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July 11, 2017 • No. 434

Trends in Health Savings Account Balances, Contributions, Distributions, and Investments, 2011‒2016: Statistics from the EBRI HSA Database By Paul Fronstin, Ph.D., Employee Benefit Research Institute A T

A

G L A N C E

The Employee Benefit Research Institute (EBRI) developed the EBRI HSA Database to analyze the state of and individual behavior in Health Savings Accounts (HSAs). The HSA database contains 5.5 million accounts with total assets of $11.4 billion as of Dec. 31, 2016. This Issue Brief is the first longitudinal study from the HSA database and supplements the annual cross-sectional analyses. It examines trends in account balances, individual and employer contributions, distributions, invested assets and account-owner demographics from 2011‒2016. Plan sponsors who wish to introduce or continue offering HSA-eligible health plans as part of their workplace benefit program can leverage this long-term view of account holder behaviors when developing strategies to increase employee financial wellness. Key findings: On average, account holders appear to be using HSAs as specialized checking accounts rather than investment accounts. HSAs offer a valuable tax incentive to set aside money on a tax-favored basis for current or future medical expenses. However, most account holders appear to be using the accounts to cover current expenses, such as deductibles, coinsurance and copayments, rather than fully taking advantage of the tax preference by contributing the maximum.  Average total contributions—combined individual and employer contributions—increased from $2,348 to $2,922 between 2011 and 2016. This average was just above the minimum allowable deductible amount for family coverage, but less than one-half the allowable contribution maximum for family coverage.  Overall, 63 percent of account holders withdrew funds. The average annual amount distributed was $1,771 in 2016, implying an average rollover of $1,151.  Very few account owners invested their HSA balance in investments other than cash despite the tax saving possibilities. In 2016, 4 percent had investments other than cash. Longer experience with HSA improves account holder prospects for financial security. The rollover feature of HSAs enables account holders to build up a balance for unexpected major medical expenses—in the near future and/or for retirement.  Average end-of-year balances, by the year the account was opened, show that financial security increases over time. Accounts opened in 2004 (or earlier) had an average $14,873 year-end account balance, while accounts opened in 2016 had an average $1,027 year-end account balance.

A research report from the EBRI Education and Research Fund © 2017 Employee Benefit Research Institute

 Annual 2016 contributions are higher the longer an account owner had an account. Individual contributions averaged $3,658 among those who opened their account in 2005, but only averaged $1,290 among those who opened their account in 2016.  Older, larger accounts offer a stronger hedge against unexpected bills. Those accounts opened in 2005 had an average annual distribution of $2,756, while those only opened in 2016 took $1,051 in distributions.  Over time, account owners appear to see the value in investing. In 2016, 11 percent of accounts opened in 2005 had investments other than cash, compared to only 1 percent among those opened in 2016. It is possible that rules requiring minimum balances may have prevented owners of relatively new accounts from investing as the accounts would not have reached the minimum balance requirement.

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Paul Fronstin is director of the Health Education and Research Program at the Employee Benefit Research Institute (EBRI). This Issue Brief was written with assistance from EBRI’s research and editorial staffs. Any views expressed in this report are those of the authors and should not be ascribed to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute-Education and Research Fund (EBRI-ERF), or their staffs. Neither EBRI nor EBRIERF lobbies or takes positions on specific policy proposals. EBRI invites comment on this research.

Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). It may be used without permission but citation of the source is required.

Recommended Citation: Paul Fronstin, “Trends in Health Savings Account Balances, Contributions, Distributions, and Investments, 2011‒2016: Statistics from the EBRI HSA Database,” EBRI Issue Brief, no. 434, (Employee Benefit Research Institute, July 11, 2017).

Report Availability: This report is available on the Internet at www.ebri.org

Table of Contents Introduction .......................................................................................................................................................... 5 About the EBRI HSA Database ................................................................................................................................ 5 Trends in HSA Balances ......................................................................................................................................... 7 Trends in Contributions to HSAs ............................................................................................................................. 7 Trends in Distributions from HSAs ......................................................................................................................... 10 Trends in Investing HSA Assets ............................................................................................................................ 14 Conclusion .......................................................................................................................................................... 14 Appendix—What is an HSA? ................................................................................................................................. 19 Eligibility ......................................................................................................................................................... 19 Contributions ................................................................................................................................................... 19 Investments .................................................................................................................................................... 19 Distributions .................................................................................................................................................... 20 Archer Medical Savings Accounts ...................................................................................................................... 20 ERISA Compliance ........................................................................................................................................... 20 References .......................................................................................................................................................... 20 Endnotes ............................................................................................................................................................ 21

Figures Figure 1, Statutory HSA Limits, 2004–2017 .............................................................................................................. 6 Figure 2, Percentage of Employers Offering HSA-Eligible Health Plan/HRA, by Firm Size, 2010–2016, With Projections Through 2019 ........................................................................................................................................... 6 Figure 3, EBRI HSA Database: Accounts and Assets, 2011‒2016 ............................................................................... 8 Figure 4, HSAs, by Year Account was Opened .......................................................................................................... 8 Figure 5, Average End-of-year Account Balance, by Year, 2011‒2016 ........................................................................ 9 Figure 6, Average End-of-year Account Balance, by Year Account was Opened, 2016 ................................................. 9 Figure 7, End-of-year Average Account Balances by Account-owner Demographics, 2011‒2016 ................................ 10 Figure 8, Percentage of Accounts With Individual and Employer Contributions to HSAs, by Year, 2011‒2016 .............. 11

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Figure 9, Annual Average Individual and Employer Contributions to HSAs, 2011‒2016 .............................................. 11 Figure 10, Annual Average Total Contributions to HSAs, 2011‒2016 ........................................................................ 12 Figure 11, Annual Average Individual and Employer Contributions to HSAs, by Year Account was Opened, 2016 ........ 12 Figure 12, Average Annual Individual and Employer Contributions by Account-owner Demographics, 2011‒2016 ....... 13 Figure 13, Percentage of Accounts With a Distributions from HSAs, by Year, 2011‒2016........................................... 15 Figure 14, Annual Average Distribution from HSAs, 2011‒2016 ............................................................................... 15 Figure 15, Annual Average Distributions from HSAs, by Year Account was Opened, 2016 .......................................... 16 Figure 16, Percentage of Accounts With Distributions from HSAs, by Year Account was Opened, 2016 ....................... 16 Figure 17, Average Annual Distributions by Account-owner Demographics, 2011‒2016 ............................................. 17 Figure 18, Presence of Investments Other Than Cash, 2011‒2016 .......................................................................... 17 Figure 19, Presence of Investments Other Than Cash, by Year Account was Opened, 2016....................................... 18 Figure 20, Percent With Investments Other Than Cash, by Account-owner Demographics, 2011‒2016 ...................... 18

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Trends in Health Savings Account Balances, Contributions, Distributions, and Investments, 2011‒2016: Statistics from the EBRI HSA Database By Paul Fronstin, Ph.D., Employee Benefit Research Institute Introduction The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) allows individuals enrolled in high-deductible health plans meeting certain requirements to open and fund health savings accounts (HSAs), a taxexempt trust or custodial account that is funded with contributions and assets that an individual can use to pay for health care expenses. Individuals can contribute to an HSA only if they are enrolled in an HSA-eligible health plan. HSAs benefit from a triple tax advantage: employee contributions to the account are deductible from taxable income, 1 any interest or other capital earnings on assets in the account build up tax free, and distributions for qualified medical expenses from the HSA are excluded from taxable income to the employee.2 Enrollment in HSA-eligible health plans and the number of HSAs have increased since the plans first became available in 2004. In 2016, enrollment in these HSA-eligible health plans was estimated to be between 20.23 and 23.64 million policyholders and their dependents. One-quarter of smaller employers (10‒499 employees) and 61 percent of larger employers (500 or more employees) offered an HSA-eligible health plan in 2016.5 It has also been estimated that there were about 20 million HSAs holding $37 billion in assets as of Dec. 31, 2016. 6 The number of HSAs could be even larger, as it has been estimated that 7.3 million HSA-eligible health plan enrollees had not opened an HSA. 7 Enrollment in HSA-eligible health plans is expected to continue to grow. According to Mercer’s survey of employers, 25 percent of employers with 10–499 employees and 61 percent of employers with 500 or more employees offered an HSA-eligible health plan or HRA in 2016 (Figure 2). By 2019, 34 percent of employers with 10–499 employees and 72 percent of employers with 500 or more employees said they were very likely to offer such a health plan. While there is growing literature around how individuals in HSA-eligible health plans use and pay for medical services,8 there are very few sources of data on the HSAs themselves and the owners of such accounts. The most recent report by America’s Health Insurance Plans (AHIP) includes data on account balances, contributions, distributions, and account owner demographics based on 2012 data. 9 Also, Devenir reports limited, aggregate trend data going back to 2006 from a survey of HSA providers.10 The EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey (CEHCS), conducted annually since 2005, collects self-reported demographic information on enrollees in HSA-eligible health plans and on their HSA balances, contributions, and distributions.11 In light of existing data limitations, EBRI created the EBRI HSA Database to collect a large, representative repository of administrative information from record-keepers about HSAs and account owners. This Issue Brief is the first longitudinal study to examine trends in cross-sectional data from the EBRI HSA Database. It examines account balances, individual and employer contributions, distributions, investments and account-owner demographics from 2011‒2016.

About the EBRI HSA Database The EBRI HSA Database is a representative repository of information about individual HSAs. The 2016 data covers 27 percent of the universe of HSAs and 31 percent of HSA assets.12 The database is unique because it includes data provided by a wide variety of account record-keepers and, therefore, represents the characteristics and activity of a broad range of HSA owners.13

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Figure 1 Statutory HSA Limits, 2004–2017

Individual

Family

Individual

Family

Individual

Family

Per-Person Catch-up Contribution Limit

2004

$1,000

$2,000

$2,600

$5,150

$5,000

$10,000

$500

2005

1,000

2,000

2,600

5,150

5,000

10,000

600

2006

1,050

2,100

2,700

5,450

5,250

10,500

700

2007

1,100

2,200

2,850

5,650

5,500

11,000

800

2008

1,100

2,200

2,900

5,800

5,600

11,200

900

2009

1,150

2,300

3,000

5,950

5,800

11,600

1,000

2010

1,200

2,400

3,050

6,150

5,950

11,900

1,000

2011

1,200

2,400

3,050

6,150

5,950

11,900

1,000

2012

1,200

2,400

3,100

6,250

6,050

12,100

1,000

2013

1,250

2,500

3,250

6,450

6,250

12,500

1,000

2014

1,250

2,500

3,300

6,550

6,350

12,700

1,000

2015

1,300

2,600

3,350

6,650

6,450

12,900

1,000

2016

1,300

2,600

3,350

6,750

6,550

13,100

1,000

2017

1,300

2,600

3,400

6,750

6,550

13,100

1,000

Minimum Deductible

Maximum Out-ofPocket Limit

Maximum Contribution

Source: https://www.treasury.gov/resource-center/faqs/taxes/pages/health-savings-accounts.aspx

Figure 2 Percentage of Employers Offering HSA-Eligible Health Plan/HRA, by Firm Size, 2010–2016, With Projections Through 2019 100%

Employees 90%

10-499

500+

5,000+

87%

80% 80% 72% 70%

73%

63% 59%

59%

72%

61%

60% 51% 48%

50%

48% 39% 36%

40% 32% 30%

34%

23% 26%

20% 20% 10%

22%

23%

2012

2013

28% 25%

17%

0% 2010

2011

2014

2015

2016

Very likely to offer in 2019

Source: Figure 6 in http://www.mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2016.html

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As of Dec. 31, 2016, the EBRI Database includes:  5.5 million health savings accounts.  $11.4 billion in assets. Since 2011, the database has grown from 800,000 to 5.5 million accounts, and assets have grown from $1.5 billion to $11.4 billion (Figure 3). Most HSAs in the EBRI HSA Database were initially opened within the past few years. Overall, 77 percent of the accounts were opened between 2013 and 2016 (Figure 4). Nearly two-thirds (64 percent) of the 5.5 million HSAs received individual or employer contributions in 2016, while 36 percent did not receive any contributions. The EBRI HSA Database does not include health plan coverage data, but one of the possible explanations for the inclusion of non-contributors is that some of those individuals are not currently enrolled in an HSA-eligible health plan. The remainder of this Issue Brief focuses on 3.5 million HSAs in the EBRI Database that had either an individual or employer contribution.

Trends in HSA Balances End-of-year balances have been trending upward (with the exception of the dip between 2013 and 2014). Between 2011 and 2016, end-of-year account balances increased from $1,990 to $2,536 (Figure 5). Account balances are highly correlated with the length of time an account has been open. The longer an account has been open, the larger the account balance. Accounts opened in 2016 ended the year with an average balance of $1,027, while those opened in 2010 ended 2016 with an average balance of $4,970, and those opened in 2004 (or earlier) ended 2016 with an average balance of $14,873 (Figure 6). When examining end-of-year balances by age, balances for all age groups experienced increases, except for balances of those under age 25. While account balances generally have increased with age, those ages 25‒34 have seen their average balances increase from $1,092 to $1,430, a 31 percent increase, while those ages 45‒54 saw their average balances increase from $2,336 to $2,888, a 24 percent increase (Figure 7). Account owners ages 65 and older have experienced the largest increase in average balances, increasing from $2,599 in 2011 to $4,424 in 2016, a 70 percent increase, but also appear to have had the most variability in their balances. This may have had something to do with the fact that once they were eligible for Medicare, they were no longer able to contribute to their account, and they may have been more likely to be taking distributions as a result of their use of health care services and because the excise tax related to non-qualified distributions no longer applied. The EBRI HSA Database does not contain employee or family earnings or income data. However, ZIP code data are available for most of the sample and were used to match to county-level data on median household income, as well as education and race data by county. It was found that in all years the account owners in higher-income counties had higher average account balances than those in lower-income counties. Otherwise, account balances increased very little (a 7 percent increase) between 2011 and 2016 among owners in counties where the median household income was less than $50,000, compared with an increase of 33 percent for those in counties with $50,000‒$99,999 in median household income and an increase of 26 percent for those in counties with $100,000 or more in median household income. When examining differences by account-owner education level, education matters. In all years, account owners in counties where 50 percent or more of adults have a college education had higher account balances than account owners in counties with fewer adults who have a college education. There was no relationship between the percentage of minorities in a county and account balances.

Trends in Contributions to HSAs The percentage of individuals making a contribution trended slightly downward between 2011 and 2015 and then increased in 2016. The percentage with employer contributions has trended up. In 2011, 53 percent of account holders made a contribution to their account, but by 2015 only 45 percent did (Figure 8). Between 2015 and 2016 individual ebri.org Issue Brief • July 11, 2017 • No. 434

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Figure 3 EBRI HSA Database: Accounts and Assets, 2011‒2016 12.0 $11.4

10.0 2011

2012

2013

2014

2015

2016

8.0 $7.4

6.0

$5.5

5.5

4.0 4.0 $3.2 2.9 $2.1 2.0

1.6 0.8

$1.5

1.1

Accounts (millions)

Assets (billions)

Source: EBRI HSA Database.

Figure 4 HSAs, by Year Account was Opened 30%

25% 25% 21% 19%

20%

15% 12% 10% 7% 6% 5%

3% 0.21%

0.33%

1%

2004 or Earlier (Includes MSA Rollovers)

2005

2006

1%

2%

2%

2008

2009

0% 2007

2010

2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

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Figure 5 Average End-of-year Account Balance, by Year, 2011‒2016 $3,000

$2,536

$2,507

$2,440

$2,500

$2,346

$2,313

$1,990 $2,000

$1,500

$1,000

$500

$0 2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 6 Average End-of-year Account Balance, by Year Account was Opened, 2016 $16,000

$14,873

$14,000

$12,000

$10,000 $8,767 $9,789 $7,353

$8,000

$6,069

$5,806

$6,000

$4,970

$5,273 $3,957

$4,000 $2,818

$2,624 $1,909

$2,000

$1,027

$0 2004 or earlier

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

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Figure 7 End-of-year Average Account Balances, by Account-owner Demographics, 2011‒2016 2011 Age <25 $846 25‒34 1,092 35‒44 1,657 45‒54 2,336 55‒64 3,304 65+ 2,599 Median Household Income in County Less than $50,000 1,907 $50,000‒$99,999 2,034 $100,000 or more 2,584 Percent With a College Degree in County Less than 30% 1,883 30%-49% 2,080 50% or more 2,413 Percent Minority in County Less than 15% 1,995 15%‒29% 1,928 30% or more 2,033 Source: EBRI HSA Database.

2012

End-of-year Balance 2013 2014

2015

2016

$955 1,293 1,920 2,660 3,832 3,450

$963 1,433 2,099 2,810 4,170 4,508

$748 1,362 2,130 2,806 4,189 4,923

$760 1,408 2,167 2,767 3,949 3,551

$769 1,430 2,257 2,888 4,135 4,424

2,174 2,395 3,112

2,481 2,512 3,246

2,193 2,641 3,355

1,984 2,580 3,187

2,039 2,705 3,262

2,159 2,458 2,811

2,435 2,560 2,965

2,260 2,692 3,137

2,109 2,645 2,970

2,182 2,782 3,008

2,331 2,306 2,306

2,472 2,421 2,570

2,490 2,459 2,556

2,410 2,415 2,453

2,508 2,539 2,557

contributions increased to 48 percent. The percentage of accounts with an employer contribution increased from 41 percent to 49 percent between 2011 and 2016. For both individual and employer contributions, among those with such contributions, contribution levels have been increasing (with the exception of between 2013 and 2014). Average annual individual contributions have increased from $1,475 in 2011 to $1,987 in 2016, while average annual employer contributions have increased from $873 to $935 (Figure 9). As a result, total contributions have increased from $2,348 to $2,922 between 2011 and 2016 (Figure 10). Contributions in 2016 were higher the longer an account owner had an account. This was more true for individual contributions than for employer contributions. Individual contributions averaged $3,658 among those who opened their account in 2005, but only averaged $1,290 among those who opened their account in 2016 (Figure 11). Similarly, in 2016, employer contributions averaged $1,101 in accounts opened in 2005, but only averaged $691 in accounts opened in 2016. Regardless of year, individual contributions increased with age. In 2016, account owners 25‒34 contributed $1,164 on average, while those ages 55‒64 contributed $2,676 on average (Figure 12). Employer contributions also increased with age, though the differences were less pronounced than for individual contributions, and the differences were limited to those below and above age 35. Similarly, in all years, individual contributions were higher among account owners residing in counties with higher median household income. Employer contributions also increased with median household income by county, which may have reflected higher overall compensation in higher-income areas of the country. Individual and employer contributions increased with educational levels by county, but did not seem to vary by the county-wide racial mix.

Trends in Distributions from HSAs Until 2016, there had been a decline in the percentage of accounts taking a distribution. In 2015, 53 percent of accounts had a distribution, down from 61 percent in 2011, but between 2015 and 2016, the percentage of accounts with a distribution increased from 53 percent to 63 percent (Figure 13). Among those with a distribution, the average annual amount distributed has varied between $1,700 and $1,800 between 2011 and 2016, with 2013 being an exception at $1,934 (Figure 14). ebri.org Issue Brief • July 11, 2017 • No. 434

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Figure 8 Percentage of Accounts With an Individual and Employer Contributions to HSAs, by Year, 2011‒2016 60% 53% 50%

48%

48%

49%

47%

46% 48%

47% 40%

45%

44%

45%

41% Individual Contribution

30%

Employer Contribution

20%

10%

0% 2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 9 Annual Average Individual and Employer Contributions to HSAs, 2011‒2016 $3,500 2011

2012

2013

2014

2015

2016

$3,000

$2,500

$2,011

$1,987

$2,000 $1,770

$1,500

$1,805

$1,864

$1,475 $1,176 $975

$1,000

$873

$920

$948

$935

$500

$0 Individual Contributions

Employer Contributions

Source: EBRI HSA Database.

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Figure 10 Annual Average Total Contributions to HSAs, 2011‒2016 $3,500 $3,187 $2,922

$3,000 $2,812

$2,745

$2,500

$2,725

$2,348

$2,000

$1,500

$1,000

$500

$0 2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 11 Annual Average Individual and Employer Contributions to HSAs, by Year Account was Opened, 2016 2004 or earlier

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

$5,000 $4,669

$2,688 $2,089

$2,500

$2,433

$2,748

$2,620

$2,892

$2,127

$1,194

$1,125

$1,243

$1,215

$1,290

$1,257

$1,500

$1,246

$1,880

$2,000

$1,101

$3,000

$2,838

$3,093

$3,500

$3,658

$4,000

$3,351

$4,500

$1,258 $965 $937 $954

$1,000

$691

$500 $0 Individual Contribution

Employer Contribution

Source: EBRI HSA Database.

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2012

Source: EBRI HSA Database.

Age <25 $573 $552 25‒34 1,095 1,064 35‒44 1,786 1,733 45‒54 2,073 2,031 55‒64 2,429 2,439 65+ 2,328 2,460 Median Household Income in County Less than $50,000 1,714 1,617 $50,000‒$99,999 1,808 1,825 $100,000 or more 2,358 2,359 Percent With a College Degree in County Less than 30% 1,723 1,678 30%‒49% 1,793 1,809 50% or more 2,252 2,194 Percent Minority in County Less than 15% 1,748 1,794 15%‒29% 1,728 1,723 30% or more 1,894 1,796

2011 $525 1,101 1,860 2,178 2,630 2,576 1,612 2,001 2,454 1,715 2,026 2,302 1,880 1,893 1,952

$598 1,203 1,960 2,305 2,737 2,707 1,973 2,023 2,454 1,956 2,042 2,289 1,979 1,942 2,084

Individual Contributions 2013 2014

1,903 1,915 1,861

1,693 2,025 2,246

1,594 1,993 2,397

$535 1,122 1,876 2,189 2,553 2,457

2015

1,966 2,032 1,964

1,765 2,132 2,329

1,669 2,089 2,494

$571 1,164 1,962 2,303 2,676 2,552

2016

868 864 887

835 904 853

771 912 1,057

$465 710 947 983 982 945

2011

1,021 955 946

962 984 990

925 994 1,042

$552 803 1,041 1,090 1,102 1,078

2012

1,097 1,094 1,289

1,090 1,263 1,114

1,050 1,239 1,244

$622 966 1,350 1,291 1,203 1,136

946 904 974

905 967 1,001

852 972 1,082

$524 769 1,033 1,048 1,029 989

Employer Contributions 2013 2014

Average Annual Individual and Employer Contributions, by Account-owner Demographics, 2011‒2016

Figure 12

970 929 958

918 976 1,019

875 979 1,087

$526 783 1,036 1,056 1,028 1,035

2015

950 913 944

897 964 962

853 964 1,027

$534 772 1,017 1,041 1,008 976

2016

In 2016, distributions were higher in accounts that had been open the longest. Those opened in 2005 had an average annual distribution of $2,756, while those opened in 2016 took $1,051 in distributions (Figure 15). The higher distributions associated with older accounts may suggest that individuals have been actively building up their account balances over time, and, as major health expenses have been incurred, account owners have been able to then take larger distributions. This is also supported by the fact that older accounts were more likely than younger ones to take a distribution. About 90 percent of the accounts opened before 2013 had a distribution, whereas only 57 percent of accounts opened in 2016 had a distribution (Figure 16). Distributions increased with account owner age in each year. They ranged from $1,126 in 2016 for those 25‒34 to $2,165 for those 55‒64 (Figure 17). Distributions also increased with income and education, but they did not vary by race. Higher-income accounts were slightly less likely to take a distribution (61 percent) than lower-income accounts (63 percent) in 2016 (data not shown in figure).

Trends in Investing HSA Assets Very few account owners invest their HSA balance in investments other than cash. The percentage of accounts with investments may be low for a number of reasons. First, in order to invest, account owners often must have a minimum account balance. As reported above, most accounts are new, and therefore, many will not have a large enough account balance to take advantage of investments. Second, not all HSA providers offer investments other than cash. Third, account owners may not be aware of the option to invest. Fourth, account owners may be using the account only to pay for out-of-pocket expenses and therefore may not want to take short-run risks with investment fluctuations. In 2016, 4 percent of accounts had investments other than cash, up from 2 percent in 2011 (Figure 18). However, the longer an account had been open, the more likely it was to have investments other than cash. Only 1 percent of accounts opened in 2016 had investments other than cash, compared with 11 percent in accounts opened in 2005 (Figure 19). Because the percentage of account owners investing HSA balances in something other than cash is generally small, any differences by age, income, education and race are also small. However, there are some notable differences. Older account owners are more likely than younger ones to have non-cash investments (Figure 20). Account owners in higher-income counties are more likely than those in lower-income counties to invest, and those in more highly educated counties are more likely than those in lower-educated counties to invest.

Conclusion This study examines data from the EBRI HSA Database. It is the first longitudinal study to examine trends in crosssectional data from the EBRI HSA Database. It examines account balances, individual and employer contributions, distributions, investments and account-owner demographics from 2011‒2016. In 2016, enrollment in these HSA-eligible health plans was estimated to be between 20.2 and 23.6 million policyholders and their dependents. It was estimated that there were about 20 million HSAs holding $37 billion in assets as of Dec. 31, 2016. The number of employers expected to offer an HSA-eligible health plan either as an option or as the only health plan option is expected to continue to increase both in the absence of public policy changes and possibly because Congress is interested in expanding HSAs. As a result, HSA-eligible health plans and HSAs are expected to grow as a vital component of employment-based health coverage in the United States. Plan sponsors that wish to introduce or retain HSA-eligible health plans as part of their workplace benefit program can use past trends to inform future strategies. For instance, as individuals become more familiar with HSAs, they are using the accounts more as designed. Specifically, account balances are growing over time, enabling longtime account holders to withdraw larger sums when unexpected major health expenses occur. Plan sponsors that value employee financial wellness can work with administrators and advisors to take a long-term view of HSA account balance growth. ebri.org Issue Brief • July 11, 2017 • No. 434

14

Figure 13 Percentage of Accounts With a Distribution from HSAs, by Year, 2011‒2016 70% 63% 61% 59%

60%

60% 56% 53%

50%

40%

30%

20%

10%

0% 2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 14 Annual Average Distributions from HSAs, 2011‒2016 $3,000

$2,500

$1,934

$2,000 $1,726

$1,770

$1,763

$1,748

$1,771

2014

2015

2016

$1,500

$1,000

$500

$0 2011

2012

2013

Source: EBRI HSA Database.

ebri.org Issue Brief • July 11, 2017 • No. 434

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Figure 15 Annual Average Distributions from HSAs, by Year Account was Opened, 2016 $3,000 $2,756 $2,558

$2,537

$2,520

$2,496

$2,500

$2,336

$2,378 $2,268 $2,177

$2,000

$1,864

$1,797 $1,623

$1,500

$1,000 $1,051

$500

$0 2004 or earlier

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 16 Percentage of Accounts With Distributions from HSAs, by Year Account was Opened, 2016 100% 89%

91%

89%

89%

91%

90%

91%

89%

90%

90%

88% 85% 80%

80%

70% 57%

60%

50%

40%

30%

20%

10%

0% 2004 or earlier

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

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Figure 17 Average Annual Distributions, by Account-owner Demographics, 2011‒2016 Distributions 2011 Age <25 $637 25‒34 1,148 35‒44 1,772 45‒54 1,989 55‒64 2,085 65+ 1,819 Median Household Income in County Less than $50,000 1,776 $50,000‒$99,999 1,678 $100,000 or more 1,975 Percent With a College Degree in County Less than 30% 1,751 30%‒49% 1,668 50% or more 1,945 Percent Minority in County Less than 15% 1,668 15%‒29% 1,624 30% or more 1,825

2012

2013

2014

2015

2016

$643 1,178 1,806 2,052 2,157 1,861

$671 1,277 2,011 2,239 2,316 1,969

$596 1,165 1,857 2,086 2,178 1,914

$588 1,155 1,856 2,091 2,135 1,801

$550 1,126 1,825 2,097 2,165 1,772

1,805 1,741 1,911

1,906 1,948 2,134

1,690 1,844 2,041

1,577 1,840 2,098

1,570 1,841 2,028

1,789 1,730 1,928

1,900 1,969 1,988

1,723 1,857 1,949

1,652 1,856 1,947

1,647 1,861 1,918

1,785 1,690 1,812

1,925 1,870 1,966

1,816 1,767 1,806

1,838 1,767 1,719

1,829 1,809 1,686

Source: EBRI HSA Database.

Figure 18 Presence of Investments Other Than Cash, 2011‒2016 25%

20%

15%

10%

5% 5%

4%

4%

2015

2016

3% 2% 2%

0% 2011

2012

2013

2014

Source: EBRI HSA Database.

ebri.org Issue Brief • July 11, 2017 • No. 434

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Figure 19 Presence of Investments Other Than Cash, by Year Account was Opened, 2016 25%

20%

15% 12% 11% 10%

10%

9%

9%

9%

8%

8%

7%

5% 5%

5% 3% 1%

0% 2004 or earlier

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Source: EBRI HSA Database.

Figure 20 Percent With Investments Other Than Cash, by Account-owner Demographics, 2011‒2016 2011 Age <25 0% 25‒34 1% 35‒44 2% 45‒54 2% 55‒64 2% 65+ 2% Median Household Income in County Less than $50,000 1% $50,000‒$99,999 2% $100,000 or more 3% Percent With a College Degree in County Less than 30% 1% 30%‒49% 2% 50% or more 3% Percent Minority in County Less than 15% 1% 15%‒29% 2% 30% or more 2%

2012

Percent With Investments 2013 2014

2015

2016

1% 2% 2% 3% 3% 2%

1% 3% 3% 3% 4% 4%

1% 4% 5% 6% 7% 8%

2% 4% 4% 4% 5% 3%

2% 4% 4% 4% 5% 3%

2% 3% 5%

3% 4% 6%

3% 6% 9%

2% 5% 7%

2% 5% 7%

2% 3% 4%

3% 4% 6%

4% 6% 8%

3% 5% 7%

3% 5% 6%

2% 2% 3%

3% 3% 4%

4% 5% 6%

3% 4% 5%

3% 4% 5%

Source: EBRI HSA Database.

ebri.org Issue Brief • July 11, 2017 • No. 434

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Appendix—What is an HSA? A health savings account (HSA) is a tax-exempt trust or custodial account that is funded with contributions and assets that an individual can use to pay for health care expenses. Individuals can contribute to an HSA only if they are enrolled in an HSA-eligible health plan. An employee’s contributions to the account are deductible from taxable income, an employer’s contributions to the account for an employee are excludable from the employee’s gross income, and distributions for qualified medical expenses from the HSA are excluded from taxable income to the employee. Tax-free distributions are also allowed for certain premium payments (see below). Any interest or other capital earnings on assets in the account build up tax-free. Finally, HSAs are always funded, unlike similar types of health accounts known as health reimbursement arrangements (HRAs) and flexible spending accounts (FSAs), which can be and are typically set up as unfunded, notional arrangements.

Eligibility An individual who is covered by an HSA-eligible health plan may (but is not required to) open and make contributions to an HSA. To be an HSA-eligible health plan for 2017, the plan must have an annual deductible of at least $1,300 for individual coverage and $2,600 for family coverage, and the plan’s out-of-pocket maximum may not exceed $6,550 for individual coverage or $13,100 for family coverage with the deductible counting toward this limit. (These minimum allowable deductibles and maximum out-of-pocket limits are indexed to inflation.) Certain primary preventive services— typically those deemed to prevent the onset of disease—can be and often are exempt from the deductible and covered in full. (These preventive services are in addition to those preventive services that the Patient Protection and Affordable Care Act of 2010 (ACA) requires be covered in full.) Otherwise, all health care services must be subject to the HSA’s deductible. Additional HSA contribution requirements are that (1) an individual may not be enrolled in other health coverage, such as a spouse’s plan, unless that plan is also an HSA-eligible health plan, (2) an individual may not be claimed as a dependent on another person’s tax return, and (3) an individual may not be enrolled in Medicare. Notwithstanding these requirements, an individual is not precluded from making HSA contributions merely because he or she has supplemental coverage with deductibles below the statutory HSA-eligible health plan minimum for such things as vision care, dental care, certain specific diseases, and/or insurance that pays a fixed amount per day (or other stipulated period) for hospitalization.

Contributions Individuals and employers are allowed to contribute to HSAs. As noted above, contributions are excluded from gross income if the employer makes them, and deductible from taxable income if the individual account owner makes them. For 2017, a worker with individual coverage is allowed to make an annual HSA contribution of $3,400, while a worker with family coverage can contribute as much as $6,750. These dollar limits are indexed for inflation. Additionally, individuals who have reached age 55 and are not yet enrolled in Medicare may make an additional $1,000 catch-up contribution. The catch-up contribution is not currently indexed to inflation. If an employer does make contributions to an HSA, the contributions must be the same dollar amount or the same percentage of the deductible for all employees.14

Investments HSAs can be invested in the same investment options that have been approved for individual retirement accounts (IRAs)—i.e., bank accounts, certificates of deposit (CDs), money market funds, stocks, bonds, and mutual funds. Many HSA custodians, however, require that an HSA have at least a minimum balance in order to invest HSA funds in options beyond cash or cash equivalents. And some HSA custodians do not offer investment options beyond cash. If an HSA owner is able to invest HSA funds in options beyond cash, the owners are responsible for making the investment decisions.

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Distributions An individual may take distributions from an HSA at any time. The individual need not be covered by an HSA-eligible health plan at the same time the individual withdraws money from the HSA. Distributions are generally treated as taxable income, but they are excluded from an individual’s taxable income if they are used to pay for qualified medical expenses. Distributions for premiums for COBRA coverage, long-term-care insurance, health insurance while receiving unemployment compensation, and insurance while eligible for Medicare (other than for Medigap) are also tax free. HSA distributions for nonqualified medical expenses are not excludable from gross income and, in addition to being taxable, are subject to a 20 percent penalty, which is waived if the HSA owner dies, becomes disabled, or is eligible for Medicare. Individuals are able to transfer funds from one HSA to another without subjecting the distribution to income and penalty taxes as long as the transfer occurs within 60 days of the date funds are received.

Archer Medical Savings Accounts Prior to the availability of HSAs, Archer Medical Savings Accounts (MSAs) were authorized as a demonstration project under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Workers were eligible to set up an MSA if employed at a firm with 50 or fewer employees. The self-employed were also eligible. Both were required to be covered by a high-deductible health plan in order to be able to contribute to an MSA. When the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created HSAs, existing MSAs were grandfathered, but as of Dec. 31, 2007, no new MSAs could be opened. However, individuals with MSAs are allowed to transfer those account balances to HSAs. Amounts that continue to be held in grandfathered MSAs can be distributed tax free for qualified medical expenses.

ERISA Compliance Unlike HSA-eligible health plans offered by an employer, when employer involvement in an HSA is limited, the HSA is not subject to the Employee Retirement Income Security Act (ERISA). Thus, for example, HSAs are not subject to ERISA when the employer does not contribute to the HSA, or when the establishment of the HSA is completely voluntary on the part of the employee.15 In addition, the employer may not limit the ability of employees to move their HSA funds to another HSA, impose conditions on using the HSA funds, or make or influence investment decisions. There are other considerations for employers as well when offering an HSA. 16

References AHIP. An Analysis of Health Savings Account Balances, Contributions, and Withdrawals in 2012. Washington, DC: AHIP Center for Policy and Research, 2014. Brot-Goldberg, Zarek C., Amitabh Chandra, Benjamin R. Handel, and Jonathan T. Kolstad. "What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics." NBER Working Paper No. 21632 (National Bureau of Economic Research), October 2015. Bundorf, M. Kate. "Consumer-Directed Health Plans: Do They Deliver?" Research Synthesis Report No. 24 (Robert Wood Johnson Foundation, October 2012). Fronstin, Paul, and Anne Elmlinger. "Consumer Engagement in Health Care: Findings from the 2016 EBRI/Greenwald & Associates Consumer Engagement in Health Care Survey." EBRI Issue Brief, no. 433 (Employee Benefit Research Institute, May 2017). Fronstin, Paul, and M. Christopher Roebuck. "Health Care Spending after Adopting a Full-Replacement, High-Deductible Health Plan With a Health Savings Account: A Five-Year Study." EBRI Issue Brief, no. 388 (Employee Benefit Research Institute, July 2013).

ebri.org Issue Brief • July 11, 2017 • No. 434

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. "Quality of Health Care After Adopting a Full-Replacement, High-Deductible Health Plan With a Health Savings Account: A Five-Year Study." EBRI Issue Brief, no. 404 (Employee Benefit Research Institute), September 2014. Fronstin, Paul, Martin J. Sepulveda, and M. Christopher Roebuck. “Consumer-Directed Health Plans Reduce The LongTerm Use Of Outpatient Physician Visits And Prescription Drugs.” Health Affairs 32, no. 6, June 2013:1126−34. . “Medication Utilization and Adherence in a Health Savings Account-Eligible Plan.” American Journal of Managed Care 19, no. 12, December 2013: e400-7.

Endnotes 1

Both employees and employers can contribute to an HSA. While employee contributions to the account are deductible from

taxable income, employer contributions to the account for an employee are excludable from the employee’s gross income. See Figure 1 for historical statutory HSA limits. 2

More detailed information about HSAs can be found in the appendix

3

See https://www.ahip.org/wp-content/uploads/2017/02/2016_HSASurvey_Draft_2.14.17.pdf

4

See Fronstin and Elmlinger (2017).

5

See Figure 6 in https://www.mercer.com/newsroom/national-survey-of-employer-sponsored-health-plans-2016.html

6

See http://www.devenir.com/wp-content/uploads/2016-Year-End-Devenir-HSA-Market-Research-Report-Executive-Summary-

1.pdf The number of enrollees in HSA-eligible health plans differs from the number of HSAs for various reasons. The number of enrollees is composed of the policyholder and any covered dependents and generally is higher than the number of HSAs because one account is usually associated with a family. Hence, the number of individuals enrolled in an HSA-eligible health plan generally is higher than the number of accounts. However, over time, the number of accounts can grow relative to the number of enrollees because when an individual or family is no longer covered by an HSA-eligible health plan, they are allowed to keep the HSA open. Furthermore, individuals and families can have more than one account. 7

See Fronstin and Elmlinger (2017).

8

See the literature review in Bundorf (2012) as well as more recent research in Brot-Goldberg, et al. (2015), Fronstin and

Roebuck (2013); Fronstin, Sepulveda and Roebuck (June 2013); Fronstin, Sepulveda and Roebuck (December 2013), and Fronstin and Roebuck (2014). 9

See http://www.devenir.com/wp-content/uploads/2016-Year-End-Devenir-HSA-Market-Research-Report-Executive-Summary1.pdf 10

See http://www.devenir.com/research/2015-year-end-devenir-hsa-research-report/

11

See Fronstin and Elmlinger (2017).

12

According to Devenir, there were over 20 million accounts holding $37 billion in assets as of Dec. 31, 2016. See http://www.devenir.com/wp-content/uploads/2016-Year-End-Devenir-HSA-Market-Research-Report-Executive-Summary-1.pdf 13

Several recordkeeping organizations have provided de-identified data on HSA owners as of year-end 2015. Records are de-

identified prior to inclusion in the database to conceal the identity of account owners, but the data are coded so that account owners can be tracked over time, a unique aspect of the EBRI HSA Database. At no time has any nonpublic personal information that is personally identifiable, such as Social Security number, been transferred to or shared with EBRI. A unique aspect of the de-identified coding is that the EBRI HSA Database can link the accounts of each individual with more than one account in the database while still preventing the identification of the individual, thus permitting the aggregation of the HSA

ebri.org Issue Brief • July 11, 2017 • No. 434

21

balances of individuals with multiple accounts, within or across recordkeepers contributing to the database, providing a more complete picture of the number of individuals with accounts and their HSA balances. Moreover, the EBRI HSA Database contains information about the year of birth of account owners, individual and employer contributions, beginning- and end-ofyear account balances, and the month and year the HSA was opened. A very small percentage (less than 0.5 percent) of accounts have an account-opening date prior to 2004. An HSA that was funded by amounts rolled over from an MSA was considered established on the date the MSA was established. 14

There are exceptions to the comparability rule. For instance, employers may make matching contributions that are conditional on a contribution by the employee if done through a cafeteria plan. Furthermore, employers may contribute more to the HSAs of non-highly compensated employees. 15

See https://www.dol.gov/ebsa/regs/fab_2004-1.html

16

See https://www.dol.gov/ebsa/regs/fab_2006-2.html

ebri.org Issue Brief • July 11, 2017 • No. 434

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Mar 8, 2016 - 8/12/14 KEN PAXTON CAMPAIGN. STATE. ATTORNEY. GENERAL. SUPPORT. MONETARY. $5,000.00. July 2014 DEREK SCHMIDT.