2. No associations between HDHP enrollment and behavioral risk factors among individuals with no choice of health plans

3. Negative statistically-significant associations between HDHP enrollment and behavioral risk factors only among individuals with the potential to self-select into a plan

4. Associations between HDHP enrollment and favorable behavioral risk factors appear driven by individuals who chose their plans

5. Cross-sectional analysis of nationally-representative data from the 2007 Health Tracking Household Survey

6. Analytic sample comprised of adults age 18 to 64 enrolled in one private health insurance plan

7. Individuals with an annual deductible of at least $1,100 per person or $2,200 per family classified as HDHP enrollees

8. All others classified as traditional plan enrollees

9. Individuals analyzed in 3 coverage source groups ranging from the least to the greatest potential for plan self-selection:

10. Univariate logistic regression to measure unadjusted associations between HDHP enrollment and obesity and smoking

12. One policy tool promoted as a way to encourage patients to modify behavioral risk factors like obesity and smoking is high-deductible health plans (HDHPs)

13. Lower rates of behavioral risk factors among HDHP enrollees have been cited as evidence that these plans are responsible for encouraging healthy lifestyle behaviors

14. These analyses fail to account for important factors that may explain these associations

15. Potential confounders

16. Health plan self-selection

18. Greater evidence for a selection effect than for a health-promoting effect as an explanation for negative associations between HDHP enrollment and behavioral risk factors

20. To determine whether associations between HDHP enrollment and rates of obesity and smoking differ by the degree to which individuals can self-select into a health planUnderstanding behavioral risk factors in high-deductible health plans Jeffrey T. Kullgren, MD, MPHa,b,c; Kevin G. Volpp, MD, PhDb,c,d,e; Daniel E. Polsky, PhDc,d,e aRobert Wood Johnson Foundation Clinical Scholars; bPhiladelphia Veterans Affairs Medical Center; cLeonard Davis Institute of Health Economics Center for Health Incentives, University of Pennsylvania; dDivision of General Internal Medicine, University of Pennsylvania School of Medicine; eThe Wharton School, University of Pennsylvania Association between HDHP enrollment and obesity Association between HDHP enrollment and smoking *Unadjusted odds of outcome relative to traditional plan enrollees among all privately insured adults **Odds of outcome relative to traditional plan enrollees with same coverage source and adjusted for gender, age, annual household income, race/ethnicity, education, risk tolerance, employment status, marital status, MSA category, and US Census region