Annual patient out-of-pocket costs were 1.6 to 2.4 times as high to receive recommended care in HDHPs vs non-HDHPs, with absolute differences ranging from $63.68 to $85.85.
Key Findings
Results
Adults with diabetes enrolled in HDHPs faced significantly higher annual out-of-pocket costs for guideline-concordant care compared to non-HDHP enrollees.
Estimated annual OOP cost for guideline-concordant diabetes care was $153.91 (95% CI, $150.18-$157.64) in HDHPs vs $68.06 (95% CI, $66.34-$69.78) in non-HDHPs (P < .001).
This represents approximately a 2.3-fold difference in OOP costs between HDHP and non-HDHP enrollees for diabetes care.
The absolute difference in annual OOP costs for diabetes care was approximately $85.85.
Study used 2022-2023 national commercial insurance claims data with entropy balancing and generalized linear models with geographic fixed effects.
Results
Adults with hypertension enrolled in HDHPs faced significantly higher annual out-of-pocket costs for guideline-concordant care compared to non-HDHP enrollees.
Estimated annual OOP cost for guideline-concordant hypertension care was $128.94 (95% CI, $127.25-$130.64) in HDHPs vs $53.89 (95% CI, $53.20-$54.58) in non-HDHPs (P < .001).
This represents approximately a 2.4-fold difference in OOP costs between HDHP and non-HDHP enrollees for hypertension care.
The absolute difference in annual OOP costs for hypertension care was approximately $75.05.
Results
Adults with comorbid diabetes and hypertension enrolled in HDHPs faced significantly higher annual out-of-pocket costs for guideline-concordant care compared to non-HDHP enrollees.
Estimated annual OOP cost for guideline-concordant care for comorbid diabetes and hypertension was $164.18 (95% CI, $160.93-$167.44) in HDHPs vs $100.60 (95% CI, $98.80-$102.39) in non-HDHPs (P < .001).
This represents approximately a 1.6-fold difference in OOP costs between HDHP and non-HDHP enrollees for comorbid care.
The absolute difference in annual OOP costs for comorbid diabetes and hypertension care was approximately $63.68.
The comorbid condition group showed the smallest relative difference but the highest absolute OOP costs in both plan types.
Results
Across all chronic conditions studied, annual patient OOP costs were 1.6 to 2.4 times as high to receive recommended care in HDHPs vs non-HDHPs.
The magnitude of the absolute difference in OOP costs ranged from $63.68 to $85.85 across the three condition groups.
Authors note that 'the magnitude of the difference in OOP costs was relatively small' in absolute terms.
Estimates were weighted to ensure observed costs were representative of the full sample of chronically ill persons.
All between-group comparisons were statistically significant at P < .001.
Methods
The study cohort comprised 539,590 adults receiving guideline-concordant care for diabetes, hypertension, or both, drawn from national commercial insurance claims.
Participants were adults aged 18 to 64 years with employer-sponsored insurance and previously diagnosed diabetes, hypertension, or both.
Data were from 2022 to 2023 national commercial insurance claims; data were analyzed from July 2025 to April 2026.
After entropy balancing, groups exhibited mean covariate balance: males represented 57.9% of HDHP enrollees and 57.8% of non-HDHP enrollees.
Age distributions were similar across groups, with 45.4% of both HDHP and non-HDHP enrollees aged 55 to 64 years.
To enter the cohort, persons had to have already received guideline-concordant care for their chronic illnesses.
Background
HDHPs are associated with reduced use of care, including medically necessary care, but the magnitude of OOP cost burden for guideline-concordant chronic illness care had been poorly understood prior to this study.
HDHPs enroll a substantial share of privately insured Americans.
Prior HDHP studies primarily evaluated health care utilization rather than quantifying OOP cost magnitude.
The study was designed to fill this gap by estimating OOP costs required to receive guideline-concordant care in HDHPs vs non-HDHPs.
Authors describe findings as providing 'novel evidence quantifying the magnitude of cost burden experienced by chronically ill patients under various insurance mechanisms.'
What This Means
This research suggests that Americans with chronic conditions like diabetes and high blood pressure pay substantially more out of their own pockets for recommended medical care when enrolled in high-deductible health plans (HDHPs) compared to traditional insurance plans. Analyzing insurance claims from over 539,000 adults in 2022-2023, researchers found that people with HDHPs paid roughly 1.6 to 2.4 times more annually for the same guideline-recommended care. For example, a person with diabetes in an HDHP paid about $154 per year out-of-pocket versus about $68 for someone in a traditional plan — a difference of roughly $86 per year.
While these absolute dollar differences ($64 to $86 per year depending on the condition) may appear modest, they represent costs for only the minimum recommended care. The study is notable because it focused exclusively on people who were already successfully receiving recommended care, meaning these cost differences reflect what it takes just to maintain basic, evidence-based disease management — not elective or extra care. People with both diabetes and high blood pressure faced the highest total out-of-pocket costs ($164 in HDHPs vs. $101 in non-HDHPs annually).
This research matters because HDHPs cover a large and growing share of working-age Americans, and higher cost-sharing has previously been linked to people skipping or delaying necessary medical care. By quantifying exactly how much more chronically ill patients must pay for the same recommended care under HDHPs, this study provides concrete evidence about the financial barriers these plans create for people managing ongoing health conditions. The findings add important context to ongoing policy discussions about how insurance design affects access to essential health care.