Applied Health Economics and Health Policy

, Volume 16, Issue 3, pp 367–380 | Cite as

Out of Pocket Costs and Health Insurance Take-Up Rates

  • Vasilios D. Kosteas
  • Francesco Renna
Original Research Article



Over the first ten years of this century, the share of the US population covered by employer-sponsored health insurance plans experienced a significant decline. A decrease in the take-up rate accounts for about a quarter of this decline. Usually, the increasing share of the premium that is paid by workers is used to explain the decline in the take-up rate. However, in recent years the increase in copayments, deductible and coinsurance rate has far outpaced the increase in worker contribution.


In this study we analyze the impact of out-of-pocket (OOP) costs, which consist of both workers’ contribution toward the premium and expected expenditures, on the take-up rate for firms that offer multiple plan types.


Using data from the Employer Health Benefits Survey we estimated a pooled ordinary least squares and a fixed effects model. Since we have information about different types of health insurance plans offered by the firm, we derive the cross-price elasticity of coverage.


Our fixed effects estimations suggest that workers respond to an increase in the out-of-pocket contributions for Health Maintenance Organization (HMO) plans by switching to PPO plans without impacting the overall take-up rate, while workers respond to increases in the out-of-pocket contribution for Preferred Provider Organization (PPO) plans by switching to HMO plans or dropping out of the group coverage.


In general, we found that the estimated elasticities are too small to explain the overall drop in take-up rates even in light of the large increases in required worker contributions and expected expenditures. Still, we highlight the growing importance of expected expenditures in explaining take-up rates.


Author Contributions

This research project is part of VDK and FR research agenda on firms offering multiple health insurance plans. The idea for this study was developed during a meeting between VDK and FR. FR contributed to survey of the literature review and the development of the theoretical model. VDK worked on the data assembly and empirical estimation. All authors contributed to revisions of the manuscript.

Compliance with Ethical Standards

The procedures followed in this study were in accordance with the ethical standards. Only secondary publicly available data was utilized. VDK and FR do not have any conflict of interest and have received no funding for this study.

Data availability

the data that support the findings of this study are available from Kaiser Family Foundation/Health Research & Educational Trust, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Family Foundation/Health Research & Educational Trust.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of EconomicsCleveland State UniversityClevelandUSA
  2. 2.Department of EconomicsThe University of AkronAkronUSA

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