NCHS Data Brief ■ No. 28 ■ February 2010

u.s. department of health and human services

Centers for Disease Control and Prevention

National Center for Health Statistics

Impact of Type of Insurance Plan on Access and Utilization 

of Health Care Services for Adults Aged 18–64 Years With 

Private Health Insurance: United States, 2007–2008 

Robin A. Cohen, Ph.D.

Key findings

Data from the National 

Health Interview Survey

•	 Almost 18% of adults under 

age 65 with private health 

insurance were enrolled in 

some type of high deductible 

health plan (HDHP), including 

5% who were enrolled in a 

consumer-directed health plan 

(CDHP), 2% with a flexible

spending account (FSA) for 

medical expenses, and 12% in

a HDHP-only plan. 

•	 Approximately 17% of

adults aged 18–64 years 

enrolled in an HDHP had 

unmet medical or prescription 

drug needs due to cost, 

compared with 10% among 

adults aged 18–64 years 

enrolled in a traditional health 

plan only (no FSA).

•	 Privately insured adults 

aged 18–64 years with an 

FSA or health savings account 

(HSA) were more likely to 

receive a flu shot or have

contact with an eye doctor in 

the past 12 months than those 

with neither an FSA nor an 

HSA.

National attention to consumer-directed health care has increased following 

the enactment of the Medicare Prescription Drug Improvement and 

Modernization Act of 2003 (P.L. 108–173), which established tax-advantaged

health savings accounts (HSAs) (1). Enrollment in consumer-directed health 

care products has increased over the past several years (2). Consumerdirected health care may enable individuals to have more control over when 

and how they access care, what types of care they use, and how much they 

spend on health care services. This report examines types of private health

plans and their association with utilization and access to health care services 

for adults aged 18–64 years in 2007–2008.

Keywords: High deductible plan • consumer-directed plan • flexible spending 

account • National Health Interview Survey

In 2007–2008, 18% of adults aged 18–64 years with private 

health insurance were enrolled in an HDHP, including 5% 

who were enrolled in a CDHP.

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NCHS Data Brief ■ No. 28 ■ February 2010

■  2  ■

In 2007–2008, four out of five adults aged 18–64 years with private health insurance were

enrolled in a traditional health plan (Figure 1), including 68% without an FSA and 14% with an 

FSA (Traditional plan + FSA).

Adults aged 18–64 years enrolled in an HDHP-only or an HDHP + FSA were 

more likely to report unmet medical or prescription drug needs due to cost 

than adults enrolled in a traditional health plan with or without an FSA. 

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Seventeen percent of adults aged 18–64 years enrolled in an HDHP + FSA and 16.6% enrolled in 

an HDHP-only had an unmet medical or prescription drug need due to cost compared with 9.7%

of adults aged 18–64 years enrolled in a traditional health plan without an FSA (Figure 2). Adults 

enrolled in a traditional plan + FSA were less likely to have unmet medical or prescription drug 

needs (7.6%) compared with adults enrolled in a traditional health plan only. Twelve percent of

adults aged 18–64 years enrolled in a CDHP had an unmet medical or prescription drug need.
NCHS Data Brief ■ No. 28 ■ February 2010

■  3  ■

Adults aged 18–64 years with either an FSA or an HSA were more likely to 

get an influenza vaccination than those without an FSA or an HSA. 

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The percentage of adults aged 18–64 years with private health insurance who received an 

influenza vaccination in the past 12 months was highest among those enrolled in a traditional plan

+ FSA (37.5%), an HDHP + FSA (36.3%), or a CDHP (33.6%) (Figure 3). Adults aged 18–64

years covered by either a traditional plan only (26.7%) or an HDHP-only (25.8%) had lower rates

of receiving an influenza vaccination in the past 12 months.
NCHS Data Brief ■ No. 28 ■ February 2010

■  4  ■

Adults aged 18–64 years with either an FSA or an HSA were more likely to 

have contact with an eye doctor than those without an FSA or an HSA. 

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The percentage of adults aged 18–64 years with private health insurance who had seen or talked 

to an eye doctor in the past 12 months was highest among those enrolled in a HDHP + FSA 

(52.2%), a traditional plan + FSA (48.2%), or a CDHP (45.4%) (Figure 4). Adults aged 18–64 

years covered by either a traditional plan only (36.4%) or an HDHP-only (36.8%) had lower rates 

of having contact with an eye doctor in the past 12 months.

Adults aged 18–64 years with an FSA were more likely to have had contact 

with a medical specialist within the past year than those without an FSA. 

The percentage of adults aged 18–64 years with private health insurance who had contact with 

a medical specialist in the past 12 months was highest among those who had a traditional plan + 

FSA (30.8%) or an HDHP + FSA (34.6%) (see Table). Adults aged 18–64 years with a traditional 

plan only had the lowest rate of contact with a medical specialist in the past 12 months (23.9%).

The percentage of adults aged 18–64 years who had at least one contact with a dentist in the past 

12 months ranged from 68.0% among those enrolled in an HDHP-only plan to 82.5% enrolled 

in a traditional plan + FSA. Almost 71% of adults aged 18–64 years enrolled in a traditional plan

only had contact with a dentist in the past 12 months.

Most privately insured adults aged 18–64 years had a usual source of medical care. The 

percentage who had a usual source of medical care ranged from 87.7% among those enrolled in

an HDHP-only plan to 92.5% among those enrolled in a traditional plan + FSA. 

The percentage of adults aged 18–64 years who had at least one contact with a doctor or other 

health care professional in the past 12 months ranged from 83.8% among those enrolled in an 

HDHP-only to 89.8% for those enrolled in an HDHP + FSA. 
NCHS Data Brief ■ No. 28 ■ February 2010

■  5  ■

Table. Percentage (with standard errors) of privately insured adults aged 18–64 years with selected types of 

health care access and utilization of health services, by type of private health insurance: United States, 2007–

2008

Type of private 

health insurance

Has a usual source 

of medical care1

At least one contact 

with a doctor or 

other health care 

professional in the 

past 12 months

At least one contact 

with a dentist or 

dental professional 

in the past year2

At least one contact 

with a medical 

specialist in the 

past 12 months

Percent (standard error)

Traditional plan3 only 91.0 (0.33) 85.8 (0.39) 70.6 (0.52) 23.9 (0.44)

Traditional plan3 with 

FSA4

92.5 (0.63) 89.3 (0.75) 82.5 (0.88) 30.8 (1.12)

HDHP5 with HSA6

(CDHP)7

90.7 (1.38) 86.0 (1.58) 77.2 (2.10) 27.3 (1.80)

HDHP5 with FSA4 92.3 (1.79) 89.8 (2.14) 77.3 (3.82) 34.6 (3.61)

HDHP5 only 87.7 (0.95) 83.8 (0.98) 68.0 (1.17) 26.0 (1.15)

1

Persons with a usual source of medical care have a place that they usually go to when they are sick or need advice about their health. Persons who mentioned 

that the hospital emergency room was their usual source of medical care were considered not to have a usual source of medical care.

2

The data in this table are based on a question in the survey that asked respondents, “About how long has it been since you last saw a dentist?” Respondents 

are instructed to include all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

3

A traditional plan is a private health plan with an annual deductible of less than $1,100 for self-only coverage or $2,200 for family coverage for 2007 and 2008. 4

FSA is a flexible spending account for medical expenses that must be used within a specified time. 5

HDHP is a high deductible health plan. An HDHP is a private plan with an annual deductible of not less than $1,100 for self-only coverage or $2,200 for family

coverage for 2007 and 2008. 6

HSA is a health savings account. For this analysis HSAs also include Health Reimbusible Accounts (HRAs). Any unspent funds in these accounts are carried

over to subsequent years.

7

CDHP is a consumer-directed health plan. A CDHP is a High Deductible Health Plan (HDHP) coupled with an HSA.

SOURCE: CDC/NCHS, National Health Interview Survey. Estimates are based on household interviews of a sample of the civilian noninstitutionalized 

population.

Summary

Although HDHPs and CDHPs still comprise a relatively small share of the private health 

insurance market, their market share has increased (2). The use of FSAs has also increased. 

Privately insured adults aged 18–64 years with HDHPs were more likely to experience unmet

medical and prescription drug needs compared with individuals enrolled in traditional health 

plans and CDHPs. For privately insured adults aged 18–64 years, having either an FSA or an 

HSA was associated with increased health care utilization for influenza vaccination, dental visits,

and eye doctor visits, which are services typically paid out of pocket by consumers. 

Definitions

Private insurance: Is indicated when respondents report that they were covered at the time of 

the interview by private health insurance through an employer or union, or if they purchased a 

policy on their own. Private health insurance includes managed care such as health maintenance 

organizations (HMOs). It does not include military health plans. 

High deductible health plan (HDHP): Private health plan with an annual deductible of not less 

than $1,100 for self-only coverage or $2,200 for family coverage for 2007 and 2008.

Traditional plan: Private health plan with an annual deductible of less than $1,100 for self-only 

coverage or $2,200 for family coverage for 2007 and 2008.

Consumer-directed health plan (CDHP): An HDHP with a special account to pay for medical 

expenses; unspent funds are carried over to subsequent years. A person is considered to have a
NCHS Data Brief ■ No. 28 ■ February 2010

■  6  ■

CDHP if there was a “yes” response to the following question: “With this plan, is there a special 

account or fund that can be used to pay for medical expenses? The accounts are sometimes 

referred to as Health Savings Accounts (HSAs), Health Reimbursement Accounts (HRAs), 

Personal Care Accounts, Personal medical funds, or Choice funds, and are different from 

Flexible Spending Accounts.”

Health Savings Account (HSA): For this report, HSAs also includes HRAs.

Flexible spending account (FSA): Account that is offered by some employers to allow employees 

to set aside pre-tax dollars of their own money for their use throughout the year to reimburse

themselves for their out-of-pocket expenses for health care. For this type of account, any money

remaining in the account at the end of the year, following a short grace period, is lost to the 

employee. A person was considered to by covered by an FSA based on a “yes” response to 

the question “Do you or anyone in your family have a Flexible Spending Account for health 

expenses? These accounts are offered by some employers to allow employees to set aside pre-tax 

dollars of their own money for their use throughout the year to reimburse themselves for their 

out-of-pocket expenses for health care. With this type of account, any money remaining in the 

account at the end of the year, following a short grace period, is lost to the employee.”

Persons who were covered by a CDHP and who also had a family member with an FSA were 

considered not to be covered by an FSA. 

Dental contact: Dental contact is based on a question in the survey that asked respondents,

“About how long has it been since you last saw a dentist?” Respondents are instructed to include 

all types of dentists, such as orthodontists, oral surgeons, and all other dental specialists, as well 

as dental hygienists. 

Doctor or other health professional: Doctor refers to medical doctor (M.D.) and osteopathic 

physician (D.O.), including general practitioners and all types of specialists (such as internists, 

gynecologists, obstetricians, psychiatrists, and ophthalmologists). Other health care professional 

includes physician assistants, psychologists, nurses, physical therapists, chiropractors, etc.

Emergency room visit: Includes emergency room visits that resulted in a hospital admission.

Influenza vaccination: Includes both the flu shot and the nasal spray.

Doctor or other health care professional contact: This may include a contact while a person 

is in the hospital as well as a contact from a home visit, but not a contact made to arrange 

appointments. 

Unmet need: A person was considered to have an unmet need if he or she delayed or did not get 

medical care due to cost or did not get a prescription drug due to cost in the past 12 months.

Usual source of care: Usual source of care was measured by asking the respondent, “Is there a 

place that you USUALLY go when you are sick or need advice about your health?” Persons who 

report the emergency department as their usual source of care are defined as having no usual

source of care in this report.

Most access and utilization measures in this report are based on the 12 months prior to interview, 

with the exception of a usual source of care. Usual source of care is a person’s status at the time
NCHS Data Brief ■ No. 28 ■ February 2010

■  7  ■

of interview. Insurance coverage is also a person’s status at the time of interview. Therefore, an

individual’s insurance status may have been different at the time health services were sought or

received. This analysis does not take into account single service dental plans, which may have an 

impact on use of dental services.

Data source and methods

Data from the 2007 and 2008 National Health Interview Survey (NHIS) were used for

this analysis. NHIS collects information about the health and health care of the civilian 

noninstitutionalized population in the United States. Interviews are conducted in the respondents’

households primarily, but follow-ups in order to complete interviews may be conducted over 

the telephone. Questions about health insurance coverage are asked of family respondents in the 

family component of the survey. The questions may be viewed on the NHIS website:

http://www.cdc.gov/nchs/nhis.htm. Most questions on access and utilization are from the sample

adult component of the NHIS. However, questions on unmet medical need due to cost are from

the family core component of the NHIS. Only persons aged 18–64 years with private health 

insurance were included in this analysis. The questions about HDHPs, CDHPs, and FSAs were

first included in the 2007 NHIS. Detailed questions about private health insurance plans are asked

on a plan basis. Information is collected on up to four private health insurance plans per family. 

Questions about HDHPs and CDHPs were asked for each private health insurance plan. The 

question about FSAs was asked on a family basis and includes all persons in the family without

regard to insurance status. In 2007 and 2008, 92,450 persons aged 18–64 years were included in

the family core component on the NHIS and 36,147 persons aged 18–64 years were included in

the sample adult component of the NHIS. 

NHIS is designed to yield a nationally representative sample, and this analysis uses weights to 

produce national estimates. Data weighting procedures are described in more detail elsewhere 

(3) (http://www.cdc.gov/nchs/nhis/methods.htm). Point estimates and estimates of 

corresponding variances for this analysis were calculated using the SUDAAN software package 

(4) to account for the complex sample design of the NHIS. The Taylor series linearization

method was chosen for variance estimation. All estimates shown meet the National Center for 

Health Statistics (NCHS) standard for having a relative standard error less than or equal to 30%.

Differences between percentages were evaluated using two-sided significance tests at the 0.05

level. Terms such as “similar” and “no difference” indicate that the statistics being compared were 

not significantly different. Lack of comment regarding the difference between any two statistics

does not necessarily suggest that the difference was tested and found to not be significant.

NHIS is conducted continuously throughout the year by interviewers of the U.S. Census Bureau 

for the Centers for Disease Control and Prevention’s NCHS. For further information about NHIS,

visit the NCHS website: http://www.cdc.gov/nchs/nhis.htm.

About the author

Robin A. Cohen is with the Centers for Disease Control and Prevention’s National Center for

Health Statistics, Division of Health Interview Statistics.
NCHS Data Brief ■ No. 28 ■ February 2010

References

1. United States Government Accountability Office. Consumer-directed

health plans: Early enrollee experiences with health savings accounts and

eligible health plans. GAO–06–798. Washington. 2006.

2. Martinez ME, Cohen RA. Health insurance coverage: Early release of 

estimates from the National Health Interview Survey, January–June 2009. 

Hyattsville, MD: National Center for Health Statistics. December 2009. 

Available from: http://www.cdc.gov/nchs/nhis.htm.

3. Botman SL, Moore TF, Moriarity CL, Parsons VL. Design and 

estimation for the National Health Interview Survey, 1995–2004. National 

Center for Health Statistics. Vital Health Stat 2(130). 2000.

4. Research Triangle Institute. SUDAAN (Release 9.1). Research Triangle 

Park, NC: Research Triangle Institute. 2004.

Suggested citation

Cohen RA. Impact of type of insurance 

plan on access and utilization of health care 

services for adults aged 18–64 years with 

private health insurance: United States, 

2007–2008. NCHS data brief, no 28. 

Hyattsville, MD: National Center for Health 

Statistics. 2010.

Copyright Information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to

source, however, is appreciated.

National Center for Health 

Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Associate 

 Director for Science

Division of Health Interview Statistics

Jane F. Gentleman, Ph.D., Director

U.S. Department of

Health & Human Services First Class mAIL

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ISSN 1941–4927 (Print ed.)

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CS209773

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DHHS Publication No. (PHS) 2010–1209