For many deciding on a health insurance plan in the United States, several aspects of the total health care cost come to mind such as the premium, co-payments, out-of-pocket spending, and the deductible. The deductible is an important component of cost-sharing for the insurance plan because it is the amount a policy holder must pay out-of-pocket for health care services until a certain amount is met. Once the amount required by the deductible is met, an insured individual obtains assistance in covering a percentage of the cost for health care services. After meeting the deductible, the reduction in out-of-pocket spending helps patients who must undertake high medical costs.

Some patients face high deductibles that may not be easily met. Many consumers with higher deductibles would ideally become more prudent in making health care decisions due to the initial high upfront cost, and this would in turn reduce overutilization of services [1,2]. However, patients with high deductibles have been known to delay elective, non-emergent surgery towards the end of the year until their deductible has been met to avoid initial high out-of-pocket spending [3]. In otolaryngology, the relationship between the expansion of higher deductible health plans and ear surgery volume has been observed, and there were notable increases towards the end of the year [4]. For parents of pediatric patients, they may also forgo tonsillectomy and/or tympanostomy tube placement for their child due to an unmet deductible and high out-of-pocket spending [5]. Chronically ill patients such as with COPD have also been observed to delay and forgo care due to high deductibles [6]. This behavior led to increased frequency of emergency room visits and hospitalizations, and in turn increased health care spending. For the sickest patients needing increased usage of health care services, it is detrimental to forgo health care due to cost, and many patients have been shown to make their decisions based on cost [1,[7], [8], [9]].

High deductible health plans (HDHPs) are not new, and in 2007 it was noted that at least 18 % of insured employees had this form of insurance [10]. There was an associated expansion in HDHPs and rising deductibles when the Affordable Care Act (ACA) was passed on March 23, 2010 [[11], [12], [13], [14], [15]]. Despite increased enrollment in HDHPs that had a lower premium, many patients still experienced high out-of-pocket spending. Some reasons for an increase in deductibles are an increase in health care and pharmaceutical costs, but a major reason for the growth in deductibles is the increased enrollment in HDHPs [16]. There was a notable increase in enrollment in HDHPs for patients with cancer of the breast, colon, or lung, and these patients were found to have experienced an amplified increase in out-of-pocket spending [17]. For these patients with a likely financial burden of a cancer diagnosis, delaying or foregoing health care has not yet been investigated.

This study aims to illustrate how financial awareness of rising deductibles contributes to a change in the rate and postoperative outcomes for thyroidectomies. In relation to major health care policy changes and guidelines, this study will also evaluate the effect of repealing the ACA's individual mandate on December 22, 2017, and if patients are financially sensitive after changes to the 2015 American Thyroid Association (ATA) Management Guidelines. There are no studies that have investigated the relationship between expansion/rise of deductibles and thyroid surgery, but there are prior studies in otolaryngology that have found a correlation with ear surgeries and adenotonsillectomy [4,5]. Since patients tend to make decisions about health care based on cost, the authors expect that the cases of thyroidectomy will increase towards the end of the year. The authors also anticipate that there will be an increased rate of postoperative complications for patients that delayed surgery. With the TriNetX database, health care data will be evaluated by comparing the first and fourth quarters of the fiscal year. The fiscal year is January 1st to December 31st, in which the first quarter is from January 1st to March 31st, while the fourth quarter is October 1st to December 31st.