Has Enrollment in HSA-Eligible Health Plans Stalled?

Are we seeing fewer enrollments in HSA-eligible health plans? It’s hard to tell. Some surveys look at year-over-year growth of enrollment in HSA-eligible plans, which seems to be leveling off. Other surveys look at the number of health savings accounts being established, which continues to rise – for instance, EBRI finds that 21 percent of all HSAs were established in 2016. Are plan participants driving these differences as they change jobs and/or dis-enroll from HSA-eligible plans while maintaining ownership of existing HSAs and establishing new ones with new plans and / or new employers? What role does public policy play? )

Executive Summary

Both the number of health savings accounts (HSAs) and enrollment in HSA-eligible health plans have grown significantly since HSAs first became available in 2004. In 2017, enrollment estimates in HSA-eligible health plans vary considerably from 21.4 million to 33.7 million policyholders and their dependents. But there is one consistency between the enrollment estimates – most sources show that growth appears to have slowed in 2017, especially when looking at the market share of HSA-eligible health plan enrollment.

This Issue Brief examines trends in enrollment in HSA-eligible health plans. It compares surveys of individuals, employers, and health plans. It also puts enrollment trends in the context of the health policy environment.

• This Issue Brief examines the findings from five surveys.

Two surveys (conducted by EBRI/Greenwald & Associates and the National Center for Health Statistics (NCHS)) interview individuals with private health insurance obtained either through employment, directly from insurers, or through public exchanges.
Two surveys (conducted by Kaiser Family Foundation (KFF) and Mercer) interview employers to determine enrollment.
One survey (conducted by America’s Health Insurance Plans (AHIP)) polls insurance companies and obtains estimates for individuals with private health insurance either through employment, directly from insurers, or through public exchanges.

• Enrollment estimates for 2017 range from 21.4 million to 33.7 million individuals. AHIP, whose estimates generally are the lowest, has not released 2017 estimates yet. AHIP, EBRI/Greenwald & Associates, and NCHS estimates are in the low 20-million range, while KFF and Mercer estimates are in the lower 30million range. Surveys conducted by AHIP, EBRI/Greenwald & Associates, and NCHS cover the entire privately insured market, whereas those conducted by KFF and Mercer 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.

• All of the surveys find substantial growth in HSA-eligible health plan enrollment since HSAs were established in 2004.

• The surveys consistently find that there was very little growth in HSA-eligible health plan enrollment from 2014 to 2017.

• Two studies focus on growth in the number of HSAs rather than enrollment growth in HSA-eligible health plans. Devenir collects data from about 100 HSA providers and tracks the number of accounts universally. It finds that the number of accounts increased from 16.8 million at the end of 2015 to 20 million at the end of 2016. The Employee Benefit Research Institute (EBRI) HSA Database, which contains 5 million HSAs as of the end of 2016, finds that most HSAs have been established relatively recently and this indirectly supports the notion that we should be seeing growth in enrollment in HSA-eligible health plans. Data from the EBRI HSA Database show that 21 percent of HSAs were established in 2016.

E A A D Why Wh One Enr ll of e ndno ve spit oll fin at r m te he age a Mi e a l iss Mi e nt t ll su n e ght td of e he s ght rue E st v e inr m su y t 2 o s fin H ar 0 o B tc vS 1 e o ll ee 6 s for A ns d ym . s sh H su ide T C e h o b o 2 nt e ow rst ldi 01 E unt is a i m 7 r nt ng G w ng Bac ploy ia he r a s lit o l g nge tS the wt le r eho ow e ror fr h Ra tB o the k w Growt h in e no m n H su e 21 rfe S H it rt.4 mi c v S e A e e R A nt s y - e -s a , E e se g ll ligib by Ti li ion to ra c h Whe ow gib c rch ule r ta h h Il tm 33 n e in HSA e ely st a .7 mi e lt H n Enrollm it p h p u e or P ta e - te la lli e r lth Plan a r (E ligib n e on yiod BR g nr indi rle ow I) ol he v lm H te idua h in a SA D e nt lt nt E h p l s a nr si Do . ny a la nc A to n e a H g e e ba ll Ii v P H s nr m e se , SA n ye Not ollm w e , w s w hic nt a e h h e ? rn ic . rG g t e h , W e co r tne e hil he o strwt n e a a E t b lly 20 a B lis in h RI 17 rhe s e ? /G p 5 d ior s a r m e in 200 te s illion nw yte he a ar 4 ld . & Paul Fronstin is director of the Health Education and Research Program at the Employee Benefit Research Institute Has Enrollment in HSA-Eligible Health Plans Stalled? low w Fi Ass it gur h cons o ec st eia 2 show e te st HS s ist im su As a ea nt rts t v e e , ls o ow y he ha f inds fs not g g trrh ow ow e d e tta rh in h e n ta le d a c t a of ha rtsed os he t2 s t 0 im num 20 1 he p 61 lie , f 7 b su s e e in er rst d vof nr e s t im yoll e s, a hnr tm a e ttolle he s y e m nt re e ost H e t g s for . is row A a H tSAs h t I th. le P he , aSp E st A B a H e one RI v c Ie ifi P /Gr be , cy E ae eB lle e a y RI n nw r, e in /Gr aa st q m ld e ue a ost e blished r & nw st A ion re of ss ald oc th & e ila a e A tsu la te e ss s td riv v oc at e e nd o y ily as tt re he e N tha sC , cle H e ta S ngth of n nd sh te ly ow st N a iC m sn H a d low S tt t i m esu h s , e is a r no, v re ey in a snd , ( EBRI). This Issue Brief was writte n with assistance from the Institute’s research and editorial staffs. Any views The Se It is ve su in ratr l evfre a ey cst ts a or ing s lso m tha a re y tp b su or et r v hold ceoyns s ing on isteb e nt a nr c g k ollm r g ow row etnt h r t h in in HS ates ove HA SA -e-rligib e ligib sele lec le the he tim alt ae h p lt h p pe la rla iod ns n s a e. rnr e In o oll not m r de se how nt r s to . in Ie tg xa c a g m n b row ine et h, g ar r ow g wue hil th d e r tsu a ha te rtv s ove e the ys on loom r titm he ing e, 1 t som By Pa ne the he g a su low etone iv rv ul Fro e 20 e in g y ha s r dire -ow m d th ill b t a ns c ion r h follow t e t ly e etn x in, su a a em nge nr ppo Ph.D. ine e olle d , rt w b bd s t ot y hil in th , a h e h e E e rK a n mplo m FF t ehe oti ir p loy a r he on nd la m ye a t r lg e Me th h p e nt e a Ben r jt -um c w la be a n f re sed p e sh e inds st in e fi im he otu R nr a a tld be ha tlt oll e e h i s ts m a e 19 ns se e ra e nt ur rch I pe in t . e aiFor r n nc cg gr he eent ns e a low xa nd ow ha titut m e d tcp r h ov b le 30 in e ee , e - r e in 201 n e m ag n ill e rollm nr io ob olle n r 3, ta e a K d in nge ne FF in t t id n sh . he in t H Aow H ir SA he I s P he -, a e non a E n ligible lt B8 p h p RI -g/G e rla oup r h r n le ce e ee nt a nw m ss lt rh a e a t r pla d h k ld uc e a tn & . n tion s. See Fronstin and Elmlinger (2017). w e num Cxpress a ed e ill b xa a ecrm e tof d ine a x sho in t e st av a his e b uld rli ash rg eha e p e or d a v nnu te H a SA arc e ac s l e tg a hose le r re ow ra sh tt eof h r d ow e tahe ing nr teoll s for ag ut m row h e o nt the t rh s a g . r follow The ow nd tsh h in su in ould rg v t o e four y H not s on SA t im -bee eligib e nr a p sc oll ele rrm ibe iod he ent d s: a lt t c o h p oun the la t ns off the , ic b num e ut rs, t the breus rre of tis ee p no s, or ot eop ev le ide e he nr nc rolle espon of d tiha sor n a ts . n A a one And H ssIo Py Me c e ia fin at rre d cD , e s s 28 a , rt ta f ha a inds nd p fterom r e N c nr 1 p e Cnt H oll tS e h m h r e c c ae E ov e d nt nt BR e b r e in g I HSA e trche n e ow re at e nr sed h nt olle D in HS ira e fr t d a om p ba r 1 A iv -- 2 ye se a e 1 mi tligib e sh ly all row le in ion to 20. s, a su he tnd rh a ea lt dth p 2 2 m 3 p 2 mi 1 a la pe re k n e rec lli tre , nr c on nt e w ollm n he ha b t of erd te e w H a n b e s K te , e SAs w en 2005 follow n e FF nr and eolle ere d aMe e nd b dy st r 3 20 c 27 a -e 4 ye blishe r16 p ce ov . a r c rN e s e d in 2 rC nt (H onl Fi S a g nd y ur d 0 id e 1 e59 m 6 not 6 .p ). loy p esrm tcae e rnt tn t -based of EBRI, Employee Benefit Research Institute-Education and Research Fund (EBRI-ERF), or their staffs. Neither EBRI Som HSA-ee ligib emple loy he era s ha lth p vla e n a chose t a n HSA specifi-c e ligib point le in heta im lth e. pW lans hil ep r tim hea E ril By RI a/Gr s ae w enw ay a to ldsa &v A es on socp iarteem s ium surv s. ey I tfi is nds alsto ha ptla 19 usi p be ler cte ha ntt Feb Septe 2.m 1 b6 e, r 20 201 10 • 8 N • o N.o 3 . 46 441 See https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf ? 2007-2009 c he golle row altch p tth, ing la ren e spe s nr . ollm H cteiv nc e ely e nt , , td in 201 he at a A H un 4 IP . til 201 , Sim EBRI ila 0, /Gr rly a, nd eN eC nw fH inds S a ld sh t & h ow a A ts ss it no o in cc ig a rrt eow e assed , th in and from 20 NC 1 H 64 follow S m eill st ion to ime ad te b s sh 22 y 17 m ould ill pion in e rb ce e nt la 20 rg g17 re ow r. tt The ha h in n K20 FF1 a 5nd . Hence of nor rece e nr E nt Bolle RI low -e E s a R he F lob r ae lt h in ne bie wsu s or , im ra n ptc ly ae k in epg s p r e tm he osit ium reions is in e con nr reollm aspe sese c , nt ific a sg p s row how olicty h, n in p no rop Fi su os gur ra vls e e . y10 E dB ,ir R e cI om c tinv lyb m iine tees c d asu w om riteh low m s d ent ise une on nrollm tm his pe loy nt resea m fre om nt rch. m H SA ay -h ea ligib ve le Introduction ? 2010-2012 Me it 3 E Bis RI r cpe /Gr oss r, e how ible enw eta v ha ld ert , & su Fi A g css h st uro ec a ia 1 sh tis tets t ic ow ael s j aam nom us w t atas una he lie s a opb p re le osit dtr o e iv. sep ing aw ra hta et H aSA pp efr ao rs t m o HR be A low esti m graow tes th in befor 20 e17 2015 . Ult . im The ateE ly B, RI m/Gr oree e ynw eara s ld he cau ased lth p e la m np sloy tha et r s t mo ayhold be offs off e on tting plane ns w to em nrov ollm e te o nt H. SA Unpu -elig bible lishe he d a Elt Bh p RI la tans bul . ations of enrollment and disenrollment data See https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/ In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) included a provision that created ? 2013-2016 & and Ass m oor cia e tr ees su searrv ce h int y sh o ow ths e is q nr ue ollm stion entare is cne on csi es st sa en ry tly to in t behe tte r low unde 20r-st ma ill nd ion ra trends nge, in HS whicA h ma -eligib y indic le hea atlt eh p tha latn e it w nr aollm s ent. in t Copyrig he Truv ht e n He Inform alth a Atna ioln: yti cThi s’ Ma s re rk pe or tSc t is an C cop oy m right mere cd ia l C by la the im s Em and ploy En ec eount Bene erfit s D Re atsea abarse ch I indic nstit au te te t h (E aB t RI 10 p ). Ietr m cea nt y b oe f health savings accounts (HSAs) and HSA-eligible health plans. The provision allows individuals enrolled in high- 4 ? 2017 See https://www.mercer.com/newsroom/mercer-national-health-survey-employers-finding-new-ways-to-hold-the-line-on- overestimating HSA enrollment before 2017. used without permission but citation of the source is required. persons with individual coverage and 8 percent of persons with family coverage disenrolled from their HSA-eligible deductible health plans meeting certain requirements to open and fund a health savings account (HSA), a tax-exempt Figure 1 he Ha alths -b eE nefit n-r coo stll -gro me wth.html nt i n HSA-Eligible Health Plans Stalled? health plan between 2013 and 2014. References Surveys on HSA-Eligible Health Plan Enrollment trust or custodial account that is funded with contributions and assets that an individual can use to pay for health care These time periods were chosen because they represent distinct public policy periods. Public policy was stable from R 5 ecommended Citation: Paul Fronstin, “Has Enrollment in HSA-Eligible Health Plans Stalled?,” EBRI Issue Brief, By Pa See http ul Fro s://wns wwt.in, cdc.g Ph.D. ov/nch,s E /dmplo ata/nhye is/ee a Ben rlyrelee afi set/ R inse urs20171 earch I 1.pdns f titute e Ag xpe arw ns ae l, s. I Rajndivi ended r,ua Ol lse n ca a n Maz coure ntribu nko, te atnd o a Nir n HS Me An only ache mi. if the "Hyig a hr-e De ed nr uc olle tibd le in a Hean HS lth Pla A- ns eligib Redle uc he e H ae lta h p lth la Ca n, rea nd Costt he And y b enefit 2007 to 2009, as there were no major health policy initiatives in Congress. It was post-MMA and pre-ACA. The Patient Another difference between the number of insurance enrollments and the number of HSAs is that insurance enrollments no. 441 (Employee Benefit Research Institute, Feb. 16, 2018). 2017 HSA-Eligible Health Plan Utilization, Including Use Of Needed Preventive Services." Health Affairs 36, No. 10 (October 2017): 1762-1768. from a triple-tax advantage: employee contributions to the account are deductible from taxable income, any interest or 6 Protection and Affordable Care Act (ACA) passed in March 2010, and was followed by years of uncertainty regarding measure only current participants, while data on HSAs are potentially counting the number of people who have See page 3 in https://www.segalco.com/media/3289/segal-aca-ahca-bcra-chart.pdf Enrollment Estimate other capital earnings on assets in the accoun A t T buil d A up taG x frL ee, Aand N dC istrE ibu tions for qualified medical expenses from how the ACA would be regulated and its impact on insurance markets. Policy stability returned from 2013 to 2016. The Survey Years Sample established an account at any point in time. While an individual can only establish and contribute to an HSA if he or she R Fron epsor tin, t a Pa vaila ul, and bili Ann ty: e Thi Elmli s r ng ep eor r. t"Con is as vume ailab rle Eng on ag the eme Int nt ein rne Hte a alth t wC w aw re.e : b Find ri.or ing g s from the 2016 7 the HSA are excluded from taxable income to the employee. See http://vbidcenter.org/draft-executive-order-enables-innovation-in-hsa-hdhps/ regulations for most parts of the ACA had been released (a Pnd ercew ne t o re f T b ota eing l implemented, though that often meant is enrolled in an HSA-eligible health plan, after disenrolling, the individual may continue to keep the HSA. They are not EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey." EBRI Issue Brief, no. 433 (Employee Both the number of health savings accounts (HSAs) and enrollment in HSA-eligible health plans have grown (Millions) Enrollment) implementation of significant health plan changes. The end of 2016 brought renewed uncertainty with the presidential able to make contributions to an HSA after disenrolling from an HSA-eligible health plan, but they are able to keep the Benefit Research Institute, May 2017). Both the number of HSAs and enrollment in HSA-eligible health plans have grown Isi nd ginif vidic uaa lsnt un ly d esi r n agc ee 6 5 H w SA iths afi nr ys t became significantly since HSAs first became available in 2004. In 2017, enrollment estimates in HSA-eligible health plans election and the possibility of repeal and replacement of the ACA. It can be argued that when it comes to enrollment in H SA open and use the money at any time in the future for past or future medical expenses. EBRI/Greenwald & Associates, Consumer Engagement in private health insurance (calculated Table of Contents available in 2004. In 2017, enrollment estimates in HSA-eligible health plans vary considerably from 21.4 million to 33.7 vary considerably from 21.4 million to 33.7 million policyholders and their dependents. But there is one health plans, 2017 should be included with the 2013-2016 policy stability years because decisions about workplace Health Care Survey (CEHCS) 2 1.4 11% 2005-2017 from survey of adults) Introduction .......................................................................................................................................................... 4 policyholders and their dependents. But there is one consistency between the enrollment estimates – most sources consistency between the enrollment estimates – most sources show that growth appears to have slowed in 2017, The he Ame alt rE ih b cB a’RI se H ne eH aSA lfit ths In D a sa u nd rta a nb p ca er iv se Pla an tsh e s (o h Aw H eIa s t Plt ),h insu * ha Sutr v the ey r a o rnc e f a er e co av e prot ag ee nt off ialle yr e la dr g thr e num ough th ber eof pu Hb SA lics m tha artk e m tp ala y c no e w long eree m r b ad e ec ur long rent ble yfo re show that growth appears to have slowed in 2017, especially when looking at the market share of HSA-eligible health e Hspe SA-c Eia ligib lly w le h He en a loo lth Pkla inn En g atr t ollm he m ent a rket ................................ share of HSA-eligible ................................ health plan enrollme ................................ nt. ........................ 4 Health Savings Account - High Deductible Health Plans 20.2 11% 2005-2016 Health insurers a the sso 20 cia 16 te d e le wc itth a ion. n HS A-eligible health plan. At the end of 2016, the EBRI HSA Database contained 2.0 million HSAs that p Kla aisn e er Fnr ami ollm ly Fo eun ntd.a tion (KFF), Employer Health Employers with three or more d Aid ver not age r e Ecnr eiv oll em ae ny nt cG ornt ow ribut th Ra ions in 201 tes, by Ti6, a me cP ce orunt ioding ................................ for 36 percent of the ................................ accounts in the data ................................ base. The lack of ... 8 Benefits Survey 31.5 19% 2006-2017 workers This Issue Brief examines trends in enrollment in HSA-eligible health plans. It compares surveys of individuals, As can be seen from Figure 5, growth rates in HSA-eligible health plan enrollment have been trending down across contributions may indicate that the accounts were no longer eligible for contributions because their account owner was Mercer, National Survey of Employer-Sponsored Health A Thi ccs ount Issu G e rB ow rie th f ................................ examines trends in enr ................................ ollment in HSA-eligible ................................ health plans. It exam ................................ ines surveys of individu ..................... als, 9 employers, and health plans. It also puts enrollment trends in the context of the health policy environment. most of the surveys examined in this paper over all of the distinct policy periods. no Planlong s er enrolled in an HSA-eligible health pla n. The 33p .7ercenta 20% ge of accoun 2006t -s no 2017 t E re mp ce loiv ye ing rs wc ith ont 10r ibut or mo ions re w ow rka es 3 rs 1 employers, and health plans. It puts the trends in enrollment in the context of the health policy environment. It also Why Might HSA Counts Show Growth When Enrollment Does Not? ..........................................................................11 Individuals under age 65 with any percent in 2013, 30 percent in 2014, 41 percent in 2015, and then 36 percent in 2016 (Figure 9). Other than the discus ? ses Th wis hyIssu incon e Br sisie tefnc exa ies m ein xis ets t ac hre o f ss in td he in gs varfiou rom s w fiv ay es in w surve hic ysh t . rends in enrollment are measured, and ends with National Center for Health Statistics (NCHS), National private health insurance (calculated What Might Be Holding Back HSA-Eligible Health Plan Enrollment Growth? ...............................................................12 decline from 41 percent to 36 percent between 2015 and 2016, the percentage of accounts not receiving any a H ed ais lth c u Inss teion o rview f S uw rvha ey t( N m Hight IS) be holding back grow th in 21H .9SA-eligib 10% le health p 201la 0-n e 2017nrollm from e su nt rv.e y of adults) contributions appears to be trending up, which would imply that simply looking at the number of accounts is not a good o Two surveys (conducted by EBRI/Greenwald & Associates and the National Center for Health References ...........................................................................................................................................................13 * 2016 estimates are used in the table above because 2017 estimates are not yet available. proxy to measure trends in HSA-eligible health plan enrollment. Statistics (NCHS)) interview individuals with private health insurance obtained either through Endnotes .............................................................................................................................................................14 HSA-Eligible Health Plan Enrollment employment, directly from insurers, or through public exchanges. It can be challenging to determine how many people are enrolled in an HSA-eligible health plan and how that number There are a number of questions that can be asked about the various surveys. Are the AHIP, EBRI/Greenwald & has been chao nging Tw . For o su trvey he ms ( ost c opn adu rt, ctthe ed by re a rKa e jise ustr Fa a ha m ndful o ily Fou f su nda rv tion eys u (KFF sed) ta o ndd Me eterm rcine er) in thet e num rview be e r m of ploy peop ers t le o Figures Associates, and NCHS surveys underestimating the privately insured marketplace? Are the KFF and Mercer surveys enrolled in an HSA-eligible health plan. This Issue Brief examines data from the following five surveys, with all but one determine enrollment. Figure 1, Surveys on HSA-Eligible Health Plan Enrollment overestimating the employment-based marketplace? Is it possible that a combination of both is occurring? conducted annually since as far back as 2006: Account Growth o One survey (conducted by America’s Health Insurance Plans (AHIP)) polls insurance companies Figure 2, HSA-Eligible Health Plan Enrollment in Millions, 2005-2017 1 A Ins HItP e aunde d of rerxa epm orini ts ng enr eollm nrollm ente,nt a s m in HSA any -he eligib alth p le he lans alt h p do not lans r , eespond xamin a to tio the n o su f trhe ve y num . EBbRI er/Gr of eH eSA nws fin ald d &s r Ass ecoc ent ia tg ersow als th o . ? EBRI/Greaen nw d obt ald a &in A sss eo st cim iata ets eC s f onsu or im ndivid er Eng uaals w gem itehnt pri in vH ateea h lth ea Clt ah re in Sur sura ven yc e either through employment, potentially underreport enrollment because enrollment estimates are based on a panel of respondents who have agreed Two studies focus on HSAs themselves rather than enrollment into HSA-eligible health plans. Devenir collects data from ? Survey of dire Hec atlt ly h S from ins avings u Are ccrs, ount or t – h Hrou igh gh p Deduc ublic tible e xc He haaltnh P ges. lans conducted by America’s Health Insurance Figure 3, HSA-Eligible Health Plan Enrollment as a Percent of Total Private Health Insurance Market, 2005-2017 2 t ao bout par t10 icip 0 aH te SA in online provide su rs a rvn ed y s. traY ck oung s the e rnum , minor beri tof y, a m ca co leunt s as uni re less ve rlik saelly ly. tIt o p fin ardts icipa thatte t he in suc num h p be arne of lsa , c bcut oun wt es inc ightin reg a sed the Plans (AHIP) In addition, new research findings indicate some of the impacts of HSA-eligible health plans may be holding back 3 ? Enrollment estimates for 2017 range from 21.4 million to 33.7 million individuals. AHIP, whose estimates data tries to correct for such underreporting. However, to the degree that HSA-eligible health plan participants are less from 16.8 million at the end of 2015 to 20 million at the end of 2016 (Figure 7). While it also shows an increase to 21 Figure ? 4, E Pm erc ploy enta erg e H e oa f lt Enro h Be lle ne esfit in s Sur HSAv-e Elyig cib ond le H uc ea te lth d b Py la ns the , 2014 Kaiser -2017 Fam ily Foundation (KFF) enrollment growth. For example, a recent systematic review of the research has found that HSA-eligible health plans 4 generally are the lowest, has not released 2017 estimates yet. AHIP, EBRI/Greenwald & Associates, and lik mill ely ion a to c pc aou rtic nt ipa s b te y in online the midd le pa o ne f 201 ls, the 7, mos EBRI t /G of rtehe enw gra ow ld t& h in Ass the ocia etst es a b elis sth im maetnt e w of ill aunde ccount rres oc portc u ernr s a oll t m the ent e. nd of Simila ? rly, NF aigur tione a l Sur 3 show veys of the E m cha plo nge yer -in HSA Sponsor -ee ligib d Hle ea he lth P altla h p nsla c n e ond nr uc ollm tede n bty aMe s ar cp ee rrc ent of the total commercially may be associated with a reduction in appropriate preventive care and medication adherence (Agarwal, Mazurenko and 5 Figure 5, Average Growth Rates in HSA-Eligible Health Plan Enrollment, by Select Time Periods NCHS estimates are in the low 20-million range, while KFF and Mercer estimates are in the lower 30- Furthermore, EBRI /Greenwald & Associates conduct surveys only in English, whereas NCHS conducts its survey in both calendar years in anticipation of coverage that begins January 1, and so the growth between the end of 2016 and mid- ? National Health Interview Survey conducted by the National Center for Health Statistics (NCHS) insured market using the AHIP, EBRI/Greenwald & Associates, and NCHS surveys. AHIP finds that enrollment increased Menachemi 2017). These findings may cause employers to hold back from adopting HSA-eligible health plans. They million range. Surveys conducted by AHIP, EBRI/Greenwald & Associates, and NCHS cover the entire E 20 nglish 17 sh a ould nd Sp not anis beh. v iewed as slow growth. Devenir notes that 24 percent of the accounts in 2016 were unfunded, from 1 percent to 11 percent between 2005 and 2016, while NCHS finds that enrollment increased from 3 percent to 10 m ay also cause employers that offer HSA-eligible health plans as a choice to hold back from moving to only offering Figure 6, Length of Time Enrolled in an HSA or HRA Plan, 2017 As can be priva seetn in ely in Fig su ur re e d m 1, two arket of , w the h e fiv re ea su s trh vose eys c (E on BRI du /Gr cte ed b enw ya KFF ld & a An ss d Me ociar te ce s r c and ov N er o CHS n) ly int em erploy viewm indiv ent-idua base lsd with which supports the point that many accounts are established toward the end of calendar years in anticipation of percent between 2010 and 2017. EBRI/Greenwald & Associates find a constant 11 percent enrollment share from 2015 HSA-eligible health plans. Despite examining enrollment only in employment-based health plans, KFF and Mercer have larger enrollment private he he aa ltlt h in h pla surn as n. ce He ob nc ta eine , th de e A itHIP her , E thrBR oug I/h e Gre m epnloy wa m lde nt & A , dss ire oc ctia lyt e frso, a m n ins d u NrCHS ers, or est tim hroug ates sh h public ould be exch la ange rger t s. h Ta wno coverage that begins in January. to 2017. Figure 7, Total HSA Accounts, 2009-2017 estimates than AHIP, EBRI/Greenwald & Associates, and NCHS, and actually underreport such enrollment. KFF collects of the fivteh ose surv re eyport s (KFF ed by and KMe FFr a ce nrd ) in Me tercer rvie, bu w em t t ph loy e da ers t tao sh de ow ter jm uine st t h ee nr oppo ollmesit nt e–. these surveys do not include the I n addition, growth in HSA-eligible health plan enrollments may be held back because what constitutes an HSA-eligible data only on employers with three or more workers, and Mercer collects data only on employers with 10 or more The EBRI HSA Database, which contains 5 million HSAs as of the end of 2016, finds that most HSAs have been smallest employers and do not include estimates from the non-group market. And one of the five surveys (AHIP) The surveys are also consistent in the finding that there was very little growth in HSA-eligible health plan enrollment Fi he ga ure lth p 8,la Hn d SAs oe , b s not y Ye ap r rAc ovc ide oun et m wpaloy s O ep re s t ne he d ir desired level of flexibility around the design of the health plan. Under ? All of the surveys find substantial growth in HSA-eligible health plan enrollment since HSAs were e wst or ak belis rs. he d relatively recently and this indirectly supports the notion that we should be seeing growth in enrollment in su from rve 20 ys 14 ins t uo ra20 nc1 e7 c , oam s se panie en i sn aFi nd gur ob et a 4in . E s B eRI stim /Gr ae te es fo nwarld in & div Aidua ssocls ia w teit sh p and rivK aFF te he find alt th insu hat enr raoll ncm e eob ntt a in HS inedA e-it ehe ligib r le current IRS rules, to qualify as an HSA-eligible health plan, the health plan deductible must cover all health care established in 2004. HSA-eligible health plans. Data from the EBRI HSA Database show that 21 percent of HSAs were established in 2016 Fi thr gure oug 9, h e Pm erc ploy enta mg ee nt o, f d H irSeAs ct ly W fr ithou om t in Any sure Con rs, or t tribution hroug s, h 20 p13 ublic -2016 exc hanges. he alth plans was steady from 2016 to 2017, while Mercer and NCHS find that enrollment increased by 1 percentage services, with the exception of certain preventive services. More employers (and presumably more employees) may (Figure 8). point between 2016 and 2017. Three surveys – NCHS, KFF and Mercer -- find a 2-4 percentage point increase in offer and/or enroll in HSA-eligible health plans if plan sponsors had more discretion over which services could be ? The surveys consistently find that there was very little growth in HSA-eligible health plan enrollment from Figure 10, Premium Increases Among Employers With 10 or More Employees, Worker Earnings and Inflation, 6 7 enrollment between 2015 and 2016. However, similar to the lack of growth between 2016 and 2017, four surveys find excluded from the deductible. Recently both members of Congress and the Trump administration have shown an 2014 to 2017. 1988-2016 EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 ?137X/90 0887 ?137X/90 $ .50+.50 either no growth (Mercer and NCHS) or a one-percentage point growth (AHIP and KFF) between 2014 and 2015. interest in expanding the number of people enrolled in HSA-eligible health plans by increasing the HSA contribution limits ? and Tw by o studie enhancs f ing ocH uSA s on -eligib grow le the h in alt h p thela n ns um , w be hic r h ofm H aSAs ra y move th p ela r t n sp han onso enrrollme s sittin ng t grow on the th si in d H elin SA e- ne eligible ed to h ad ed a ltah n © 2018, Employee Benefit Research Institute ?Education and Research Fund. All rights reserved. HSA-eligib pla len he s. a D lte h p vela nir n.c ollects data from about 100 HSA providers and tracks the number of accounts universally. It finds that the number of accounts increased from 16.8 million at the end of 2015 to 20 million at the e e e e e e e e e e e e eb b b b b b b b b b b b br r r r r r r r r r r r ri. i. i. i. i. i. i. i. i. i. i. i. i.o o o o o o o o o o o o or r r r r r r r r r r r rg g g g g g g g g g g g g IIIIIIIIIIIIIs s s s s s s s s s s s ss s s s s s s s s s s s su u u u u u u u u u u u ue e e e e e e e e e e e e B B B B B B B B B B B B Br r r r r r r r r r r r rief ief ief ief ief ief ief ief ief ief ief ief ief • • • • • • • • • • • • • Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb Feb............. 16 16 16 16 16 16 16 16 16 16 16 16 16,,,,,,,,,,,,, 2 2 2 2 2 2 2 2 2 2 2 2 20 0 0 0 0 0 0 0 0 0 0 0 01 1 1 1 1 1 1 1 1 1 1 1 18 8 8 8 8 8 8 8 8 8 8 8 8 • • • • • • • • • • • • • N N N N N N N N N N N N No o o o o o o o o o o o o............. 4 4 4 4 4 4 4 4 4 4 4 4 44 4 4 4 4 4 4 4 4 4 4 4 41 1 1 1 1 1 1 1 1 1 1 1 1 11 10 13 14 12 2 3 5 6 8 4 9 7 EBRI Education and Research Fund © 2018 Employee Benefit Research Institute