Health Care Behaviors and Decision-Making Processes among Enrollees in a State High-Risk Insurance Pool: Focus Group Findings

Abstract

Purpose.

To better understand the relationship between health insurance coverage and health care behaviors of persons with potentially disabling conditions enrolled in a state high-risk insurance pool.

Design.

Six focus groups with risk pool enrollees at two sites.

Setting.

Suburban areas in the state of Kansas.

Participants.

Forty-two individuals 29 to 62 years, all with potentially disabling physical or mental health conditions.

Method.

Qualitative analysis of focus group transcripts using pile sorting and theme identification.

Results.

High premiums and deductibles limit participants' ability to afford basic health services and access to prescription medications despite their middle-class socioeconomic status. Participants report delaying or forgoing needed medical care because of lack of coverage and/or out-of-pocket costs. They employ numerous and potentially dangerous strategies to minimize costs, especially for prescription medications. Some report “saving up” needed procedures until their total costs will exceed that year's deductible.

Conclusion.

Individuals in the risk pool were making medical decisions on the basis of cost rather than need. Many shared stories of medical complications as a result of delayed care, and most expressed stress related to the difficulty of making decisions about their care and use of prescribed medications. The individual, nongroup insurance market, with its higher out-of-pocket costs, may not meet the needs of people with chronic health conditions.