Health Affairs

Abandon High‑Deductible Health Plans Linked to Health Spending Accounts | Jeanne Lambrew

The Health Affairs podcast episode focuses on Jeanne Lambrew’s argument to abandon, rather than expand, high‑deductible health plans (HDHPs) paired with health spending accounts. Lambrew traces the policy’s origins to 1990s conservative think‑tanks, noting three legislative boosts—the 2003 Medicare Modernization Act, the ACA’s clarification, and the recent One Big Beautiful Bill—that have entrenched HDHPs with health savings or flexible spending accounts in the market. Lambrew highlights that average deductibles have climbed to about $1,900 for employer‑based coverage and $2,800 for individual plans, while only one‑third of workers with employer insurance possess a spending account. She stresses that most health spending is driven by a small, sick population—20% of dollars go to the sickest patients—and that high deductibles act as a surcharge for those with pre‑existing conditions. Moreover, research shows HDHPs do not spur meaningful price shopping; utilization drops across the board, and accounts have negligible impact on total spending, sometimes prompting unnecessary purchases to avoid forfeiting balances. Key examples include the administration’s push to expand catastrophic plans with $31,000 family deductibles and a surge from 2% to 43% of marketplace enrollees selecting plans eligible for health savings accounts. Lambrew also cites the president’s “Great American Health Plan” rhetoric, which frames shifting cost burdens to consumers as the primary solution, despite evidence that such shifts increase out‑of‑pocket strain without lowering prices. The discussion concludes that without stronger government involvement—such as eliminating deductibles in ACA marketplace gold and silver plans or linking premium tax credits to higher‑value coverage—high‑deductible structures will exacerbate affordability challenges. State‑level experiments may provide a natural laboratory to assess whether expanding HDHPs with spending accounts truly improves cost transparency or merely deepens consumer financial risk.