United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Health, 

Committee on Ways and Means, House of 

Representatives

HEALTH SAVINGS 

ACCOUNTS 

Participation Grew, and 

Many HSA-Eligible Plan 

Enrollees Did Not Open 

HSAs while Individuals Who 

Did Had Higher Incomes 

Statement of John E. Dicken 

Director, Health Care 

For Release on Delivery

Expected at 10:30 a.m. EDT 

Wednesday, May 14, 2008

 

GAO-08-802T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 14, 2008

HEALTH SAVINGS ACCOUNTS 

Participation Grew, and Many HSA-Eligible Plan 

Enrollees Did Not Open HSAs while Individuals Who 

Highlights of GAO-08-802T, a testimony Did Had Higher Incomes

before the Subcommittee on Health, 

Committee on Ways and Means, House of 

Representatives 

With health care spending 

increasing, Congress enacted 

legislation effective in 2004 

establishing Health Savings 

Accounts (HSA) to be coupled with

eligible high-deductible health 

plans. The novel structure of 

eligible health plans coupled with 

HSAs has raised questions about

who selects them and how they are 

used. Proponents contend that the

lower premiums of the health plans

and the tax-free savings potential

of HSAs appeal to consumers, 

while the health plans’ high 

deductibles encourage enrollees to 

be more astute health care

consumers. However, critics are 

concerned that HSA-eligible plans 

may attract enrollees who seek

lower premiums but lack the 

resources to contribute to an HSA, 

and wealthy enrollees who may use 

the HSA primarily to accumulate

tax-advantaged savings. 

This statement focuses on (1) 

participation in HSA-eligible highdeductible health plans and HSAs, 

(2) the income characteristics of

HSA account holders, and (3) the 

funding and use of HSAs. This 

statement is based primarily on 

findings from GAO’s April 2008 

report entitled Health Savings 

Accounts: Participation Increased 

and Was More Common among

Individuals with Higher Incomes

(GAO-08-474R). For that report

GAO reviewed industry data on the 

participation in HSA-eligible plans 

and HSAs, and analyzed Internal

Revenue Service (IRS) data on tax

filers who claimed deductions for 

HSAs. The statement also draws on

findings from related GAO reports 

issued in 2006. 

GAO found that the number of individuals participating in HSA-eligible highdeductible health plans and HSAs increased significantly since 2004. A series

of health insurance carrier surveys reported that the number of lives covered 

by HSA-eligible plans increased significantly from about 438,000 in September

2004 to an estimated 6.1 million in January 2008. GAO’s analysis of IRS data

showed that the number of tax filers ages 19 to 64 reporting HSA activity 

nearly tripled from about 120,000 in 2004 to about 355,000 in 2005. Industry 

estimates indicated continued growth in HSA participation in 2006 and 2007. 

However, many HSA-eligible plan enrollees did not open an HSA. From 2005

through 2007, 42 percent to 49 percent of HSA-eligible plan enrollees reported 

that they had not opened an HSA, and 20 percent to 24 percent did not plan to 

open an HSA, citing their inability to afford an HSA or a belief they did not 

need an account. 

Tax filers who reported HSA activity and enrollees in certain HSA-eligible 

plans had higher incomes on average than other tax filers. For example,

among tax filers between the ages of 19 and 64, the average adjusted gross 

income (AGI) for those reporting HSA activity in 2005 was about $139,000, 

compared with about $57,000 for other filers. About 59 percent of HSA filers 

had AGIs of $60,000 or more, compared with 26 percent of other tax filers. 

Moreover, income differences between HSA and other filers existed across all 

age groups and within different tax filing statuses, such as single or joint tax 

filers. 

Among all filers reporting HSA activity in 2005, average contributions—

reflecting both individual and employer contributions—were about $2,100, 

compared to average withdrawals of about $1,000. Among filers who reported 

HSA contributions in 2005, about 41 percent did not withdraw any HSA funds 

that year, while about 22 percent withdrew as much or more than their 

reported contributions. About 93 percent of reported withdrawals were 

claimed for qualified medical expenses. Some HSA-eligible plan enrollees

GAO interviewed for a 2006 report were unsure what medical expenses 

qualified for payment using their HSAs, and few researched the cost of 

services before obtaining care. 

To view the full product, including the scope 

and methodology, click on GAO-08-802T. 

For more information, contact John E. Dicken 

at (202) 512-7114 or dickenj@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today as you examine issues related to tax 

advantaged health savings accounts (HSA) and HSA-eligible highdeductible health plans. With health care spending increasing in the United 

States, Congress enacted legislation effective in 2004 establishing HSAs to 

be coupled with HSA-eligible high-deductible health plans.1

 The novel

structure of HSA-eligible plans coupled with HSAs—a type of consumer 

directed health plan2

—has raised questions about who selects them and 

how they use the accounts. Proponents of consumer-directed health plans 

contend that the lower premiums of HSA-eligible plans and the tax-free 

savings potential of HSAs appeal to many consumers, while the high 

deductibles encourage them to be more astute health care consumers.3

However, some critics are concerned that HSA-eligible plans may attract 

enrollees who seek lower premiums but lack the resources to contribute 

to an HSA, and wealthy enrollees who may seek to use the HSA primarily 

to accumulate tax-advantaged savings rather than pay for medical 

expenses. 

My comments today are based primarily on findings from our April 2008 

report entitled Health Savings Accounts: Participation Increased and 

Was More Common among Individuals with Higher Incomes.

4

 My 

remarks focus on (1) participation in HSA-eligible high-deductible health 

plans and HSAs, (2) the income characteristics of HSA account holders, 

and (3) the funding and use of HSAs. 

 1

HSA-related tax advantages were authorized by the Medicare Prescription Drug, 

Improvement and Modernization Act of 2003 for individuals covered by HSA-eligible health

plans—plans that meet minimum deductibles and maximum out-of-pocket spending limits.

Pub. L. No. 108-173, §1201, 117 Stat. 2066, 2469. Both employers and individuals may—but 

are not required to—contribute to HSAs, up to an annual limit.

2

Consumer-directed health plans generally include three basic components—a health plan 

with a high deductible; an associated tax-advantaged account to pay for medical expenses 

under the deductible; and decision-support tools to help enrollees evaluate health care 

treatment options and costs. 

3

HSA contributions up to annual limits are exempt from income tax, and withdrawals for

qualified medical expenses are not federally taxed. Contributions exceeding the limit are

subject to federal tax. Withdrawals for nonqualified expenses are also subject to federal 

tax, and—if withdrawn before age 65—an additional tax penalty. 

4

GAO-08-474R (Washington, D.C.: Apr. 1, 2008). 

Page 1 GAO-08-802T
In conducting our work for the April 2008 report, we analyzed industry 

data, Internal Revenue Service (IRS) data, and nationally representative 

survey data. To examine participation in HSA-eligible health plans we 

obtained estimates of the number of lives covered by HSA-eligible health 

plans from 2004 to 2007 from America’s Health Insurance Plans (AHIP). 5

For this statement we updated this information to 2008 based on AHIP’s 

more recent estimates. To examine participation in HSAs, we analyzed 

2004 and 2005 tax filer data from the IRS Statistics of Income (SOI) sample 

to estimate the number of tax filers reporting HSA activity in those years,6

reviewed various estimates of the number of HSAs in 2006 and 2007 that

were reported in health care and financial industry publications,7

 and 

examined data from nationally representative surveys of HSA-eligible plan 

enrollees conducted from 2005 to 2007.8

 To examine income 

characteristics of HSA account holders, we analyzed IRS tax data from the 

2005 SOI sample. To examine funding and use of HSAs, we analyzed IRS 

tax data from the 2005 SOI sample and data from nationally representative 

employer surveys conducted from 2005 through 2007.9

 We performed this 

work from September 2007 through February 2008, and a detailed 

explanation of our scope and methodology is included in the report. I will 

also draw on findings from our related reports issued in 2006.

10 We 

conducted all our work in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. 

 5

AHIP is a trade association representing health insurers. 

6

We defined HSA activity for a given year as any reported contributions to or withdrawals

from an HSA in that year. 

7

We also interviewed officials from the organizations that prepared the estimates—Atlantic 

Information Services, Financial Research Corporation, and Information Strategies

Incorporated—however, we did not verify the reliability of the estimates. 

8

Blue Cross Blue Shield Association, CDHP Member Experience Surveys, 2005, 2006, and 

2007. 

9

Kaiser Family Foundation and Health Research and Educational Trust, Employer Health

Benefits: Annual Survey (Menlo Park, Calif., and Chicago, Ill.: 2005, 2006, and 2007) and 

Mercer, National Survey of Employer-Sponsored Health Plans (New York, N.Y: 2005, 2006, 

and 2007). 

10A list of these related GAO products is included at the end of this statement. 

Page 2 GAO-08-802T
In summary, we found that the number of individuals participating in HSAeligible health plans and HSAs increased significantly since 2004; however, 

HSA-eligible health plans still represented a small share (about 2 percent 

in 2006) of individuals with private health coverage. While participation in

both the eligible health plans and the HSAs grew, survey estimates indicate

that more than 40 percent of the health plan enrollees did not open an 

HSA, citing among other reasons their inability to afford an HSA or a belief 

that the accounts were not needed. Tax filers who reported HSA activity in 

2005 had higher incomes on average than other tax filers—about $139,000 

compared with about $57,000. Among all filers reporting HSA activity in 

2005, average contributions—reflecting both individual and employer 

contributions—were about $2,100, compared to average withdrawals of 

about $1,000. Among filers who reported HSA contributions in 2005, about 

41 percent did not withdraw any HSA funds that year, while about 

22 percent withdrew as much or more than their reported contributions. 

About 93 percent of reported withdrawals were claimed for qualified 

medical expenses. We reported in 2006 that some HSA-eligible plan 

enrollees we interviewed were unsure what medical expenses qualified for 

payment using their HSAs, and that few researched the cost of services 

before obtaining care. 

Most Americans—about 202 million in 2006—receive health coverage 

through private health plans. Over the past several years, insurers have 

expanded their portfolio to include insurance plans with high deductibles,

lower premiums, and, generally, an associated savings account to pay for

services up to the deductible. These consumer-directed health plans are 

designed to reduce health care spending and encourage more consumer 

control. To help achieve these goals, insurers typically offer online tools to

enrollees designed to help them evaluate the cost and quality of health 

care services. Experts suggest that reliable information about the cost of 

particular health care services and the quality of specific health care 

providers would help enrollees become more actively engaged in making 

health care purchasing decisions. 

Background 

Beginning in 2004, insurers began to market HSA-eligible consumerdirected health plans. HSA-eligible health plans are required to meet 

certain statutory criteria, including minimum deductible amounts, which 

are higher than health plan deductibles on average, and maximum limits 

Page 3 GAO-08-802T
on enrollee out-of-pocket spending.11,12 HSA-eligible plans are sold either to 

an individual or through group plans, such as those offered by employers. 

HSAs are tax-advantaged savings accounts established to pay for qualified

medical expenses.13 Individuals are eligible to open an HSA and contribute 

funds if they are enrolled in an HSA-eligible plan and have no other health 

coverage, with limited exceptions.14 Both employers and individuals may—

but are not required to—contribute to HSAs, up to an annual limit.15

Individuals may claim a deduction on their federal income taxes for their 

HSA contributions not exceeding the limit. HSA withdrawals for qualified

medical expenses are not federally taxed; withdrawals for nonqualified 

expenses are subject to tax and, when withdrawn before age 65, an 

additional tax penalty. HSA account holders may access their account

funds by check, by debit card, or by allowing providers to directly debit 

their account funds. Account administrators, such as financial institutions, 

report to IRS the contributions and withdrawals made to and from the 

accounts they manage, and individual account holders report to IRS the 

amount of withdrawals they used for qualified medical expenses or other 

expenses. Unused HSA balances may accumulate from year to year 

without limit and earn interest. HSAs are owned by the account holder and 

individuals may keep their accounts if they switch jobs or are no longer 

enrolled in an HSA-eligible health plan. 

 11An out-of-pocket spending limit is the most an enrollee is required to pay toward the cost

of covered services. The out-of-pocket spending limit includes deductibles and other

payments, but not premiums.

12These amounts are annually adjusted for cost-of-living increases. In 2008, the minimum 

deductible amount is $1,100 for single coverage and $2,200 for family coverage, and the 

maximum limit on enrollee out-of-pocket spending is $5,600 for single coverage and

$11,200 for family coverage. 

13Qualified medical expenses are generally identified under the Internal Revenue Code 

(26 U.S.C. § 213(d)). 

14Limited coverage (including specific injury or accident, disability, dental care, or vision 

care) in addition to the HSA-eligible plan is permissible.

15The annual contribution limit is adjusted annually for inflation. In 2008, contributions are

allowed up to $2,900 for single coverage or $5,800 dollars for family coverage, regardless of

the amount of the deductible. In 2007, contributions were allowed up to $2,850 for single 

coverage or $5,650 for family coverage. Prior to 2007, contributions were limited to the 

lesser of the deductible amount for the HSA-eligible plan or the limits specified for each 

year. 

Page 4 GAO-08-802T
Industry estimates indicate significant increases in the number of 

individuals covered by HSA-eligible health plans. For example, a series of 

insurance carrier surveys conducted by AHIP found that the number of 

lives covered by HSA-eligible plans increased significantly from about 

438,000 in September 2004 to an estimated 6.1 million in January 2008.16

Despite the growth, HSA-eligible plan coverage represented only about 

2 percent of individuals with private health coverage in 2006.17

Participation in HSAs also increased significantly. IRS data show that the

number of tax filers between the ages of 19 and 64 reporting HSA activity 

nearly tripled from about 120,000 in 2004 to about 355,000 in 2005. In 

addition, although industry estimates varied, all indicated continued 

growth in HSA participation in 2006 and 2007. For example, one industry 

publication estimated that the number of HSAs managed by major 

financial institutions more than doubled between 2006 and 2007.18

Participation in HSAEligible Plans and 

HSAs Increased 

Significantly, and 

Many HSA-Eligible 

Enrollees Did Not 

Open an HSA 

Despite the growth in HSA participation, many HSA-eligible plan enrollees 

did not open an HSA. Nationally representative surveys of HSA-eligible 

plan enrollees conducted in 2005 through 2007 found that 42 percent to 

49 percent reported that they had not opened an HSA, and 20 percent to 

24 percent did not plan to open one.19 Reasons survey respondents cited 

for not planning to open an HSA included that they could not afford them 

or they did not believe they needed them. On the basis of an analysis of 

publicly available survey data and data obtained from IRS, we also 

reported that roughly 45 percent of HSA-eligible plan enrollees in 2004 did

not report contributions to an HSA.20 Similarly, industry representatives we 

spoke with told us that many HSA-eligible plan enrollees did not have an 

HSA. The representatives also said that they expect that there would 

 16America’s Health Insurance Plans, January 2008 Census Shows 6.1 Million People 

Covered by HSA/High-Deductible Health Plans (Washington, D.C.: April 2008). The

estimates included plans from the individual and group markets. 

17GAO analysis of America’s Health Insurance Plans’ 2006 and 2007 estimates of lives 

covered by HSA-eligible health plans, and the U.S. Census Bureau’s 2006 Current 

Population Survey estimate of lives covered by private health insurance.

18Atlantic Information Services, Inc., “Number of HSAs Doubles Over Past Year; Firms Now 

Hold Nearly $2 Billion, ICDC Finds,” Inside Consumer-Directed Health Care 

(Mar. 9, 2007). 

19Blue Cross Blue Shield Association, CDHP Member Experience Surveys, 2005 through

2007. 

20See GAO-06-798. 

Page 5 GAO-08-802T
always be some share of eligible consumers who would choose not to 

open an HSA. 

Tax filers who reported HSA activity and enrollees in certain HSA-eligible

plans had higher incomes on average than other tax filers. Among tax 

filers between the ages of 19 and 64, the average adjusted gross income 

(AGI) for those reporting HSA activity in 2005 was about $139,000, 

compared with about $57,000 for other filers.21 About 59 percent of HSA 

filers had AGIs of $60,000 or more, compared with 26 percent of other tax 

filers.22 Moreover, income differences between HSA and other filers 

existed across all age groups. (See fig. 1.) Income differences between 

HSA and other filers also existed within different tax filing statuses, such 

as single or joint tax filers. In 2006 we reported similar findings based on 

different data sources covering different time periods. For example, we 

reported that about 51 percent of HSA filers in 2004 had AGIs of $75,000 or

more, compared with 18 percent of all tax filers under age 65. 23 In addition, 

we reported that among active federal employees enrolled in the Federal

Employees Health Benefits Program in 2005, 43 percent of HSA-eligible 

plan enrollees earned federal incomes of $75,000 or more, compared with 

23 percent for all enrollees.24

HSA Account Holders 

Reported Higher 

Incomes than Other 

Tax Filers 

 21The median income of HSA filers in 2005 was about $72,000 compared with about $32,000 

for other filers.

22Other tax filers include both insured and uninsured individuals. The uninsured tend to

have lower incomes than those with health insurance coverage. For returns of married

couples filing jointly, the AGI included the combined AGIs of both filers. 

23See GAO-06-798. 

24See GAO-06-271. 

Page 6 GAO-08-802T
Figure 1: Comparison of HSA and Other Tax Filers’ Average Adjusted Gross Income 

by Age, 2005 

Notes: Analysis was limited to tax filers between the ages of 19 and 64. HSA filers included those 

reporting any contributions to or withdrawals from an HSA. Contributions include those made by 

individual tax filers or by employers or other individuals on their behalf, but do not include any funds 

that were transferred to an HSA from a medical savings account. Withdrawals did not include those 

made to avoid a tax penalty by removing contributions that were in excess of the allowable limits, or 

those made to transfer funds from one HSA to another. For returns of married couples filing jointly,

returns were categorized based on the age of the primary tax filer, and the AGI included the 

combined AGIs of both filers. 

Page 7 GAO-08-802T
The total value of account holder and employer HSA contributions in 2005 

was about twice that of account holder withdrawals—about $754 million 

compared to $366 million. Among all filers reporting HSA activity, the 

average HSA contribution was about $2,100, the average HSA withdrawal 

was about $1,000, and average contributions and withdrawals generally 

increased with both income and age. Employer survey data provided 

varying estimates of the extent to which employers contributed to their 

employees’ HSAs. For example, a series of surveys reported that more 

than a third of large employers offering HSA-eligible plans did not 

contribute to their employees’ HSAs in 2005, 2006, or 2007.25 Another 

survey reported that 47 percent of small and large employers offering HSAeligible plan coverage for families did not contribute to their employees’ 

HSAs in 2007.26

HSA Contributions 

Exceeded 

Withdrawals and Most 

Withdrawals Were 

Claimed for Qualified 

Medical Expenses 

The extent to which account holders withdrew HSA funds varied, but of 

the funds withdrawn, most were claimed for qualified medical expenses. 

Among filers who reported HSA contributions in 2005, about 41 percent 

did not withdraw any HSA funds that year, while about 22 percent 

withdrew as much or more than their reported contributions.27 This is 

consistent with statements from industry experts that characterized HSA 

account holders as either savers or spenders, where savers primarily used 

HSAs as a tax-advantaged savings vehicle.28 Of the HSA funds that were 

withdrawn in 2005, about 93 percent were claimed for qualified medical 

expenses. The remaining 7 percent of withdrawals were for nonqualified

expenses, which are subject to tax and, if withdrawn before age 65, an 

additional tax penalty. 

We reported in August 2006 that some HSA-eligible plan enrollees we 

interviewed were unsure what medical expenses qualified for payment 

using their HSAs, and few researched the cost of services before obtaining 

 25Mercer, National Survey of Employer-Sponsored Health Plans, 2005, 2006, and 2007.

26Kaiser Family Foundation and Health Research and Educational Trust, Employer Health

Benefits: 2007 Annual Survey. 

27HSA withdrawals may exceed contributions in a given year if balances are carried over 

from prior years. 

28GAO-06-514. 

Page 8 GAO-08-802T
care, although many researched the cost of prescription drugs.29 In 

addition, we reported in April 2006 that consumer-directed health plan 

experts and employers told us the tools provided by insurance carriers to 

assist consumers in assessing the price and quality of health care 

providers and services did not provide sufficient information to allow 

enrollees to fully assess the cost and quality trade-offs of health care 

purchasing decisions.30 They cited several reasons for this, including 

potential legal barriers to greater price transparency and a lack of 

consensus on what would make ideal quality measures. 

Mr. Chairman, this concludes my prepared remarks. I would be happy to 

answer any questions that you or other Members of the Subcommittee 

may have. 

For future contacts regarding this statement, please contact 

John E. Dicken at (202) 512-7114 or at dickenj@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found on

the last page of this statement. Randy DiRosa, Assistant Director; 

Gerardine Brennan; Stephen Ulrich; and Timothy Walker made key 

contributions to this statement. 

 29See GAO-06-798. Information on HSA-eligible plan enrollee experiences was gathered

from focus groups we conducted of employees from three large employers that offered 

HSA-eligible health plans. These focus groups also revealed that participants generally 

reported positive experiences, but most would not recommend the plans to consumers

who use maintenance medications, have a chronic condition, have children, or may not 

have the funds to meet the high deductible. 

30See GAO-06-514. 

Page 9 GAO-08-802T
Page 10 GAO-08-802T

Related GAO Products 

Health Savings Accounts: Participation Increased and Was More 

Common among Individuals with Higher Incomes. GAO-08-474R. 

Washington, D.C.: April 1, 2008. 

Health Savings Accounts: Early Enrollee Experiences with Accounts and 

Eligible Health Plans. GAO-06-1133T. Washington, D.C.: September 26, 

2006. 

Consumer-Directed Health Plans: Early Enrollee Experiences with 

Health Savings Accounts and Eligible Health Plans. GAO-06-798. 

Washington, D.C.: August 9, 2006. 

Consumer-Directed Health Plans: Small but Growing Enrollment Fueled 

by Rising Cost of Health Care Coverage. GAO-06-514. Washington, D.C.: 

April 28, 2006. 

Federal Employees Health Benefits Program: First-Year Experience with

High-Deductible Health Plans and Health Savings Accounts. GAO-06-271. 

Washington, D.C.: January 31, 2006. 

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