those who had met their deductible as compared with those who had not. These findings were not observed in controls (nonelective arm fracture). For those with met deductibles, those with high deductibles were much more likely to undergo tonsillectomy than those with low, moderate, and government deductibles. Unmet high deductibles were least likely to undergo tonsillectomy.Health insurance plan type influences the incidence of pediatric elective surgery such as tonsillectomy but not procedures such as nonelective repair of arm fracture. High deductibles may discourage elective surgery for those deductibles that are unmet, risking inappropriate care of vulnerable pediatric patients. However, meeting the deductible may increase incidence, raising the question of overutilization.

The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were sub...

Background: Cost-sharing disproportionately affects people with chronic illnesses needing more care. Our qualitative study examined lived experiences navigating insurance benefits and treatment for bipolar disorder, which requires ongoing access to behavioral specialists and psychotropic medications. Methods: Forty semi-structured telephone interviews with individuals with bipolar disorder and employer-sponsored health insurance, or their family caregivers, explored health care needs, coverage details, out-of-pocket (OOP) costs, and perspectives on value. An iterative analytic approach identified salient themes. Results: Most individuals in our sample faced an annual insurance deductible, from $350-$10,000. OOP costs for specialist visits ranged from $0-$450 and for monthly psychotropic medications from $0-$1650. Acute episodes and care for comorbidities, including medication side effects, added to cost burdens. Medication nonadherence due to OOP costs was rare; respondents frequently pointed to the necessity of medications: “whatever it takes to get those”; “it's a life or death situation.” Respondents also prioritized visits to psychiatrist prescribers, though visits were maximally spaced because of cost. Psychotherapy was often deemed unaffordable and forgone, despite perceived need. Interviewees cited limited networks and high out-of-network costs as barriers to specialists. Cost-sharing sometimes led to debt, skimping on nonbehavioral care or other necessities, exacerbated or prolonged mood symptoms, and stress at home. Limitations: Volunteer respondents may not fully represent the target population. Conclusions: Many people with bipolar disorder in US employer-sponsored plans experience undertreatment, hardship, and adverse health consequences due to high cost-sharing. More nuanced insurance benefit designs should accommodate the needs of individuals with complex conditions.