Impact of high deductible health plans and the 2020 public health emergency on alcohol use disorder treatment access, outcomes, and subpopulations

Excessive alcohol use is the 5th-leading risk factor for premature death and serious morbidity. The health and economic burden associated with alcohol use is concentrated in ~14 million adults with alcohol use disorder. Pharmacological and behavioral interventions, especially when combined, reduce alcohol use and related harms and assist long-term recovery. However, only ~5% adults with alcohol use disorder receive formal treatment in health care settings. Recent societal phenomena, namely the rapid rise of high-deductible health plans and reduced health care used due to the 2020 public health emergency, might contribute to delayed alcohol use disorder diagnosis and treatment. Deferred care might especially affect low-income and rural residents. In the last decade, high-deductible plans requiring potentially prohibitive out-of-pocket payments for alcohol use disorder services have expanded rapidly, now covering 57% of workers. The 2020 public health emergency led to stay-at-home orders and closure of nonessential businesses, dramatically reducing healthcare use. The overarching goal of this proposal is to examine major societal factors affecting alcohol use disorder treatment access among lower- versus higher-income populations, including modifiable high-deductible health plans and the 2020 public health emergency. The study will assess alcohol use disorder-related measures before and after 2 key change dates of interest: the date that employers mandate a switch to high-deductible health plans (using a rolling cohort accrual period), and March 2020 when restrictions due to the 2020 public health emergency began. More specifically, the project seeks to: (1) determine the effect of high-deductible health plans on alcohol use disorder diagnosis, treatment, and adverse outcomes; (2) assess whether high-deductible health plans differentially affect alcohol use disorder diagnosis, treatment, and adverse outcomes among key subpopulations; and (3) examine the 4-year impact of the 2020 public health emergency on alcohol use disorder diagnosis, treatment, and adverse outcomes among key subpopulations. The study will draw from an 18-year rolling sample (2007-2024) of ~50 million members aged 18-64 enrolled through a national health insurer. The study will apply rigorous, quasi-experimental interrupted time series designs with segmented regression and segmented survival analyses. We expect that findings will demonstrate the health insurance benefit designs that optimize access to AUD treatment, informing potential modifications to Internal Revenue Service regulations that exempt certain services from high out-of-pocket costs under high-deductible plans. Findings could also help inform policymaking by identifying subgroups at risk of delayed diagnosis and treatment during public health emergencies.