Most adults enrolled in high-deductible health plans don't use a health savings account to save for healthcare expenses, even if they have one.
According to a study published Friday in JAMA Network Open, about a third of adults enrolled in a high-deductible health plan, or HDHP, didn't have an HSA, while nearly 60% of adults in those plans did have one. Another 10% of people surveyed didn't know if they had an HSA or didn't answer the survey question.
Among people who had an HSA, more than half of them didn't contribute to it during the past year.
"These findings are concerning given that the proportion of employers offering HDHPs has increased dramatically in the past 15 years," Duke University's Matthew Maciejewski and Anna Hung wrote in their commentary on the study.
More than a third of people surveyed hadn't thought about contributing to an HSA, while another third said they couldn't afford to save for healthcare.
"Employers and health plans have potentially important roles to play in helping individuals with HSAs better understand these accounts and make financially advantageous decisions about their saving for healthcare," according to the study.
Nearly half of individuals who contributed to an HSA saved $2,000 or more. Most people that funded an HSA didn't have any other savings for healthcare expenses.
"Current legislative efforts to increase the HSA contribution limit would likely have little effect on healthcare savings for the vast majority of people," the study said.
People with high-deductible plans can use HSAs to save for healthcare expenses tax-free. Some experts like high-deductible plans because they can lower premiums and encourage people to use less care or choose higher-value care. But many worry high-deductible health plans and HSAs are too complicated for most people to understand and use, often leading people to delay needed care thanks to higher out-of-pocket costs and inadequate savings.
"For HDHPs to realize the goals of motivating patients to shop around for healthcare, increasing their price sensitivity and minimizing the chance that they forgo necessary care, a high proportion of HDHP enrollees must enroll in an HSA and contribute sufficient funds to meet their out-of-pocket expenses," Maciejewski and Hung wrote.
Over the past decade, many employers have pushed more of their workers into high-deductible plans to control healthcare spending, leading to renewed calls to break the link between employment and health insurance as workers bear more healthcare costs.
"HDHPs seem to be shifting a substantial amount of risk from employers to employees. This is particularly concerning for low-income families who may not have discretionary income to contribute to an HSA," Maciejewski and Hung wrote.
More people might take advantage of HSAs if employers and policymakers make them easier to understand and enroll in, experts say. For example, workers would be more likely to enter and fund HSAs if employers automatically signed them up with a monthly contribution. Workers would have to opt-out of an HSA rather than opt into it. Research shows people are most likely to choose the default option in the majority of cases.
According to the study, adults with a master's degree or higher were far more likely to have an HSA than people with a high school education or less. Likewise, individuals with an HSA were significantly more likely to contribute to their HSA if they knew a lot about health insurance.
About 70% of people that enrolled in a plan through a health insurance exchange lacked an HSA, while people enrolled in high-deductible plans were significantly more likely to have an HSA if their employer offered more than one plan.
The share of people with private coverage enrolled in high-deductible plans rose from 25% in 2010 to 40% in 2016, according to the researchers.