Health Care-Related Savings Accounts, Health Care Expenditures, and Tax Expenditures.

Importance: Approximately 30% of US families with employer-sponsored health insurance, disproportionately drawn from high-income groups, benefit from flexible spending accounts (FSAs) or health savings accounts (HSAs). The combined association through both out-of-pocket spending and premiums of these tax-favored accounts with health care expenditures and tax expenditures remain uncertain. Objective: To compare the health care and health-related tax expenditures among families holding FSAs, HSAs, or neither type of account. Design, Setting, and Participants: This cross-sectional study used family-level data from the Medical Expenditure Panel Survey from January 1, 2011, to December 31, 2019, and conducted regression models, controlling for demographic and socioeconomic characteristics, chronic conditions, prior health care expenditures, and marginal tax rates to analyze how holding tax-favored accounts is associated with families' health care spending and tax expenditures. The sample was restricted to families included in the survey for 2 years, with no members 65 years or older, and with at least 1 policyholder covered (only) by full-year employer-sponsored insurance. Data were analyzed from December 1, 2023, to April 30, 2024. Exposures: Holding FSAs or HSAs. Main Outcomes and Measures: Out-of-pocket and insurance-paid health expenditures overall and by service were measured. Health-related tax expenditures were based on tax-excluded insurance premiums and tax-sheltered out-of-pocket expenses. Results: Of the 17 038 families included in the study sample, 2628 held FSAs (weighted 17%) and 1845 (weighted 13%) held HSAs. In regression-adjusted models, families with FSAs spent a mean of 20% or $2033 (95% CI, $789-$3276) more on health care annually than non-account holding families, largely due to increased insurer-paid expenses. Families with HSAs spent a mean of 44% or $697 (95% CI, $521-$873) more on out-of-pocket expenditures and had insignificantly higher insurance-paid expenditures than families without accounts, resulting in overall expenditures comparable to those of non-account holders. The additional tax expenditures associated with FSAs were a mean of $1306 (95% CI, $536-$2076) annually per family. Both types of funds were associated with significant increases in tax expenditures from additional office-based visits ($445 [95% CI, $244-$645] for FSAs and $174 [95% CI, $11-$336] for HSAs), outpatient visits ($330 [95% CI, $132-$528] for FSAs and $250 [95% CI, $15-$485] for HSAs), dental visits ($180 [95% CI, $126-$233] for FSAs and $165 [95% CI, $104-$226] for HSAs), and vision care ($36 [95% CI, $28-$45] for FSAs and $52 [95% CI, $40-$64] for HSAs). Conclusions and Relevance: Participation in FSAs is associated with higher health care expenditures and tax expenditures, while HSAs are not associated with reduced expenditures. Tax policy could be better targeted to enhance insurance coverage and health care accessibility.

Framing Flexible Spending Accounts: A Large-Scale Field Experiment on Communicating the Return on Medical Savings Accounts.

Tax-preferred health savings devices such as Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) offer employees potentially valuable financial instruments for directing pre-tax earnings to eligible medical expenses. Despite their increasing popularity as an employee benefit, however, there is little causal evidence around individual demand for these accounts. This paper seeks to address this gap in the literature, reporting on a randomized controlled field experiment conducted with over 11,000 U. S federal employees in 2017 in order to evaluate the effectiveness of targeted messages designed to increase FSA contributions. Our results suggest that the provision of basic information about FSAs delivered via an emailed employee newsletter did not affect the likelihood of contribution or the contribution level. The addition of statements about the absolute returns or relative returns offered by the accounts similarly had no significant effects, and these null effects are observed despite relatively high email open rates. We discuss explanations for the null results and the policy implications of findings from what appears to be the first health economics experiment analyzing tax incentives around health care savings.

Health insurance design and conservative therapy for low back pain.

OBJECTIVES: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP). STUDY DESIGN: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse. METHODS: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics. RESULTS: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy. CONCLUSIONS: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

Financial burden of healthcare utilization in consumer-directed health plans.

OBJECTIVES: To evaluate the impact of enrollment in a consumer-directed health plan (CDHP) on out-of-pocket (OOP) spending and on the financial burden associated with healthcare utilization. STUDY DESIGN: Using commercial claims data from 2011 through 2013, we estimated difference-in-differences models that compared changes in outcomes for individuals who switched to CDHPs (CDHP group) with outcome changes for individuals who remained in traditional plans (traditional plan group). METHODS: We estimated the impact of CDHP enrollment on OOP spending at the point of care and on having high financial burden, defined as whether an enrollee spent 3% or more of household income on OOP spending. Additionally, we assessed these outcomes for 2 subgroups: those with lower household income and those with chronic conditions. RESULTS: Within the first year of CDHP enrollment, CDHP enrollees experienced a mean marginal increase in OOP spending of $285 (41% increase; 95% CI, $271-$299; P <.001) relative to traditional plan enrollees. The lower-income and chronic conditions subgroups experienced mean marginal increases in OOP costs of $306 (44% increase; 95% CI, $257-$353; P <.001) and $387 (56% increase; 95% CI, $339-$435; P <.001), respectively. The probability of an enrollee having excessive financial burden increased by 4.3 percentage points (95% CI, 4.0-4.6; P <.001) for the full CDHP sample. These effects were about 3 times larger for the lower-income subgroup (12.3 percentage points; 95% CI, 10.7-13.8; P <.001) and 2 times larger for the chronic conditions subgroup (8.0 percentage points; 95% CI, 6.9-9.1; P <.001). CONCLUSIONS: CDHP enrollment led to a significant increase in financial burden associated with healthcare utilization, especially for those with lower incomes and those with chronic conditions.

Impact of consumer-directed health plans on low-value healthcare.

OBJECTIVES: To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending. STUDY DESIGN: We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit. METHODS: Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan. RESULTS: Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending. CONCLUSIONS: CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.

Your Health Is Priceless.

Your health is priceless but health insurance can be expensive. As open enrollment begins, we show you how to avoid costly mistakes and still get the coverage you need.

Looking Under the Hood of the Cadillac Tax.

One effect of the Affordable Care Act's "Cadillac tax" (now delayed until 2020) is to undo part of the existing federal tax preference for employer-sponsored insurance. The specific features of this tax on high-cost health plans--notably, the inclusion of tax-favored savings vehicles such as health savings accounts (HSAs) in the formula for determining who is subject to the tax--are designed primarily to maximize revenue and minimize coverage disruptions, not to reduce health spending. Thus, at least initially, these savings accounts, rather than enrollee cost-sharing or other plan features, are likely to be affected most by the tax as employers act to limit their HSA contributions. Because high earners are the ones benefiting most from tax-preferred accounts, the high-cost plan tax will probably be more progressive than prior analyses have suggested, while having only a modest impact on total health spending.

Medical savings accounts: assessing their impact on efficiency, equity and financial protection in health care.

Medical savings accounts (MSAs) allow enrolees to withdraw money from earmarked funds to pay for health care. The accounts are usually accompanied by out-of-pocket payments and a high-deductible insurance plan. This article reviews the association of MSAs with efficiency, equity, and financial protection. We draw on evidence from four countries where MSAs play a significant role in the financing of health care: China, Singapore, South Africa, and the United States of America. The available evidence suggests that MSA schemes have generally been inefficient and inequitable and have not provided adequate financial protection. The impact of these schemes on long-term health-care costs is unclear. Policymakers and others proposing the expansion of MSAs should make explicit what they seek to achieve given the shortcomings of the accounts.

Health Savings Accounts: An Emerging Cornerstone of the Health-Wealth Bridge?.

Several trends may help make health savings accounts (HSAs) a ubiquitous part of Americans' financial planning. When one looks at the totality of factors, it is easy to see how HSAs can become a vital connection be- tween active and retiree health care needs and between retirement income and retiree medical needs. However, it is also easy to see the clouds over the horizon that could stall HSA growth in coming years. This article discusses both.

The HSA in Your Future: Defined Contribution Retiree Medical Coverage.

In 2004, when evaluating health savings account (HSA) business opportunities, I predicted: "Twenty-five years ago, no one had ever heard of 401(k); 25 years from now, everyone will have an HSA." Twelve years later, growth in HSA eligibility, participation, contributions and asset accumulations suggests we just might achieve that prediction. This article shares one plan sponsor's journey to help employees accumulate assets to fund medical costs-while employed and after retirement, It documents a 30-plus-year retiree health insurance transition from a defined benefit to a defined dollar structure and culminating in a full-replacement defined contribution structure using HSA-qualifying high-deductible health plans (HDHPs) and then redeploying/repurposing the HSA to incorporate a savings incentive for retiree medical costs.

Insurance Accounts: The Cultural Logics of Health Care Financing.

The financial exuberance that eventually culminated in the recent world economic crisis also ushered in dramatic shifts in how health care is financed, administered, and imagined. Drawing on research conducted in the mid-2000s at a health insurance company in Puerto Rico, this article shows how health care has been financialized in many ways that include: (1) privatizing public services; (2) engineering new insurance products like high deductible plans and health savings accounts; (3) applying financial techniques to premium payments to yield maximum profitability; (4) a managerial focus on shareholder value; and (5) prioritizing mergers and financial speculation. The article argues that financial techniques obfuscate how much health care costs, foster widespread gaming of reimbursement systems that drives up prices, and "unpool" risk by devolving financial and moral responsibility for health care onto individual consumers.

The effect of Health Savings Accounts on group health insurance coverage.

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2-3 percentage point increase in their group insurance coverage.

Health Savings Account Balances, Contributions, Distributions, and Other Vital Statistics, 2014: Estimates from the EBRI HSA Database.

The Employee Benefit Research Institute (EBRI) maintains a wealth of data collected from various health savings account (HSA) providers. The EBRI HSA Database contains 2.9 million accounts with total assets of $5 billion as of Dec. 31, 2014. This Issue Brief is the second annual report drawing on cross-sectional data from the EBRI HSA Database. It examines account balances, individual and employer contributions, annual distributions, investment accounts, and account-owner demographics for 2014. Enrollment in HSA-eligible health plans is estimated to be about 17 million policyholders and their dependents, and it has also been estimated that there are 13.8 million accounts holding $24.2 billion in assets as of Dec. 31, 2014. Almost 4 in 5 HSAs have been opened since the beginning of 2011. The average HSA balance at the end of 2014 was $1,933, up from $1,408 at the beginning of the year. Average account balances increased with the age of the owner of the account. Account balances averaged $655 for owners under age 25 and $5,016 for owners ages 65 and older. About 6 percent of HSAs had an associated investment account. End-of-year 2014 balance averages were higher in accounts with investment assets. Thirty-seven percent of HSAs with investment assets ended 2014 with a balance of $10,000 or more, whereas only 4 percent of HSAs without investment assets had such a balance. Among HSAs with investment assets, accounts opened in 2014 ended the year with an average balance of $6,544; whereas those opened in 2005 had an average balance of $19,269 at the end of 2014. HSAs with either individual or employer contributions accounted for 70 percent of all accounts and 86 percent of the assets in 2014. Four percent of these accounts ended the year with a zero balance. On a yearly average, individuals who made contributions deposited $2,096 to their account. HSAs receiving employer contributions received $1,021 a year, on average. Four-fifths of HSAs with a contribution also had a distribution for a health care claim during 2014. Among HSAs with claims, the average amount distributed for health care claims was $1,951. Distributions for health care claims increased with age, with the exception of those ages 65 and older. Average annual distributions were $636 for account owners under age 25; $2,373 for account owners ages 55-64; and $2,124 for account owners ages 65 and older. Average annual distributions were higher for accounts that were older. However, the likelihood of taking a distribution for health care claims was higher among accounts opened more recently.