Effect of population-tailored health insurance on cardiovascular disease outcomes and disparities - modified project summary/abstract section health care affordability has become a major problem for…

The National Heart, Lung, and Blood Institute of the Department of Health and Human Services awarded Duke University $1,532,545 on June 5, 2026, under the Cardiovascular Diseases Research program (CFDA 93.837) to analyze the effect of income-based health insurance benefit designs on cardiovascular disease outcomes and disparities among low-income workers.

The research examines whether employers' selective provision of more generous health benefits—such as free cardioprotective medicines or low deductibles—to lower-income employees while offering high-deductible health plans to higher-paid staff improves cardiovascular disease care, outcomes, and total spending. The study leverages a national health insurance claims database spanning 2012–2027 covering approximately 10 million working-age adults to determine health and financial effects of such tailored benefit designs, which approximately 11–18 percent of firms have adopted in recent years.

Duke University's Office of Research Administration is the recipient and place of performance. Work is scheduled to conclude on February 29, 2028. The award is classified as a Project Grant.

Effect of population-tailored health insurance on cardiovascular disease outcomes and disparities - modified project summary/abstract section health care affordability has become a major problem for low-income people enrolled in employer-sponsored health plans. In the last 2 decades, many employers adopted high-deductible health plans (HDHP) that require potentially prohibitive annual out-of-pocket amounts of up to $16,000 per family. Over the same period, as HDHP prevalence exceeded 30% after 2010, adverse cardiovascular disease (CVD) events began rising among working-age adults. Increases might be related to both rising CVD risk factors in younger people and financial barriers to timely care. Studies suggest that increased out-of-pocket costs under hdhps contribute to negative health outcomes. In an attempt to avoid such harms among low-income workers while providing affordable premiums, an increasing number of employers are adopting a novel approach. In recent years, approximately 11-18% of firms have selectively provided more generous health benefits to only their low-income workers. For example, employers might provide free cardioprotective medicines ("preventive drug lists") or low deductibles to hourly workers while executives receive hdhps. Such income-based benefit designs represent a potentially major advance in decades-long efforts to reduce cost-related barriers to care while enhancing cost efficiency in the private U.S. Health system. Such designs could especially improve care for CVD given its disproportionate impact on low-income people. Nevertheless, health and financial effects of such designs are unknown. The overarching goal of this project is therefore to determine whether income-based benefit designs that selectively reduce out-of-pocket costs for low-income people improve CVD care, outcomes, and total spending. Analyses will leverage a large, national health insurance claims database from 2012-2027 to study approximately 10 million working age adults at risk for adverse CVD outcomes. The specific aims are: 1. Assess trends in adoption of income-based benefit designs from 2012-2027. 2. Determine whether employer switches to income-based benefit designs that selectively provide low-cost preventive drug lists to low-income beneficiaries improve CVD outcomes and spending. 3. Examine changes in CVD outcomes and spending when employers switch to income-based benefit designs that selectively provide low-deductible health insurance to low-income beneficiaries. The research will use the most rigorous observational study designs including controlled interrupted time series and segmented survival. Results could demonstrate improved CVD outcomes and reduced employer spending compared with HDHP-only employers. In a health system dominated by cost-prohibitive hdhps and affordability challenges for low-income beneficiaries, such evidence could enhance employer adoption and inform national policymaking efforts to encourage uptake of income-based benefit designs. These efforts could move the U.S. Toward a more efficient and affordable health care system.