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Medical savings accounts: assessing their impact on efficiency, equity and financial protection in health care

  • Olivier J. Wouters (a1), Jonathan Cylus (a1) (a2), Wei Yang (a1) (a3), Sarah Thomson (a1) (a2) (a4) and Martin McKee (a2) (a5)...

Abstract

Medical savings accounts (MSAs) allow enrolees to withdraw money from earmarked funds to pay for health care. The accounts are usually accompanied by out-of-pocket payments and a high-deductible insurance plan. This article reviews the association of MSAs with efficiency, equity, and financial protection. We draw on evidence from four countries where MSAs play a significant role in the financing of health care: China, Singapore, South Africa, and the United States of America. The available evidence suggests that MSA schemes have generally been inefficient and inequitable and have not provided adequate financial protection. The impact of these schemes on long-term health-care costs is unclear. Policymakers and others proposing the expansion of MSAs should make explicit what they seek to achieve given the shortcomings of the accounts.

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Corresponding author

*Correspondence to: Olivier J. Wouters, Researcher, LSE Health and Social Care, Cowdray House, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK. Email: O.J.Wouters@lse.ac.uk

References

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Asher, M. and Nandy, A. (2006), ‘Health financing in Singapore: a case for systematic reforms’, International Social Security Review, 59(1): 7592.
Asher, M., Ramesh, M. and Maresso, A. (2008), ‘Medical savings accounts in Singapore’, Euro Observer, 10(4): 911.
Baicker, K., Dow, W. H. and Wolfson, J. (2007), ‘Lowering the barriers to consumer-directed health care: responding to concerns’, Health Affairs, 26(5): 13281332.
Barr, M. (2001), ‘Medical savings accounts in Singapore: a critical inquiry’, Journal of Health Politics, Policy and Law, 26(4): 709726.
Bloche, M. G. (2006), ‘Consumer-directed health care’, New England Journal of Medicine, 355: 17561759.
Bloche, M. G. (2007), ‘Consumer-directed health care’, Health Affairs, 26(5): 13151327.
Buchmueller, T. C. (2008), ‘Consumer-oriented health care reform strategies: a review of the evidence on managed competition and consumer-directed health insurance’, Milbank Quarterly, 87(4): 820841.
Buntin, M. B., Damberg, C., Haviland, A., Kapur, K., Lurie, N., McDevitt, R. and Marquis, M. S. (2006), ‘Consumer-directed health care: early evidence about effects on cost and quality’, Health Affairs, 25(6): w516w530.
Buntin, M. B., Haviland, A. M., McDevitt, R. and Sood, N. (2011), ‘Healthcare spending and preventive care in high-deductible and consumer-directed health plans’, American Journal of Managed Care, 17(3): 222230.
Charlton, M. E., Levy, B. T., High, R. R., Schneider, J. E. and Brooks, J. M. (2011), ‘Effects of health savings account-eligible plans on utilization and expenditures’, American Journal of Managed Care, 17(1): 7986.
Chen, S., Lo Sasso, A. T. and Nandam, A. (2013), ‘Who funds their health savings account and why?’, International Journal of Health Care Finance & Economics, 13(3–4): 219232.
Chia, N. C. and Tsui, A. K. (2005), ‘Medical savings accounts in Singapore: how much is adequate?’, Journal of Health Economics, 24: 855875.
Cress, J. R. and Zimmer, D. M. (2011), ‘Medical savings accounts and preventive health care utilization’, Journal of Economics and Management, 7(1): 122.
Cylus, J. and Thomson, S. (2012), ‘Medical savings accounts’. Background paper prepared for a Senior Policy Seminar in Bishkek, Kyrgyzstan, 29–30 November, on behalf of the WHO Regional Office for Europe.
Davis, K. (2004), ‘Consumer-directed health care: will it improve health system performance?’, Health Services Research, 39(4 Pt 2): 12191234.
Dixon, A. (2002), ‘Are medical savings accounts a viable option for funding health care?’, Croatian Medical Journal, 43(4): 408416.
Dixon, A., Greene, J. and Hibbard, J. (2008), ‘Do consumer-directed health plans drive changes in enrollees’ health care behavior?’, Health Affairs, 27(4): 11201131.
Fowles, J. B., Kind, E. A., Braun, B. L. and Bertko, J. (2004), ‘Early experience with employee choice of consumer-directed health plans and satisfaction with enrolment’, Health Services Research, 39(4): 11411158.
Fronstin, P. (2012), ‘Health savings accounts and health reimbursement arrangements: assets, account balances, and rollovers, 2006-2011’, Employee Benefit Research Institute, 367(Issue Brief): 128.
Fronstin, P. (2014), ‘Lifetime accumulations and tax savings from HSA contributions’, Employee Benefit Research Institute Notes, 35(7): 124.
Fronstin, P., Sepúlveda, M. J. and Roebuck, M. C. (2013a), Medication utilization and adherence in a health savings account-eligible plan’, American Journal of Managed Care, 19(12): e400e407.
Fronstin, P., Sepúlveda, M. J. and Roebuck, M. C. (2013b), Consumer-directed health plans reduce the long-term use of outpatient physician visits and prescription drugs’, Health Affairs, 32(6): 11261134.
Glied, S. (2008), ‘Health savings accounts in the United States’, Euro Observer, 10(4): 56.
Glied, S. and Remler, D. (2005), ‘The effect of health savings accounts on health insurance coverage’, The Commonwealth Fund, 811(Issue Brief): 18.
Goldsworthy, T. (2014), ‘The NHS is terminally ill—we need a new Healthcare system’. Adam Smith Institute, www.adamsmith.org/blog/uncategorized/the-nhs-is-terminally-ill-we-need-a-new-healthcare-system/ [20 May 2015].
Gramm, P. (1994), ‘Why we need medical savings accounts’, New England Journal of Medicine, 330(24): 17521753.
Greene, J., Hibbard, J., Murray, J. F., Teutsch, S. M. and Berger, M. L. (2008), ‘The impact of consumer-directed health plans on prescription drug use’, Health Affairs, 27(4): 11111119.
Greene, J., Hibbard, J. H., Dixon, A. and Tusler, M. (2006), ‘Which consumers are ready for consumer-directed health plans?’, Journal of Consumer Policy, 29(3): 247262.
Hardie, N. A., Lo Sasso, A. T., Shah, M. and Levin, R. A. (2010), ‘Behavioral healthcare services use in health savings accounts versus traditional health plans’, Journal of Mental Health Policy and Economics, 13(4): 159165.
Haseltine, W. A. (2013), Affordable Excellence: The Singapore Healthcare Story. Brookings Institution Press, Washington, D.C., 182pp.
Haviland, A. M., Sood, N., McDevitt, R. and Marquis, M. S. (2011), ‘How do consumer-directed health plans affect vulnerable populations?’, Forum for Health Economics and Policy, 14(2): 112.
Helmchen, L. A., Brown, D. W., Lurie, I. Z. and Lo Sasso, A. T. (2015), ‘Health savings accounts: growth concentrated among high-income households and large employers’, Health Affairs, 34(9): 15941598.
Hoffman, C. and Tolbert, J. (2006), ‘Health savings accounts and high deductible health plans: are they an option for low-income families?’, issue paper, Volume 7568. The Henry Kaiser Foundation (KFF), Washington, D.C., 23pp.
Hsiao, W. (1995), ‘Medical savings accounts: lessons from Singapore’, Health Affairs, 14(2): 260266.
Hsiao, W. (2001), ‘Behind the ideology and theory: what is the empirical evidence for medical savings accounts?’, Journal of Health Politics, Policy and Law, 26(4): 733738.
Hurley, J., Guindon, G. E., Rynard, V. and Morgan, S. (2008), ‘Publicly funded medical savings accounts: expenditure and distributional impacts in Ontario, Canada’, Health Economics, 17: 11291151.
Jost, T. (2005), ‘Consumer-driven health care in South Africa: lessons from comparative health policy studies’, Journal of Health & Biomedical Law, 1(2): 83109.
Jost, T. (2007), Health Care at Risk: A Critique of the Consumer-Driven Movement, Durham: Duke University Press.
Lee, T. H. and Zapert, K. (2005), ‘Do high-deductible health plans threaten quality of care?’, New England Journal of Medicine, 353: 12021204.
Lei, X. and Lin, W. (2009), ‘The new cooperative medical scheme in rural China: does more coverage mean more service and better health’, Health Economics, 18: S25S46.
Liu, G. G., Zhao, Z., Cai, R., Yamada, T. and Yamada, T. (2002), ‘Equity in health care access to: assessing the urban health insurance reform in China’, Social Science and Medicine, 55(10): 17791794.
Liu, J. and Chen, T. (2013), ‘Sleeping money: investigating the huge surpluses of social health insurance in China’, International Journal of Health Care Finance and Economics, 13(3–4): 319331.
Lo Sasso, A., Shah, M. and Frogner, B. (2010), ‘Health savings accounts and health care spending’, Health Services Research, 45(4): 10411060.
Lo Sasso, A. T., Rice, T., Gabel, J. R. and Whitmore, H. (2004), ‘Tales from the new frontier: pioneers’ experiences with consumer-driven health care’, Health Services Research, 39(2): 10711090.
Lueck, S. (2015), ‘New Republican proposal would leave millions uninsured or underinsured’. Center on Budget and Policy Priorities, http://www.cbpp.org/blog/new-republican-proposal-would-leave-millions-uninsured-or-underinsured [24 October 2015].
Mallya, G., Pollack, C. E. and Polsky, D. (2008), ‘Are primary care physicians ready to practice in a consumer-driven environment?’, American Journal of Managed Care, 14(10): 661668.
Massaro, T. A. and Wong, Y.-N. (1995), ‘Positive experience with medical savings accounts in Singapore’, Health Affairs, 14(2): 267272.
McConnell, K. (2005), ‘What do health savings accounts mean for the emergency department?’, Annals of Emergency Medicine, 46(6): 536540.
McKee, M. and Busse, R. (2013), ‘Medical savings accounts: Singapore’s non-solution to healthcare costs’, BMJ, 347: f4797.
McLeod, H. and McIntyre, D. (2008), ‘Medical savings accounts in South Africa’, Euro Observer, 10(4): 79.
Minicozzi, A. (2006), ‘Medical savings accounts: what story do the data tell?’, Health Affairs, 25(1): 256267.
Monheit, A. (2003), ‘Persistence in health expenditures in the short run: prevalence and consequences’, Medical Care, 41(7 Supplement): 5364.
Muhlestein, D. B., Wilks, C. E. and Richter, J. P. (2013), ‘Limited use of price and quality advertising among American hospitals’, Journal of Medical Internet Research, 15(8): e185.
Newhouse, J. P., Insurance Experiment Group (1993), Free for All? Lessons from the RAND Health Insurance Experiment, Cambridge: Harvard University Press.
Nichols, L., Prescott, N. and Phua, K. (1997), ‘Medical savings accounts for developing countries’’, in G. Schieber (ed.), Innovations in Health Care Financing, Washington, DC: World Bank, 233245.
Parente, S. T., Christianson, J. B. and Feldman, R. (2007), ‘Consumer-directed health plans and the chronically ill’, Disease Management and Health Outcomes, 15(4): 239248.
Parente, S. T., Feldman, R. and Chen, S. (2008), ‘Effects of a consumer driven health plan on pharmaceutical spending and utilization’, Health Services Research, 43(5): 15421556.
Parente, S.T., Feldman, R. and Christianson, J.B. (2004a), Evaluation of the effect of a consumer-driven health plan on medical care expenditures and utilization’, Health Services Research, 39(4): 11891210.
Parente, S. T., Feldman, R. and Christianson, J. B. (2004b), Employee choice of consumer-driven health insurance in a multiplan, multiproduct setting’, Health Services Research, 39(4): 10911112.
Park, E. (2015), ‘Cassidy health plan allows more tax sheltering for well-to-do’. Center on Budget and Policy Priorities, http://www.cbpp.org/blog/cassidy-health-plan-allows-more-tax-sheltering-for-well-to-do [18 October 2015].
Park, E. and Biniek, J. (2015), ‘Republican Study Committee health plan would likely result in many more uninsured and fewer consumer protections’. Center on Budget and Policy Priorities, http://www.cbpp.org/research/health/republican-study-committee-health-plan-would-likely-result-in-many-more-uninsured [24 October 2015].
Pauly, M. V. and Goodman, J. C. (1995), ‘Tax credits for health insurance and medical savings accounts’, Health Affairs, 14(1): 126139.
Pei, Y. (2008), ‘The issue of keeping medical saving account with the social health insurance’, Population and Economics, 168(3): 65 (in Chinese).
Reed, M., Benedetti, N., Brand, R., Newhouse, J. P. and Hsu, J. (2009), ‘Perspectives from deductible plan enrolees: plan knowledge and anticipated care-seeking changes’, BMC Health Services Research, 9: 244.
Reed, M., Graetz, I., Wang, H., Fung, V., Newhouse, J. P. and Hsu, J. (2012), ‘Consumer-directed health plans with health savings accounts: whose skin is in the game and how do costs affect care seeking?’, Medical Care, 50(7): 585590.
Reinhardt, U. E. (2006), ‘The pricing of US hospital services: chaos behind a veil of secrecy’, Health Affairs, 25(1): 5769.
Remler, D. K. and Glied, S. A. (2006), ‘How much more cost sharing will health savings accounts bring?’, Health Affairs, 25(4): 10701078.
Robinson, J. C. (2005), ‘Health savings accounts – the ownership society in health care’, New England Journal of Medicine, 353(12): 11991202.
Rowe, J. W., Brown-Stevenson, T., Downey, R. L. and Newhouse, J. P. (2008), ‘The effect of consumer-directed health plans on the use of preventive and chronic illness services’, Health Affairs, 27(1): 113120.
Sedjo, R. L. and Cox, E. R. (2009), ‘The influence of targeted education on medication persistence and generic substitution among consumer-directed health care enrolees’, Health Services Research, 44(6): 20792092.
Sheng, S. and Hou, X. (2011), ‘Inequities and inefficiency in medical saving account-the findings from Guangdong, China’, Chinese Journal of Population Science, 5(1): 75 (in Chinese).
Sichuan News (2015), ‘New healthcare reform in Chengdu city-using medical saving account to pay for commercial health insurance (in Chinese), http://scnews.newssc.org/system/20150106/000526607.html [3 July 2015].
Singapore Ministry of Health (2013), ‘Healthcare financing sources’, http://www.moh.gov.sg/content/moh_web/home/pressRoom/Parliamentary_QA/2013/healthcare-financing-sources0.html [7 December 2013].
Stanton, M. W. and Rutherford, M. K. (2006), ‘The high concentration of U.S. health care expenditures’, Issue 19, AHRQ Pub No. 06-060. Rockville, MD: Agency for Healthcare Research and Quality: Research in Action.
Thomson, S., Võrk, A., Habicht, T., Rooväli, L., Evetovits, T. and Habicht, J. (2010), ‘Responding to the challenge of financial sustainability in Estonia’s health system’, World Health Organization, Regional Office for Europe, Copenhagen, 142pp.
Thorpe, K. E. (1995), ‘Medical savings accounts: design and policy issues’, Health Affairs, 14(3): 254259.
Tollen, L. A., Ross, M. N. and Poor, S. (2004), ‘Risk segmentation related to the offering of a consumer-directed health plan: a case study of Humana Inc’, Health Services Research, 39(4): 11671188.
Wilson, A. R., Bargman, E. P., Pederson, D., Wilson, A., Garrett, N. A., Plocher, D. W. and Ailiff, P. L. (2008), ‘More preventive care, and fewer emergency room visits and prescription drugs—health care utilization in a consumer-driven health plan’, Benefits Quarterly, 24(1): 4654.
Woolhandler, S. and Himmelstein, D. U. (2007), ‘Consumer-directed health care: except for the healthy and wealthy it’s unwise’, Journal of General Internal Medicine, 22(6): 879881.
Worstall, T. (2013), ‘Why not US healthcare? Because we want something much more free market than that’. Adam Smith Institute, http://www.adamsmith.org/blog/healthcare/why-not-us-healthcare-because-we-want-something-much-more-free-market-than-that/ [1 November 2015].
Xia, Y. (2014), ‘Medical saving account for urban employee insurance-is it worth keeping?’, Microeconomics, 4(1): 51 (in Chinese).
Xinhua News (2009), ‘Share the medical saving account with your family in Zhengjiang, Jiangsu http://news.xinhuanet.com/society/2009-06/04/content_11486920.htm [3 July 2015].
Xinhua News (2015), ‘Using the 323 billion surplus in medical saving account to pay for commercial health insurance (in Chinese), http://news.xinhuanet.com/fortune/2015-01/15/c_127388775.htm [3 July 2015].
Xue, X. and Zhao, M. (2007), ‘An economic analysis of the low efficiency of private medical savings account’, Chinese Health Economics, 26(9): 73 (in Chinese).
Yi, Y., Maynard, A., Liu, G., Xiong, X. and Lin, F. (2005), ‘Equity in health care financing: evaluation of the current urban employee health insurance reform in China’’, Journal of the Asia Pacific Economy, 10(4): 506527.
Yip, W. and Hsiao, W. (1997), ‘Medical savings accounts: lessons from China’, Health Affairs, 16(6): 244251.
Yip, W. and Hsiao, W. (2009), ‘Non-evidence-based policy: how effective is China’s new cooperative medical scheme in reducing medical impoverishment?’, Social Science & Medicine, 68(2): 201209.

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