Recent research finds that growth in both the number of health savings accounts (HSAs) and those enrolled in HSA-eligible health plans has slowed.
Of course, the number of HSAs and enrollment in HSA-eligible health plans have both grown significantly since HSAs first became available in 2004. But from 2017 to 2018, the percentage of consumers enrolled in an HSA-eligible health plan was either flat or modestly increased, according to a new Issue Brief from EBRI, “Enrollment in HSA-Eligible Health Plans: Slow and Steady Growth Continued into 2018.”
As the industry and policymakers attempt to understand the characteristics of HSA-eligible health plans that may be contributing to the growth or hindrance of HSAs, EBRI emphasizes that accurately measuring the growth is important. But determining how many people are enrolled in HSAs can be challenging, as the surveys vary significantly in the way they collect data.
To get a better sense, EBRI looked at findings from five surveys that obtain their results from three different sources: individual interviews, employer interviews and insurance company polls. Consider, for example:
- EBRI/Greenwald & Associates’ Consumer Engagement in Health Care Survey and the National Health Interview Survey conducted by the National Center for Health Statistics (NCHS) found an increase in enrollment from 11% to 12% between 2017 and 2018;
- the National Survey of Employer-Sponsored Health Plans conducted by Mercer found an increase from 21% to 22%; and
- the Employer Health Benefits Survey conducted by the Kaiser Family Foundation (KFF) found no change over the period.
Moreover, EBRI found that enrollment estimates in HSA-eligible health plans for 2018 varied from 23 million to 36.8 million policyholders and their dependents. The AHIP, EBRI/Greenwald & Associates, and NCHS estimates are in the low- to mid-20-million range, while the KFF and Mercer estimates are in the low- to mid-30-million range.
EBRI explains that surveys conducted by AHIP, EBRI/Greenwald & Associates, and NCHS cover the entire privately insured market, while the KFF and Mercer surveys cover only employment-based health plans. “Hence, the AHIP, EBRI/Greenwald & Associates, and NCHS estimates should be larger than those reported by KFF and Mercer, but the data show just the opposite,” the brief observes.
“Some may be underestimating the privately insured marketplace, while others may be overestimating the employment-based marketplace. In fact, it is possible that a combination of both is occurring,” explains Paul Fronstin, EBRI’s Director of the Health Research and Education Program.
Account Growth
And while all of the surveys find substantial growth in HSA-eligible health plan enrollment since HSAs were established in 2004, the surveys consistently find slower growth in HSA-eligible health plan enrollment more recently. EBRI notes that two studies focus on growth in the number of HSAs rather than enrollment growth in HSA-eligible health plans.
Devenir – which collects data from about 100 HSA providers and tracks the number of accounts universally – finds, for example, that the number of accounts increased from 16.8 million at the end of 2015 to 25.1 million at the end of 2018.
The EBRI HSA Database – which contained 5.9 million HSAs as of the end of 2017 – finds that most HSAs have been established relatively recently, indirectly supporting the notion that there should be growth in enrollment in HSA-eligible health plans. Data from the EBRI HSA Database show that 15% of HSAs were established in 2017.
Why the Discrepancy?
So what could cause HSA counts to show growth when enrollment does not? EBRI notes that the surveys on enrollment count the number of people enrolled in an HSA-eligible health plan at a specific point in time. “These surveys do not take into account any disenrollment from HSA-eligible health plans that may be offsetting new enrollment,” the brief explains.
Another difference is that insurance enrollments measure only current participants, while data on HSAs are potentially counting the number of people who have established an account at any point in time, EBRI further emphasizes.
As for what might be holding back HSA-eligible health plan enrollment growth, Fronstin notes that, “Several factors may have caused employers to hold off on plans to move to HSA-eligible health plans, including the delay in the Cadillac tax, recent small health insurance premium increases, and low unemployment.”
Research findings also indicate some of the characteristics of HSA-eligible health plans may be curtailing enrollment growth, Fronstin explains. For instance, he notes that growth in HSA-eligible health plan enrollments may be held back because the elements of an HSA-eligible health plan may not provide employers with the desired level of flexibility in health plan design. “Ultimately, changes to public policy may be needed to expand enrollment,” Fronstin emphasizes.
