Kullgren and his research colleagues used nationally representative data to explore the relationship between HDHP enrollment and smoking among U.S. adults. After controlling for other factors, they found that associations between HDHP enrollment and smoking are only found among adults who could choose an HDHP, and not among adults who could not choose their plan.
Yes, it is true, as insurance companies contend, people in HDHPs smoke less, but it is not because they were forced into more-skin-in-the-game HDHPs. It is because HDHPs attract more nonsmokers than smokers to start with.
Kullgren's research shows that when a company goes total replacement, smokers continue to puff away. The results are also consistent with findings from the RAND Health Insurance Experiment of several years ago that showed there were no lower rates of unhealthy behaviors among individuals who had been randomly assigned to plans with high levels of cost-sharing.
"Our findings suggest that offering only an HDHP to employees with the expectation that this will reduce rates of unhealthy behaviors like smoking -- as a growing number of employers are now doing -- may not have its intended effects," Kullgren and his colleagues wrote.
If, despite Kullgren's findings, the trend toward total replacement continues unabated, as it most assuredly will, it will not be because HDHPs make us behave any differently. It will be because insurers and employers know they can use them to shift more of the cost of care to us.
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