Health Savings Accounts in the US Health Care System

 

 

 

 

 

 

 

 

MPH 439 – Prof. Neuhauser

April 25, 2006

 

 

 

 

 

 

 

Joseph Sweigart
Health Savings Accounts in the US Health Care System

 

I. Introduction

What are health savings accounts (HSA’s), and are they a good addition to the healthcare system of the United States?  Understanding the policies, goals, and potential obstacles of this new health insurance option is necessary to assess the advantages and disadvantages, and to evaluate the implications of HSA’s on individual health decisions, the medical industry, and society at large.  Additionally, information pertaining specifically to HSA’s as well as the US health care setting will enable meaningful evaluation of HSA’s as a new annex of the larger health care complex in America.

Section II is a brief analysis of the health care environment into which HSA’s will play and will provide a brief explanation of the goals of these plans at a societal level.  Section III will provide a basic description of the legislation creating HSA’s, which is necessary to understand what the programs are and how they are to be administered at the level of the individual health consumer.  Section IV further describes the goals and benefits of the HSA’s, while section V, conversely, contains the shortfalls of such plans.  Section VI provides an abbreviated discussion of the Rand Insurance Trial, a unique and pivotal economic study into the impacts of cost sharing on health care.  Finally, section VII will offer recommendations and summary conclusions.

 

II. The Health Care Setting in the United States

            The uninsured and underinsured Americans are a prominent, central shortcoming of the US health care system.  Approximately 45 million Americans live without health care coverage and, as a result, are far less likely than insured Americans to have a regular source for health care.[1] This is disconcerting because insurance coverage directly correlates to access to care.  Lack of coverage, likewise, leads to a number of adverse effects on health, including decreased likelihood of seeking preventive care, increased chance of hospitalization for preventable conditions, and increased risk of diagnoses of late-stage diseases.[2] Studies have shown that uninsured Americans are primarily families with one or more employed, working member but who are nonetheless unable to afford the often high price of health insurance premiums.[3] Federal and state programs cover the extremely poor, the elderly, the disabled, and children; many working people, however, may have too much income to qualify for Medicaid and other such programs but inadequate income to afford traditional health insurance.[4] Polling data confirms that the primary concern for most Americans is affordability.[5] While the prohibitive costs of traditional health plan premiums are surely frustrating to employees, they are upsetting to employers as well because small businesses often face great difficulty providing insurance options for their employees.[6] Thus, due to the adverse impact on both employers and employees, insurance expense is the leading reason that people go uninsured.[7]

 

III. Descriptions of Health Savings Accounts

            Health savings accounts are aimed at addressing these very problems in the US health care system through increasing access and affordability to health insurance for working Americans.  This is to be accomplished through privately-managed, tax-free savings accounts intended to be used solely to pay for medical expenses.  The cornerstone of HSA’s is a federally-legislated, tax-free, above-the-line payroll deduction which was signed into law in December of 2003 as part of the Medicare Modernization Act and became effective in January of 2004.[8]  This legislation eliminates taxes on deposits into the account and any interest or other earnings the accounts accrue.  Contributions and earnings rollover each year, and unused savings are considered part of one’s estate upon death and are able to be passed on to family members.[9] HSA investments must be used for medical expenses in order to remain tax-free.  Acceptable medical purchases include most medical and vision care, dental services, and non-prescription medications.[10] Funds used for acceptable purchases are always free of taxes and can be withdrawn without penalty.  Withdrawals for non-medical expenses are retrospectively taxed and subject to a 10 percent tax penalty for HSA owners who are not disabled and are under the age of 65.[11] Collectively, the legislation establishes a three-pronged tax advantage: tax free deposits, tax free earnings, and tax free purchasing.[12]  Both employers and employees are free to make deposits and enjoy the associated tax break.[13]

            In order to qualify for these tax-free accounts, HSA owners must be enrolled in a high deductible health plan (HDHP).  HDHP’s include a minimum annual deductible of $1,000 for individuals and $2,000 for families.[14] While these initial deductibles are quite high compared to traditional health insurance plans, maximum out-of-pocket expenditures with HSA/HDHP’s are fixed at $5,000 for individuals and $10,000 for families.[15] The 2006 maximum annual investment into an HSA is the lesser of either the deductible or $2,700 for an individual or $5,450 for a family.[16] In other words, if the HDHP deductible is less than $2,700 for an individual and $5,450 for a family, HSA owners can only deposit the amount of the deductible each year; if, though, the HDHP deductible is above $2,600 for an individual and $5,150 for a family, HSA owners can only deposit the maximum amount of $2,600 or $5,150, respectively.  See Box I for an example of an individual and Box II for an example for a family.  These maximum deposit values do not apply to HSA owners over the age of 55 in order to allow them to invest more heavily in accordance with the larger probability of high health care consumption;[17] persons enrolled in Medicare, though, are not permitted to make deposits into Text Box: Box II, A Family with an HDHP/HSA Plan.  Mrs. B is an employee of a large manufacturing firm.  Her husband, Mr. B, stays home with their three children.  Accordingly, Mrs. B carries the health insurance for the family.  In order to reduce the amount spend on health care, Mrs. B’s firm has decided to offer an HDHP option with an associated HSA into which the firm will deposit $1,000 each year.  This deposit counts toward the maximum annual deposit Mrs. B can make each year.  Mrs. B and her husband decide this is best plan for them.  Once again, the insurance provider negotiates all compensation rates with the health care providers and pays nothing until Mrs. B has paid her deductible amount.  The plan Mrs. B chooses has an annual deductible of $6,000.  After the deductible is met, the provider will cover 90% of the health care cost up to the $10,000 maximum out of pocket family contribution.  Since Mrs. B’s deductible is larger than the maximum deposit, she can put only $5,450 (the maximum family deposit) into her HSA.  For the first $1,000 of health care Mrs. B’s family receives is essentially free as that amount is deposited into her HSA each year by her employer.  For the next $5,000, Mrs. B is responsible for paying the full amount without any help from her provider.  The first year the most she can have in her account is $5,450, which means the most she can deposit before taxes if $4,450 since her employer deposits the first $1,000.  The remaining $550 necessary to reach her deductible amount and 10 percent of any additional health care her family receives would come from her pocket and be taxable.  After the first year, any money that has accumulated in the account can be used to cover the deductible amount or any of the 10 percent that Mrs. B must pay after the deductible is met.  The maximum family out of pocket contribution is $10,000, but, since Mrs. B’s employer contributes $1,000, the most she will ever have to pay in a single year is $9,000.  If Mrs. B’s family requires extensive amounts of health care in any given year, she must pay the first $6,000 as her deductible, then 10 percent up to $50,950.  After that point Mrs. B will have paid the maximum $10,000 out of pocket ($6,000 deductible plus 10 percent of the additional costs or 0.1(50,950-6000)), and her insurance provider will pay 100 percent of any other health care costs her family requires.  If Mrs. B makes the largest contribution she can and requires no health care, she can make $1,000 a year from her employer and deposit an additional $4,450 into her account which will accrue interest and rollover indefinitely.  To the other extreme, if Mrs. B deposits nothing into her account, she will still have $1,000 each year from her employer, but stands to lose up to $9,000 each year, none of which would be tax free since none of it would comes from her HSA.Text Box: Box I, An Individual with an HDHP/HSA Plan.  Mr. A works for a small business that is unable to afford to offer health care plans, but they do offers an HDHP option with an HSA.  He is unmarried and reasonably healthy in his early 30’s.  He decides to take the HDHP/HSA option.  With this plan, Mr. A has a deductible of $2,500.  Mr. A’s insurance provider negotiates all the compensation rates for the health care their customers receive and, in Mr. A’s case, will cover none of his health care costs up to the $2,500, but will pay 75 percent after the deductible up to the maximum out of pocket amount.  Given these parameters, the most Mr. A can deposit into his account each year is $2,500 (the deductible amount).  From $2,501 to $12,500 in health expenditures, Mr. A will be responsible for 25 percent of his health care costs.  At this point he will have spent the full $5,000 maximum out of pocket amount ($2,500 deductible plus 25 percent of the additional costs or 0.25($12,500-$2,500)).  After Mr. A has spent the maximum out of pocket amount, his provider will pay for any additional health care he requires.  Thus, if Mr. A makes the maximum contribution each year and spends nothing on health care, he stands to gain $2,500 a year, plus interest.  This will accrue indefinitely until Mr. A spends it or until it becomes part of his estate upon his death.  If, though, he deposits the maximum amount into his account and requires a great deal of medical attention and spends the maximum out of pocket amount each year, he stands to lose a maximum amount of $5,000 each year, $2,500 of which will be tax free from the HSA while the remainder comes out of Mr. A’s pocket or from deposits into his HSA from previous years.  Of course, if Mr. A makes no deposit, the maximum he may lose is the $5,000 maximum out of pocket amount, none of which would be tax free since none of it would come from the HSA.their HSA.[18]    

Private, third-party insurers supply plan options and negotiate rates with health care providers.  Federal legislation firmly establishes the minimum and maximum values, as previously discussed, but individual plans vary broadly within the parameters provided.  As the plans will be managed in manner similar to traditional plans, it is reasonable to assume that administrative costs of the insurance will be similar.  Also, providers are free, but not mandated, to pay for screenings and preventive care prior to beneficiaries paying the deductible amounts.  This is known as first dollar payment, and this, too, can vary from plan to plan.[19]  In some plans, though, beneficiaries must pay any and all medical expenses up to the deductible amount before the insurance provider begins to contribute.[20] Also, private financial institutions, possibly affiliated or associated with health insurance providers, will manage the savings accounts according to the desires of the HSA owners.  Investing options include basic savings accounts, certificates of deposit, money markets, or mutual fund.[21]

 

IV. Goals and Benefits of Health Savings Accounts with High Deductible Health Plans

              The central goal of HSA/HDHP’s is for working citizens who are unable to afford the high premiums of traditional plans to be able to afford the lower premiums of HDHP’s.  Similarly, companies that are too small to afford the costs of providing traditional plans to their employees will be able to provide HSA options.  In addition, employees unable to afford employer-provided coverage or employees of employers who are unable to provide any insurance coverage are free to establish individual health savings accounts independent of employers.  As such, these options could also potentially provide a reasonable means to maintain health insurance between jobs, during times of unemployment, or while laid off.[22] Since cost is the most prohibitive factor for attaining traditional health insurance plans, it is likely that the low premium of HDHP’s and the flexibility of HSA’s will do well to increase affordability and access to health insurance for working Americans.

            In addition to benefiting health care consumers, HSA/HDHP’s are also intended to improve efficiency of the US health care industry.  HDHP’s provide the necessary ingredients for a consumer-driven health care market that will be vastly unlike the traditional health care market.  Under traditional plans, health care consumers are free to make many of their own decisions related to health care, but have no incentive to know or care how much any particular procedure costs from any particular provider.  With HDHP’s, though, consumers will gain control of their health care money and so will have tangible, financial incentive to shop for quality and cost among both procedures and providers.  HSA/HDHP’s grant greater freedom in selecting providers and cover a broader spectrum of health care including alternative therapies.[23]  The operative theory driving HSA/HDHP is that consumer control of health care spending will inspire competition among the suppliers, specifically among health care providers, and will increase the efficiency in health care just as it has in countless other consumer-driven industries.

            Americans standing to benefit most from HSA/HDHP’s potentially includes a broad spectrum of health insurance consumers.  Tax-free deposits into HSA’s are relatively safe investments for healthy people who are not likely to have exorbitant health care expense.  This is especially true for young people who are likely to require little health care, and, as a result, stand to build up large savings through the tax-free payroll deduction over the course of long, healthy careers.  It is possible that people in exceedingly poor health may also benefit from HDHP’s given that these plans have a federally mandated maximum out-of-pocket expenditure while traditional health plans typically do not.  Also, as mentioned previously, uninsured persons with jobs who are unable to afford the cost of premiums for traditional health insurance plans could attain health insurance with the low premiums of HDHP’s.  Perhaps wealthy persons seeking tax shelter for lucrative investments could also benefit from HSA’s, but this is not very likely given the maximum annual investments.  Nonetheless, the potential beneficiaries of HSA/HDHP’s span the population from young to old as well as poor to rich.

            Evidence supports the ideal that these plans do, in fact, increase the access and affordability of health care on an individual level.  HSA/HDHP’s seem to be especially effective at reaching target demographics within the US health care, specifically working American families who would otherwise be uninsured or underinsured.  In fact, 43 percent of HSA/HDHP enrollees were previously uninsured, one-third earn less than $50,000 annually, and more than 75 percent are families with children.[24] Concurrently, HSA/HDHP’s decrease employer costs for providing health insurance options to employees,[25] and capped expenditures of health care are likely to be hugely appealing to employers.[26]

            Given the success of HSA/HDHP’s at the level of individual employees and employers, it is likely that many of the well-crafted societal goals will be realized as well.  These plans do a great deal to shift health care toward a consumer-driven, market model.  Individuals enrolled in HSA/HDHP’s gain more control over the health care spending, especially with regard to first dollar payments.[27] Additionally, HSA owners gain greater freedom and flexibility in health care investments, including the ability to invest now for future health care in a manner that is not currently possible with traditional health insurance plans or social security.[28] Since savings accrue from year to year, after only a very few years of heavy investment and light expenditure, HSA/HDHP members could have enough money in their account to cover the maximum out-of-pocket amount and would be virtually free of health-related financial risk for that year.  Out-of-pocket expenditure maximums will allow reasonable security when planning investment strategies and provide further mechanisms for assuring that health insurance remains affordable.  These factors all contribute to placing greater control of the health care dollar firmly in the hands of individual health care consumers.

In addition to benefiting consumers, though, HSA/HDHP’s are also likely to positively impact health providers.  Decreased numbers of uninsured patients will increase reimbursements for providers.  Market incentives in the form of more business and greater profit will reward providers who are able to provide efficient, cost-effective services, most likely including preventive and maintenance care.  Similarly, the increased presence of consumer-driven health care is anticipated to drastically reduce costs.[29] In fact, an AETNA study recently found that these plans reduce costs by 11 percent while increasing preventive care by 23 percent.  Thus HSA/HDHP’s seem to be successfully inspiring market efficiency in the health care arena.[30]

 

V. Shortfalls of Health Savings Accounts with High Deductible Health Plans

            Despite the far-reaching promise of HSA/HDHP’s, they are certainly not a comprehensive answer to all the problems plaguing the American health care system.  Though they are notably smaller than with traditional plans, gaps will undoubtedly remain between persons able to effectively participate in HSA/HDHP’s or receive Medicaid assistance; accordingly, HSA/HDHP’s alone are not universal or socialized health care.  Additionally, persons unable to afford the premiums of traditional plans may also be unable to afford the lofty deductibles of HDHP’s in order to access needed care.  People able to afford HSA/HDHP’s but too poor to make deposits into their account will not benefit from the tax break or accumulate any savings for future health expenses.  The same is true for people who cannot save or choose not to save for any reason.  People with little or no propensity for savings will gain nothing from HSA’s and may find themselves unable to afford the high deductibles of the HDHP’s.  Accordingly, the proportion of the population that is, for whatever reason, able to foresee, appreciate, and act on the reasons to save money for future healthcare expenses will negatively impact the perceptions and outcomes of these plans.  If previously uninsured, such people will still enjoy the benefit of carrying health insurance and their providers will receive improved reimbursements, but this situation still remains less than ideal. 

Chronically ill persons or other people who are likely to have high health expenditures are apt to repeatedly spend the maximum out-of-pocket amount each year and, since this amount far exceeds the maximum annual investment into an HSA, stand to benefit little from the tax break.  Accordingly, perhaps traditional plans would be a better option for such people.  Also, while the pre-set out-of-pocket maximums may be appealing to high spending patients, the variables necessary to calculate if one would benefit or suffer with an HSA/HDHP could be difficult or unforeseeable.  As such, HSA/HDHP’s have potentially negative implications on the health insurance industry because they may serve to undermine the risk pool for health care through risk stratification.  It is likely that these plans will appeal most to healthier members of the population,[31] and, as previously described, it is also likely that chronically ill or expensive patients may be more likely to opt for traditional plans.  If these trends hold true across the entire health insurance industry, the cost of the risks insured against by traditional plans would increase, and with them would go the expenses of such plans.  These expenses would surely be passed onto plan holders, thus exacerbating the problem of prohibitively pricy traditional health insurance.  This sort of risk stratification is familiar, acceptable, and arguably successful in other insurance industries, but may have adverse, less socially-acceptable affects on health care.[32] The presence and magnitude of stratification are difficult to reliably quantify,[33] but the emergence of such problems will depend largely on participation levels of HSA/HDHP’s in the future.

Among the most heavily criticized of the potential problems with HSA/HDHP’s is the potential to dis-incentivise necessary or desirable health care utilization.[34] Plans are not required to cover first dollar payments for primary or preventive care, and thus could contribute to enrollees avoiding efficient, effective health consumption and suffering from preventable conditions or presenting with late-stage illnesses as a result.  Medically necessary but expensive services and procedures may also be avoided for purely or primarily financial.  Once again chronically ill people are of grave concern because financial incentive to avoid necessary health care is likely to result in worse health and, consequently, higher expenses for both the individual and society.[35] HDHP’s without HSA’s have been shown to result in more missed care,[36] although the inclusion of HSA’s may help to alleviate this trend.  Ideally, the opposite of these negative potentials will be realized; that is, HSA/HDHP’s will encourage better prevention and adherence to therapeutic regimens since patients will be forced to realize and cope with their unhealthy choices and the expensive negative consequences of preventable problems.[37] The fact remains, though, that many people expect consumer driven health care to decrease patient desires for expensive therapies even if such therapies are medically necessary.[38]

HSA/HDHP’s are truly revolutionary because the US health care system is not currently like other free market, consumer driven industries; health care, however, may simply not be suitable for such market models.  Health consumers have imperfect medical knowledge and non-medical, non-financial, sometimes non-rational motivations for health-related decisions.  Nonetheless, the flow of information to both providers and consumers of health care will be crucial aspects of a successfully functioning health market.[39] Physicians and hospitals, though, may be hesitant to publish such performance data for fear of litigation or other undesirable consequences.[40] Also, productive access to the internet, which varies according to both income and education, is likely to provide further barriers to necessary information for certain demographics of the population.[41] As such, government regulations may be necessary to maintain the freedom and transparency of the medical market.  These concerns are of central importance as the success and popularity of a consumer-driven US health care market will ultimately determine the success and popularity of HSA/HDHP’s over time.

 

VI. The Rand Insurance Trial

Perhaps the most pertinent of any economic analysis into the effects of cost sharing on health care cost and consumption is the Rand Insurance Trial.  President Nixon requested such an experiment from the Rand Corporation in order to quantify the effects of cost sharing in the early 1970’s.  This was truly a randomized, controlled, economic experiment in which over 5,000 families were randomly assigned to receive health insurance plans with levels of 0, 25, 50, or 95 percent cost sharing.  All plans had the same maximum out of pocket spending limits which were adjusted according to pre-set standards based on income for poor participants.  The families were followed for three to five years.[42]

            The study revealed that the impact of cost sharing is likely to be a mix of desirable and undesirable outcomes.  Among the most harmful to the ideals of the HSA/HDHP’s is that cost sharing did not seem to succeed at reducing the efficiency of the health care market.  The cost per episode of health care utilization was no different among the groups, nor was the incidence of inappropriate hospitalization or antibiotic usage.[43] Instead of increasing efficiency, cost sharing served to decrease the frequency and quantity of health care utilization.  Screenings were more common among the group receiving free care, and both mental health and well visits were negatively correlated with cost sharing.  The end result of the study was that cost sharing led to worse control of hypertension, worse vision care, and worse oral health.[44]

            Potentially providing support to HSA/HDHP’s is that health care spending was undeniably reduced through cost sharing plans.[45] Surely reducing spending is not desirable if it means sacrificing health; it is not clear that this was the case in the Rand Insurance Trial, however.  Cost sharing had less affect on acute and chronic care than on other areas of health care, and the value of the increased care that was sought with free plans may have been only marginal.  It is notable that free care recipients had more self-reported diseases and increased anxiety levels.  This may indicate that the increased health utilization of this group served largely to decrease anxiety and perhaps alleviate symptoms, but had little impact on more meaningful health outcomes.  In fact, participants in the study reported no difference in self-assessed measures of health.[46] Also, it seems that the differences reported for hypertension management were actually the result of detection, not care.  Once the disease was diagnoses, management and follow-up were similar among all groups.  In sum, the study reported that cost sharing resulted in no overall difference in provider choices or the quality of care received.[47]

            It is important to factor in both the good and bad implications this study has on the future of HSA’s.  The HDHP’s of the study included no such savings accounts and no associated tax incentives, and exactly how such accounts and incentives may have affected the results cannot be reliably extrapolated.  Additionally, the study brings to bear the issue of whether subjective, self-reported indicators or more objective, pre-determined measures are of greater importance when evaluating the success of any given health plan.  Furthermore, on a more gestalt level, it is crucial to consider that the differences in spending habits and health outcomes between the groups with various levels of cost sharing are smaller than those between insured and uninsured groups;[48] consequently, increasing access to insurance through increased cost sharing is likely to be beneficial to society as a whole.  Thus, while certainly demonstrating areas of weakness and the need for improvement from HDHP’s alone, the Rand Insurance Trial may give some backing for the ideals motivating HSA’s as well as the combination of HSA/HDHP’s.

 

VI. Recommendations and Summary Conclusions

            HSA/HDHP’s are a new reality in the American health care system, and should be addressed as such.  In the relatively near future, these plans will function in conjunction with other empowerment shifts to potentially transform the appearance of health care in the US.[49] While they will surely not gain universal support or participation, a shift as small as 10-15 percent of patients to personal, market-based health care may be sufficient industry-wide changes.[50] According to one survey study, enrollment in HSA-compatible plans tripled in a ten month time period from just over one million in March 2005 to well over three million in January of 2006.[51] Consequently, participation levels may quickly reach levels adequate to necessitate industry-wide and societal modifications in health care.

Given the apparent potential popularity of HSA/HDHP’s, the policies regulating these plans may need to be modified to better articulate the goals of increasing the overall efficiency of the health care industry.  One possible modification would be to mandate that all first dollar spending for screenings and preventions be covered with all HDHP’s.  This could side-step many of the negative health-related potential outcomes of HSA/HDHP’s as well as increasing the value of added health care for individuals enrolled in the plans.  Even without modification, though, many people stand to benefit greatly from HSA/HDHP’s, as is evidenced in the previously-described growth in participation.  The introduction of a consumer-driven, market approach to health care while still maintaining privatization may prove more likely to be embraced in the US than many other schemes.  Additionally, market dynamics may, in fact, achieve the needed improvements in health administration.  As with all new ideas, though, time is needed to measure the popularity and success of this fledgling system and to evaluate its impact on the American health care system.

 

Further Reading:

Information concerning the American health care setting:

The Kaiser Commission on Medicaid and the Uninsured.  “The Uninsured: A Primer, Key Facts about Americans without Health Insurrance.  Henry J. Kaiser Family Foundation, 2006.  Available online at: http://www.kff.org/uninsured/upload/7451.pdf

 

Links to multiple HSA related resources:

Grace-Marie Turner.  “Health Savings Accounts: A Survey of the Literature.” (Galen Institute, 2006).  Available online at: http://www.galen.org/ccbdocs.asp?docID=862

 

Links to multiple resources for insurance information concerning HSA/HDHP’s:

Center for Health Transformation: Better Health, Lower Costs.  Health Savings Accounts homepage.  Available online at: http://www.healthtransformation.net/news/cht_articles_and_op_eds/#oHSA

 

Summary of conclusions from the Rand Insurance Trial:

Emmitt B. Keeler, “Effects of Cost Sharing on Use of Medical Services and Health.” Available online at: http://rand.org/pubs/reprints/2005/RP1114.pdf

 

 

 



Works Cited

 

[1] Rosemarie Sweeney. “Health Care Coverage for All.” American Family Physicians, 2004; 69(6): 1365-1377.

[2] The Kaiser Commission on Medicaid and the Uninsured. “The Uninsured: A Primer, Key Facts about Americans without Health Insurance.” Henry J. Kaiser Family Foundation, 2006: 1-5. Available online at: http://www.kff.org/uninsured/upload/7451.pdf

[3] Ibid.

[4] Ibid.

[5] HealthPollReport. “Public Opinion of consumer-Driven Plans, 11/01/04.” Available online at: http://www.kff.org/healthpollreport/Oct_2004/loader/cfm?url=/commonspot/security/getfile.cfm&PageID=48477

[6] Chris Farrell. “It’s Time to Cure Health Care.” BusinessWeek online, January 23, 2006. Available online at: http://www.buisnessweek.com/print/bwdaily/dnflash/jan2006,nf20060123_1965_db013.html

[7] The Kaiser Commission on Medicaid and the Uninsured.

[8] America’s Health Insurance Plans, “HAS’s Triple in 10 Months.” Available onile at: http://www.healthdecisions.org/HSA

[9] United States Department of Treasury, “Frequently Asked Questions.” Available online throug: http://www.treas.gov/offices/public-affairs/hsa/

[10] Britt Westgard.  “Health Savings Accounts and High-Deductible Health Plans: A Primer.” Available online at: http://www.amsa.org/uhc/HSAPrimer.pdf

[11] United States Department of Treasury.

[12] Britt Westgard.

[13] United States Department of Treasury.

[14] Ibid.

[15] Ibid.

[16] America’s Health Insurance Plans.

[17] United States Department of Treasury.

[18] Britt Westgard.

[19] United States Department of Treasury.

[20] Britt Westgard.

[21] Greg Scandlen. “HSA Tsunami.” Consumer Choice Matters, (Galen Institute) 2003; 41. Available online at: http://www.galen.org/printfriendly/asp?DocID=569&DocType=19

[22] Greg Scandlen.

[23] Britt Westgard.

[24] Grace-Marie Turner. “New studies show consumer-directed care reduces costs and improves access.” Health Issues (Galen Institute), 2004.

[25] Ibid.

[26] J.B. Silvers. “HSAs: The Good, the Bad and the Ugly.” Unpublished.

[27] Center for Health Transformation: Better Health, Lower Cost. “Health Savings Accounts.” Available online through: http://www.healthtransformation.net/news/cht_articles_and_op_eds/#oHSA

[28] Ibid.

[29] Duncan Neuhauser. “The coming Third Health Care Revolution: Personal Empowerment.” Q Manage Health Care (Lippincott Williams & Wilkins), 2003; 12 (3): 171-184.

[30] Center for Health Transformation: Better Health, Lower Cost. “Health Savings Accounts.” Available online through: http://www.healthtransformation.net/news/cht_articles_and_op_eds/#oHSA.

[31] J.B. Silvers.

[32] Ibid.

[33] Britt Westgard.

[34] United States Department of Treasury.

[35] Britt Westgard.

[36] Paul Fronstin and Sara R. Collins.  “Early Experience with High-Deductible Consumer-Driven Health Plans: Findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey.” Employee Benefit Research Institute Issue Brief No. 288 (EBRI 2005).

[37] Duncan Neuhauser.

[38] Ibid.

[39] Duncan Neuhauser.

[40] Britt Westgard.

[41] Ibid.

[42] Emmitt B. Keeler, “Effects of Cost Sharing on Use of Medical Services and Health.” Available online at: http://rand.org/pubs/reprints/2005/RP1114.pdf

[43] Ibid.

[44] Ibid.

[45] Ibid.

[46] Ibid.

[47] Ibid.

[48] Ibid.

[49] Duncan Neuhauser.

[50] J.B. Silvers.

[51] America’s Health Insurance Plans, “HAS’s Triple in 10 Months.” Available onile at: http://www.healthdecisions.org/HSA