Consumer-directed health plans generally include three components: a health plan with a high deductible, a savings account—such as an HSA—to pay for health care expenses, and enrollee decision-support tools. An insurance plan with a high-deductible. HSA-eligible plans are required to meet certain statutory criteria. The plans must have a minimum deductible amount—$1,050 for single coverage and $2,100 for family coverage in 2006—and a maximum limit on enrollee out-of-pocket spending—$5,250 for single coverage and $10,500 for family coverage in 2006. Preventive care services may be exempted from the deductible requirement, but coverage of most other services, including prescription drugs, is subject to the deductible. After meeting the deductible, the HSA- eligible plan pays for most of the cost of covered services until the enrollee meets the out-of-pocket spending limit, at which point the plan pays 100 percent of the cost of covered services. A savings account to pay for health care expenses. There are several types of savings accounts that may be associated with consumer-directed health plans, with HSAs being among the most prominent. An HSA is a tax- advantaged savings account established for paying qualified medical expenses. Individuals are eligible to open an HSA if they are enrolled in an HSA-eligible plan and have no other health coverage, with limited exceptions. HSAs are owned by the account holder, and the accounts are portable—individuals may keep their accounts if they switch jobs or enroll in a non-HSA-eligible health plan. Both employers and individuals may contribute to HSAs, and individuals may claim a deduction on their federal income taxes for their HSA contributions. HSA balances can earn interest; roll over from year to year; and be invested in a variety of financial instruments, such as mutual funds. HSA-eligible plan enrollees who choose to pay for medical expenses from their HSA may access their account funds by check, by debit card, or by authorizing insurance carriers to allow providers to directly debit their account funds. HSAs are subject to annual contribution limits. In 2006, contributions were limited to 100 percent of the deductible, but not more than $2,700 for single coverage or $5,450 for family coverage. Contributions, earned interest, and withdrawals for qualified medical expenses are not subject to federal income taxation. A financial institution, such as a bank or insurance company, typically administers the account. Decision-support tools. HSA-eligible plans typically provide enrollee decision-support tools that include, to some extent, information on the cost of health care services and the quality of health care providers. 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. These tools may be provided by health insurance carriers to all health insurance plan enrollees, but are likely to be more important to enrollees of HSA-eligible plans who have a greater financial incentive to make informed decisions about the quality and costs of health care providers and services. HSA-eligible plans had lower premiums, higher deductibles, and higher out-of-pocket spending limits than traditional plans in 2005. Specifically, data from national employer health benefits surveys regarding plans offered in the group market indicate: Premiums for HSA-eligible plans averaged 35 percent less than employers’ traditional plan premiums for single coverage and 29 percent less for family coverage in 2005. Annual deductibles for HSA-eligible plans averaged $1,901 for single coverage and $4,070 for family coverage in 2005—nearly six times greater than those of employers’ traditional plans. The median annual out-of-pocket spending limit for HSA-eligible plans offered by large employers was $3,500 for single coverage in 2005, which was higher than the median out-of-pocket spending limit of $1,960 reported for traditional plans. The HSA-eligible and traditional plans we reviewed covered the same broad categories of services, including preventive services, and also used similar provider networks in 2005. Our illustration of enrollees’ potential health care costs—including premiums, deductibles, and other out-of-pocket costs for covered services—for the three employers’ 2005 health plans we reviewed showed that HSA-eligible plan enrollees would incur higher annual costs than PPO enrollees for extensive use of health care, but would incur lower annual costs than PPO enrollees for low to moderate use of health care. Specifically, we estimated that in the event of an illness or injury resulting in a hospitalization costing $20,000, the total costs incurred by the three employers’ HSA-eligible plan enrollees would be 47 to 83 percent higher than those faced by the employers’ PPO enrollees. In contrast, we estimated that the total costs paid by HSA-eligible plan enrollees who used low to moderate amounts of health care, visiting the doctor for illnesses or injuries six times in one year, would be 48 to 58 percent lower than the costs paid by the PPO enrollees. If HSA-eligible plan enrollees used tax- advantaged funds that they, or someone other than their employer, contributed to their HSA, their costs could have been lower than our estimates. HSA-eligible plan enrollees generally had higher incomes than comparison groups. The average adjusted gross income of the estimated 108,000 tax filers reporting HSA contributions in 2004 was about $133,000, compared with $51,000 for all tax filers under age 65, according to IRS data. Moreover, 51 percent of tax filers reporting HSA contributions had an adjusted gross income of $75,000 or more, compared with 18 percent of all tax filers under age 65. (See fig. 1.) We also found similar income differences between HSA-eligible plan and traditional plan enrollees when we examined other data sources from the group and individual markets. Among Federal Employees Health Benefits Program (FEHBP) enrollees actively employed by the federal government, 43 percent of HSA-eligible plan enrollees earned federal incomes of $75,000 or more, compared with 23 percent for all enrollees in 2005. Additionally, two of the three employers we reviewed and eHealthInsurance reported that HSA-eligible plan enrollees had higher incomes than did traditional plan enrollees in 2005. The data sources we examined did not conclusively indicate whether HSA- eligible plan enrollees were older or younger than comparison groups. IRS data suggest that the average age of tax filers who reported HSA contributions was about 9 years higher than the average age of all tax filers under age 65 in 2004. Similarly, eHealthInsurance reported that in the individual market the average age of its HSA-eligible plan enrollees was 5 years higher than that of its traditional plan enrollees in 2005. In contrast, data from FEHBP and the three employers we reviewed indicate that the average age of HSA-eligible plan enrollees, excluding retirees, was 2 to 6 years lower than that of comparison groups of enrollees. Just over half of HSA-eligible plan enrollees and most employers contributed to HSAs. About 55 percent of HSA-eligible plan enrollees reported HSA contributions in 2004, according to our analysis of data obtained from IRS and a publicly available survey. HSA-eligible plan enrollees from the employers we reviewed were more likely to contribute to an HSA when their employer also offered account contributions. Among tax filers who claimed a deduction for an HSA in 2004, the average deduction was about $2,100 and the average amount deducted increased with income. About two-thirds of employers offering HSA-eligible plans contributed to their employees’ HSAs in 2005, according to two national employer health benefits surveys. In 2004, the average employer HSA contribution reported to IRS was about $1,064. Account holders used HSA funds to pay for medical care and to accumulate savings. About 45 percent of tax filers reporting an HSA contribution in 2004—made by themselves, their employers, or others on their behalf—also reported withdrawing funds in 2004. The average annual amount withdrawn by these tax filers was about $1,910. About 90 percent of these withdrawn funds were used to pay for expenses identified under the Internal Revenue Code as eligible medical expenses. IRS data show that about 40 percent of all funds contributed to HSAs in 2004 were withdrawn from the accounts by the end of the year. In addition to using HSAs for medical and other expenses, account holders appeared to use their HSA as a savings vehicle. About 55 percent of tax filers reporting HSA contributions in 2004 withdrew no money from their account in 2004. We could not determine whether HSA-eligible plan enrollees accumulated balances because they did not need to use their accounts (that is, they paid for care from out-of-pocket sources or did not need health care during the year) or because they reduced their health care spending as a result of financial incentives associated with the HSA-eligible plan and HSA. However, many focus group participants reported using their HSA as a tax-advantaged savings vehicle, accumulating HSA funds for future use. HSA-eligible plan enrollees who participated in our focus groups at the three employers we reviewed generally reported positive experiences with their plans. These focus group participants, who had voluntarily elected to enroll in HSA-eligible plans as one of several choices offered by their employers, cited the ability to accumulate savings, the tax advantages of having an HSA, and the ability to use an HSA debit card as positive aspects of HSAs. Participants reported few problems obtaining care, and when given a choice, many reported that they had reenrolled in the HSA-eligible plan. While focus group participants enrolled in HSA-eligible plans generally understood the key attributes of their plan, such as low premiums, high deductibles, and the mechanics of using the HSA, they were confused about certain other features. For example, many participants understood that certain preventive services were covered free of charge, but they also had trouble distinguishing between the preventive services and other services provided during a preventive office visit. Moreover, many participants were unsure what medical expenses qualified for payment using their HSA. Few participants researched the cost of hospital or physician services before obtaining care, although many participants researched the cost of prescription drugs. A few participants reported asking physicians about the cost of services, but others expressed discomfort with asking physicians about cost. For example, one participant said, “Americans don’t negotiate. It’s not polite to question the value of work.” Participants of one focus group also reported not initially understanding the extent to which they needed to manage and take responsibility for their health care, including by asking questions about the cost of services and medications. Participants also reported that only limited information was available regarding key quality measures for hospitals and physicians, such as the volume of procedures performed and the outcomes of those procedures. The decision-support tools provided with consumer-directed health plans we previously reviewed were limited and did not provide sufficient information to allow enrollees to fully assess cost and quality trade-offs of health care purchasing decisions. Most participants reported that they would not recommend HSA-eligible plans to all consumers. Some participants said they enrolled in the HSA- eligible plan specifically because they did not anticipate getting sick, and many said they considered themselves and their families as being fairly healthy. Most participants would recommend the plans to healthy consumers, but not to those who use maintenance medication, have a chronic condition, have children, or may not have the funds to meet the high deductible. In closing, as more individuals face the choice of enrolling in HSA-eligible plans or other consumer-directed health plans, they will likely weigh the savings potential and financial risks associated with these plans in relation to their own health care needs and financial circumstances. Because healthier individuals who use little health care could incur lower costs under HSA-eligible plans than under traditional plans, when given a choice they may be more likely to select an HSA-eligible plan than will less healthy individuals who use greater amounts of health care. It will be important to monitor enrollment trends and assess their implications for the cost of health care coverage for all HSA-eligible and traditional plan enrollees. Few of the HSA-eligible plan enrollees who participated in our focus groups researched cost before obtaining health care services. This may be due in part to a reluctance of consumers to question health care providers about the cost of their services and the dearth of information provided by insurance carriers to their enrollees about the cost of health care services under their plans—a limitation that insurance carriers are beginning to address. According to proponents, an increase in such health care consumerism can help restrain health care spending increases under the plans. Such an increase will likely require time, education, and improved decision-support tools that provide enrollees with more information about the cost and quality of health care providers and services. Finally, while HSA-eligible plan enrollees we spoke with were generally satisfied with their plans, it is notable that these enrollees each had a choice of health plans and voluntarily selected the HSA-eligible plan. Their caution that HSA-eligible plans may not be appropriate for everyone suggests that satisfaction may be lower when employees are not given a choice or when employer contributions to premiums or accounts do not sufficiently offset the potentially greater costs faced by HSA-eligible plan enrollees. 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 testimony, please contact John E. Dicken at (202) 512-7119 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 testimony. Randy DiRosa, Assistant Director; Pamela N. Roberto; and Patricia Roy made key contributions to this statement. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: Health savings accounts (HSA) and the high-deductible health insurance plans that are eligible to be coupled with them are a new type of consumer-directed health plan attracting interest among employers and consumers. HSA-eligible plans constitute a small but growing share of the private insurance market, and the novel structure of the plans has raised questions about how they could affect enrollees' health care purchasing decisions and costs. This statement is based on GAO's August 2006 report entitled "Consumer-Directed Health Plans: Early Enrollee Experiences with Health Savings Accounts and Eligible Health Plans" (GAO-06-798). In this report, GAO reviewed (1) the financial features of HSA-eligible plans in comparison with those of traditional plans, such as preferred provider organizations (PPO); (2) the characteristics of HSA-eligible plan enrollees in comparison with those of traditional plan enrollees or others; (3) HSA funding and use; and (4) enrollees' experiences with HSA-eligible plans. HSA-eligible plans had lower premiums, higher deductibles, and higher out-of-pocket spending limits than did traditional plans in 2005, but both plan types covered similar services, including preventive services. For the three employers' health plans GAO reviewed to illustrate enrollees' potential health care costs, GAO estimated that HSA-eligible plan enrollees would incur higher annual costs than PPO enrollees for extensive use of health care, but would incur lower annual costs than PPO enrollees for low to moderate use of health care. HSA-eligible plan enrollees generally had higher incomes than comparison groups, but data on age differences were inconclusive. In 2004, 51 percent of tax filers reporting an HSA contribution had an adjusted gross income of $75,000 or more, compared with 18 percent of all tax filers under 65 years old. Two of the three employers GAO reviewed, the Federal Employees Health Benefits Program, and a national broker of health insurance also reported that HSA-eligible plan enrollees had higher incomes than traditional plan enrollees in 2005. Just over half of all HSA-eligible plan enrollees and most employers contributed to HSAs, and account holders used their HSA funds to pay for medical care and accumulate savings. About 55 percent of HSA-eligible plan enrollees reported HSA contributions to the Internal Revenue Service in 2004, and about two-thirds of employers offering HSA-eligible plans contributed to their employees' HSAs. About 45 percent of tax filers reporting 2004 HSA contributions also reported that they withdrew funds in that year, and 90 percent of these funds were withdrawn for qualified medical expenses. The other 55 percent of those reporting HSA contributions did not withdraw any funds from their HSA in 2004. HSA-eligible plan enrollees who participated in GAO's focus groups generally reported positive experiences, but most would not recommend the plans to all consumers. Few participants reported researching cost before obtaining health care services, although many researched the cost of prescription drugs. Most participants were satisfied with their HSA-eligible plans and would recommend them to healthy consumers, but not to those who use maintenance medication, have a chronic condition, have children, or may not have the funds to meet the high deductible.