The story behind Health Savings Accounts

We’re back with another round of yearly open enrollments, benefit choices and premium increases and I thought it’d be a good time to talk about Health Savings Accounts(HSAs), an underutilized tool when it comes to saving for you retirement(early or otherwise).

An HSA is the most tax-advantaged account available to most investors and has many benefits that make it very attractive to most individuals. However, it is not one that’s commonly discussed in the same areas as IRAs or 401k and that’s a shame because HSAs are probably the best of breed when it comes to retirement savings accounts.

The Basics
HSAs came into being with the 2003 medicare reform bill and were one of the first steps in propagating the spread of healthcare plans based around healthcare consumerism; the idea that a person should have more influence when it came to where their healthcare dollars are spent.
The goal was to give the same preferential tax treatment given to your employer for offering comprehensive healthcare coverage to the tax payers who choose to set aside money to pay for a larger share of their own healthcare.
The American healthcare system is essentially based on one large subsidy system and explains why most people in the United States have coverage through their employer. Employer-paid contributions towards your healthcare are exempt from both federal income and payroll taxes as are any employee contributions.

The goal of an HSA was to shift at least part of that subsidy from the employer to the employee. The employer would get less of a subsidy in the form of tax exemptions due to the lower premiums that are inherent with a consumer based plan that is needed for an HSA. The employee would now get to benefit from this change in two ways – a reduction in employee paid premiums and the ability to reduce taxable income via contributions to the HSA.

In essence, the idea with the HSA was to transfer some of the tax exemption subsidy historically given to the employer to the employee.

The idea behind this concept is driven by the type of plan design that can be paired with an HSA and how it compares to what we historically consider an insurance plan.

The HSA plan design
Insurance is an exchange of premium to purchase protection from financial loss. In the not so distant past, health insurance plans often covered everything but as healthcare inflation has outpaced everything, cost sharing elements like copays, coinsurance and deductibles have become a lot more common in an effort to reduce premiums.
That trend was clear even in the early 2000 when HSAs were established. Employers were beginning to offer plans that put more of the cost of the plan on the employees in order to reduce their cost burden. Lawmakers wanted to offer an alternative option for those tax payers that wanted to take that a step further and regain more control in their plan design.
If you still picture health insurance as a rich plan design with small copays, small deductibles and relatively small out of pocket maximums then an HSA eligible plan may be a shock for you because it’s a much different design than traditional health insurance.

To qualify for an HSA, a person must be covered by a high deductible health plan(HDHP). An HDHP is a consumer based plan that puts the first dollar costs of healthcare on the plan participant(you) instead of the insurance company and in doing so reduces the premium. It places more risk on the enrolled and less risk on the insurance company.

The goal was to pair the HSA with a plan that was designed to move to the tax exemption subsidy from the employer(employers pays less in premium and get less of a tax exemption) to the employee(the employees cost-share of premium is also lower and they can now invest the additional $$ saved in premium from a traditional plan design into an HSA and get that same tax-advantage).

An HDHP plan design has to have the following to qualify for an HSA account and these may change year to year(the below is for 2017).
  • A minimum deductible of $1300 for self coverage and $2600 for family coverage
  • No copays; medical or prescription before the deductible is met(some preventive copays may be allowed)
  • A maximum out of pocket max of $6550 for self coverage and $13100 for family coverage
  • Must cover preventive visits at 100%
  • Can offer 100% coverage after deductible is met but often has coinsurance and rx copays after deductible until out of pocket maximum is reached

The downsides of an HDHP are pretty clear based on the above information and that’s the fact that the potential first dollar dollar costs before insurance kicks in at all are pretty high.

If someone has family coverage, they may have to pay $2600 before insurance cost sharing of any sort kicks in and that would not be the end of it depending on the type of coverage they have. That’s not an easy pill to swallow for those who are used to the predictability of a copay structure plan design.

That brings us to one of the main concerns around switching to an HSA eligible plan design and that’s the question mark around cost.

If you have a $30 copay then you know that your doctor visit or specialist visit will cost $30 but if you have an HDHP then you get billed the insurance negotiated rate with that doctor which is difficult to predict and can be in the hundreds of dollars for specialist visits.

In general, the upfront costs are a lot higher with an HDHP since you have no copays in the beginning. Copays may come into play after you meet your deductible but that first dollar outlay($1300/$2600 or more) is 100% the responsibility of the insured so if you’re very worried about cost predictability then an HDHP may not be for you.

The benefit of an HDHP is the premium savings that can be had and they can be substantial and worth the risk especially once you take all the tax benefits of an HSA into account.

Even if you love the predictability of traditional copay plans and don’t care for the upfront cost burden of an HDHP plan, the harsh truth is that traditional copay plans are starting to disappear as an offering or simply being priced out of existence.

The Kaiser Family Foundation says that only 55% of plans had a deductible in 2005 but how many of you have a plan with no deductible or even know a person who does now? They still exist especially in government/union jobs but they are far less common.

Enrollment in HDHP plans has doubled from 2010 to 2015 and HDHP plans now make up nearly 1/4th of all the plans offered now as deductibles grow each year. In fact, deductibles have grown 67% in that same time period and show no sign of slowing down.

There might be a time soon where your only option is an HDHP plan so making a switch earlier may allow you to get a head start on growing your health savings account and taking advantage of all the benefits that come with it.
HSA benefits
The ability to open an HSA account with an HDHP plan is one of the key benefits of that plan design and can often swing the decision in favor of an HDHP when other factors don’t clearly point you one way or the other.

Most Americans are familiar and participate in tax-advantaged retirement plans like a 401k, 403(b), IRA or Roth IRA but many still aren’t utilizing the HSA. That’s a shame as it is probably the best account available to them when it comes to the tax-advantages it offers.

An HSA is especially attractive for those retiring early because unlike the other tax-advantaged savings accounts; the funds aren’t locked up until a certain age if used for qualified medical expenses.

For 2017, the IRS allows an HSA account holder to contribute up to $3400 into the account for an individual account and up to $6750 for a family account. If you’re over the age of 55, you can make an additional catch-up contribution of $1000.

Most employers who offer an HDHP paired with an HSA will also make an automatic contribution towards your HSA each year to help with some of the first dollar costs for those that don’t or can’t contribute. Do note that any money the company contributes towards your HSA IS counted towards the maximum unlike a 401k. That means if your employer contributes $1000 towards your HSA during a calendar year, your maximum for that year would be $2400.

That money can be used to pay any medicals bills under your plan and help meet your deductible so it offsets some of the initial risk burden that comes with an HDHP plan.

After all, people used to a $25 copay may be shocked to find that a doctor visit actually costs $140. The idea behind these plans is that you save the additional dollars saved via premium reduction into an HSA to cover but the real benefits of an HSA and any dollars you contribute towards it are the tax benefits that come with it and how they can help you save for your future.

We talked about the tax-exempt subsidy that employers get when they pay for your premiums. That subsidy comes via the fact that medical premiums paid by you or your employer are exempt from federal income and payroll taxes. An HSA allows you to extend that benefit even further and take more of it into your own hands instead of allowing your employer to benefit from it all. It does so by offering some unique benefits that actually make it one of the most attractive retirement vehicles around.

  • Contributions to an HSA are pre-tax just like a traditional IRA or 401k.
  • The other big benefit is that if your HSA is offered through your employer and you make payroll deposits into your HSA, your contributions are not subject to FICA which is another 7.65% savings over a standard tax-advantaged retirement account.
  • If you make the contributions with after-tax dollars and not through your paycheck then they are tax deductible at the end of the year but you miss out on the FICA benefit.
  • Withdrawals from an HSA are tax-free if used for an eligible medical expense. That’s huge and means you never pay taxes on money in an HSA as long as it is used for a medical expense.
  • Earnings in that account are tax-free as well just like an IRA or 401k. Most HSA accounts allow you to invest money in mutual funds as well. Some require a certain dollar amount in cash before they allow you to invest in mutual funds.
  • The funds in the HSA are yours to keep forever and they can grow tax-free for as long as you want them. This is unlike an FSA(your own money – tax deductible) or HRA(employers money) which are gone after the calendar year or not yours to keep.

You can see that an HSA essentially functions like a 401k with a few added benefits. You can avoid FICA(7.65%) if the contributions are made through your payroll and pay no taxes or penalties for taking the money out early if it’s for an eligible medical expenses.

The triple tax benefit of an HSA(tax free contributions, tax free growth and tax free withdrawals for medical expenses) are huge and make an HSA a very appealing investment vehicle for early or regular retirement.

Also note that in most states HSA contributions are pre-tax for state taxes as well. This is not the case in Alabama, California and New Jersey. Certain states like CA(no tax benefit at all for state taxes!), NH and TN also tax the earnings in the account making them less desirable in those states.

There are some obvious issues here that come to mind.

One of the first ones deals with someone who doesn’t have any medical expenses and an HSA effectively becomes an IRA after you turn 65 for that lucky person. Once you turn 65, you can withdraw money for regular living expenses with no penalties as long as you pay income tax which effectively means it functions like an IRA or 401k although it doesn’t have some of the early withdrawal opportunities those accounts have. You can also take money out of the HSA for other purposes before 65 but have to pay a 20% penalty so that should only be used as a last resort.

The other question mark is what happens to HSAs if the US healthcare landscape ever changes(socialized healthcare for example). That’s hard to figure out although it’s possible they’d simply convert to standard retirement accounts in that scenario since they already function that way after 65 anyway.

Another is the an issue someone’s who not healthy might run into because an investment vehicle requires time to function well so if your goal with an HSA is to save money for retirement then you need the wonder of compounding to make that money grow for you. If you’re spending your entire account value each year to cover your deductible then you’re not growing anything and that is an issue.

Even in a scenario like that you’re still benefiting from maxing out the HSA because you’re effectively not paying any taxes on any HSA contributions and medical expense.

However, there is a key quirk of an HSA that allows you to take advantage of the tax-free growth even if you’ve got medical bills.

As of right now, you can actually use post-tax money to pay your medical bills now allowing your pre-tax dollars to grow for the future. Then you can take HSA dollars out of the account years later against those medical bills.

That means you can have a bill for $1000 in 2016, use non HSA money(post-tax) to pay for it and let your money grow tax free until 2026 when you retire. Then take out $1000 to reimburse yourself for that payment with no penalty or tax bill. The laws may change in the future so I wouldn’t count on this forever but right now that option is available to you as an HSA account holder.

Do note that keeping receipts for qualified medical expenses with an HSA is key in case you get audited.

Another benefit is that HSA funds like other retirement accounts are portable so you can take them with you whenever you switch jobs or want to change your HSA administrator.

Which is the right choice; HDHP(HSA) or Traditional?

The truth is that medical costs are expensive and not everyone can afford the type of plan design that is needed to set up an HSA.

The upfront medical costs that come with an HDHP plan can be very high and some of these plans come with deductibles that are as high as $6000 which means you’ll pay $6000 before the insurance covers anything. The reality is that some people may not have an option as that type of plan is the only affordable medical insurance and for a lot of people an HDHP is the clear option when you compare the premiums of an HDHP and a traditional copay plan.

Young or generally healthy people should have no qualms about choosing an HDHP plan and setting up an HSA accounts because their chances of actually using the insurance are low.
That means they can contribute to their HSA for years and enjoy the tax-free growth which should cover any medical issues and deductible needs in the future. Those fortunate enough to be able to cover their medical costs out of pocket without tapping into the HSA can enjoy years upon years of tax-free growth inside the HSA and benefit from the additional money in their retirement.
However, sick people may not have that same option because the high deductible nature of a plan may not be cost efficient for those that use the plan often. The premium may be lower but the lack of copays and low deductibles may mean the actual out of pocket costs including premium are higher on an HDHP plan versus a traditional plan.
There are also people who have a great benefit package from their employer and just can’t make the change to an HDHP plan just yet. There is certainly a long term benefit to an HSA over a traditional plan as it allows you tax-free growth for your future. That may make it seem like an HSA should be an obvious option for most but that’s not the case at all and it really depends on your individual case scenario.
If your employer offers a $0 deductible plan that pays for everything but costs you $250/month and also offers a $4000 deductible HDHP plan that is eligible for an HSA that costs you $20/month then the discussion can be had around whether the HDHP is a better option. The HDHP saves you $2760 in premium that you can use to fund your HSA and get a head start on future savings but also puts more risk on your end because you end up losing out if you have medical costs in excess of $2760(although the tax benefits of an HSA probably make that number a bit higher).
However, if your employer offers a $0 deductible plan that pays for everything and costs you $10/month and also offers a $4000 deductible HSA eligible plan at no cost then it’s hard to make the argument for the HSA account. I’d rather take the plan that covers everything and go see a doctor whenever I want even if I have to give up the HSA account.
The truth is that the choice between an HDHP/HSA eligible plan and one that isn’t is a personal decision based on your own personal situation. I think the trend shows that most companies are moving into the HDHP direction so the option might be out of your hands sooner than later but right now there are other viable options than an HDHP plan with an HSA.

Do note that you can have a traditional plan after you’ve started an HSA. You just won’t be able to contribute to your HSA account that year without an eligible HDHP plan.

If you know there are medical expenses coming up in a given year and your employer offers an affordable traditional plan alongside an HDHP plan then you can switch to the traditional plan for one year – get all your medical expenses out of the way and switch back to an HDHP. You’ll miss one years worth of contributions but it can be a financially advantageous decision depending on plan designs and premiums.

Investing
For me, the key part of an HSA is how well it functions as another investment vehicle that allows you to avoid taxes. Tax-advantaged accounts are key to any savings strategy because they not only allow you to avoid paying taxes now or later(or minimize them in general) but also allow you to grow your money tax-free which is huge for long term returns. Reinvesting 100% of your money versus paying taxes on your dividends and/or sales is huge when combined with the power of compounding.
The fact that an HSA allows you to invest money pre-tax, avoid FICA, grow the money tax-free and take money out without paying taxes for medical expenses is huge and makes it the best tax-advantaged account out there. There is no escaping medical costs and those of us who are fortunate enough to start young and be healthy can get a hefty amount socked away in an HSA before those big bills come due. Then once they do, you can either pay them out of pocket(and claim against the HSA later) and keep growing the money or just use the HSA account to pay them while avoiding taxes all the way.
The growth of HSA popularity has also led to improvements in the quality, fee structure and investment offerings of the various HSA administrators. I won’t go into detail about those here since I’m not overly familiar with them and only use the one that my employer provides but most offer the ability to invest in mutual funds after a certain dollar threshold is met. For me, after I have $2000 in my HSA I can invest excess money into a wide variety of mutual funds including low cost ones from Vanguard. I might do some research on HSA administrators in the future but based on my basic knowledge, the best ones out there seem to be HSA Bank, Health Savings Administrators and Optum Bank. The one thing to check and keep in mind when electing an administrators for yourself are the fees. If your employer offers an HSA then those fees are often(not always) covered by your employer.
The popularity and growth and improvements in offerings is fantastic for those of us utilizing HSAs because not only are you getting all the tax benefits that come with an HSA; you’re also getting high quality investment options to help your money grow. There are also no income limits for an HSA so anyone can contribute unlike other investment vehicles like a traditional IRA or a Roth IRA. Where the HSA really shines is if you are under the FICA phase out range and contributing through your payroll because then you save an additional 7.65% over any other savings account.
In fact the added tax-benefits of an HSA make it the best savings account even if you’re above that FICA phase-out and I would consider it a bigger priority than a 401k after you’ve met your employer match. An HSA offers the other benefits that a 401k does not and that makes it preferable in most situations. If your HSA has terrible high expense investment offerings or no investment offerings at all then a 401k could still be the way to go.
The tax shelter benefits of an HSA cannot be understated but the fact that you can pay any future medical expenses without paying any taxes is huge. The reality is that most of us underestimate the medical expenses we will face in the future and having money set aside that is efficiently being used for that purpose will be huge in our latter years. The HSA money can also be used for health premiums when you’re between jobs, medicare premiums and out of pocket expenses and qualified long-term care premiums. Health expenses are trending at a much higher rate than anything else these days and having tax-advantaged money to pay for them will be helpful for any future retirees.
HSAs are also key for those of us looking to retire early as they give you yet another tax-advantaged vehicle. Even with medical expenses, they can also be used strategically to continue the tax-free growth into the future according to current regulations.
As I mentioned before, an early retiree can pay any medical expenses out of their taxable account, put the money in the HSA to reduce their taxable income and then take it out years later as a reimbursement for that payment. That does require meticulous receipt keeping but in this way the HSA acts like a Roth and traditional IRA combined! It allows the account holder to pay no tax on the contributions, grow the money tax-free and then take it out tax-free for unrelated non-medical expenses and call it a reimbursement.
It also allows you to continue making tax-advantaged contributions after retiring(no more 401k) and reduce your taxable income while taking advantage of the future tax benefits around medical costs.
The bottom line

The reality is that HSAs aren’t for everyone. Those that have affordable high quality healthcare coverage through their employer may not want to take the additional risk that comes high deductible plan designs and that’s understandable. HSAs offer great tax benefits and potential for increasing your tax-advantaged retirement savings but that doesn’t necessarily make them an obvious choice for everyone.

If the premium cost difference between a plan that exposes you to thousands of dollars in deductible expenses and a plan design that covers everything is negligible then there’s no way I’m taking the HSA eligible HDHP plan. I still think those situations are rare aside from certain industries and most times there will be clear premium savings when comparing an HDHP plan versus a traditional copay plan and there’s where HSA eligible plans start making sense.

It really comes down to what your employer contributes towards your healthcare, what options they offer and whether the financials of choosing an HSA eligible plan over a traditional plan make sense for you. If you can save a significant amount in premium on an HSA eligible plan and put that money towards your HSA then it might make sense for you.

The simple analysis to do when comparing an HSA eligible plan against a standard plan is to take the premium savings offered by an HDHP plan and weigh it against the additional risk that type of plan puts on you and decide whether that is a risk you’re comfortable with. An HSA eligible HDHP plan will allow you to save additional money for your retirement but does offer more potential for increased upfront medical costs. As with any financial decision, the type of risk you’re comfortable with is a personal question that should weigh the potential savings increases versus the potential increased cost exposure and take into account your personal health and other variables.

The individual exchange offers a perfect example of the premium differences you can see from going to an HSA. Here are two actual plans I found on the exchange today and how they compare in cost.

The above layout is a basic benefit structure and cost for two separate medical plans for a 45 year old man. You can see that the traditional copay plan is a lot more expensive than the HSA eligible plan($3284 more expensive) but offers much better benefits. It has copays, a lower deductible and a lower out of pocket maximum.

While the HSA elgibile plan has a much higher potential out of pocket expense, it gives the person choosing the HSA over $3000 in premium that they could use to almost max out their HSA. In doing so they take on additional risk in the form of much higher first dollar costs.

What’s interesting in this scenario is that a person who meets the out of pocket max in both plans is actually better off with the HSA plan than the traditional plan as they save $3200+ in premium but only pay $3050 more in out of pocket costs. That makes it seem like the HSA is an obvious choice here but that’s only one specific scenario and insurance is all about potential scenarios. HSA eligible plans will be better in certain circumstances but copay plans will be better in others and the premium difference is often smaller than this example making it less clear.

Another thing I typically look at when comparing plans is what happens in certain scenarios and see if you’re comfortable with the risk around those scenarios..

As an example, traditional copay plan has a $100 ER copay and an ER visit is often $1000 dollars a pop. Imagine a person who has 5 ER visits during the year. With the HSA plan, they’d pay $4172 in premium then $5000 in ER costs for a total of $9172. With the traditional plan, they’d pay $7457.64 in premium and $500 in ER copays for a total of $7957 – not a huge difference but in this type of scenario the traditional plan wins.

Keep in mind that the HSA offers the ability to save $3400 in pre-tax dollars potentially saving the HSA eligible enrollee additional tax savings($850 if they’re in the 25% tax bracket) so that brings the difference closer.

There are other scenarios to plan out like rx expenses and doctor visits as the copay plan has rx copays between $5 and $50 dollars and doctor copays in the $20 range so it all depends on your expected costs in all these medical categories.

In this scenario, the HSA would be a better deal if you’re really healthy(as is almost always the case for healthy people), or sick enough to hit the full OOPM.  The copay plan would likely be better in a variety of scenarios where the copays are utilized quite often but you’re not quite hitting the HSA OOPM.

I think in this comparison, I’d lean towards choosing the HSA because the premium savings is pretty large versus the risk potential I can see but the potential scenarios are always different and varied and depend heavily on plan design and premiums and your own utilization. The plan differences(premiums) between these two plan designs might not be the same in every state and with every carrier as the actuarial values between plans can vary between carriers making one a better deal than the other.

Even if an HSA seems like it might make sense, a lot of people simply love the certainty of having a copay versus high deductibles and if they’re lucky enough to have their employer pick up most of the cost of that $7400 annual premium then the decision can be pretty clear in the other direction. It’s a lot easier to budget for doctor visits when it’s a $20 copay versus a potential $200 outlay when the premium cost to you is very low.

However for those that are going through the exchange with no subsidy or employer contribution, the choice can be more murky.

I’d urge people who are unsure about that decision to do a similar high level look around benefits including copays and then compare expected costs around certain scenarios and see if you’re comfortable with the risk versus the savings. There are calculators out there that you can use to compare two plan designs based on their benefits and premiums.

There are also situations where the choice is already made for you as more and more employers are starting to offer HDHP plans with no other choice. In those scenarios, I would certainly advise putting as much money into an HSA as possible and taking advantage of the tax savings that come with it especially if you’re doing the contributions through your paychecks and saving on FICA as well.

The ability to save for your future healthcare benefits is important as those will be a big portion of your expenses as you get older. Just looking at those premiums for the individual exchange plans for a 45 year old man makes me realize that an early retiree now could be on the hook for as much as $11000 any given year if they have health issues and that’s for a single man without family coverage. Family coverage could easily mean a potential outlay of $20000+ with deductibles doubling and premiums going higher.

In my opinion, the HSA should be the second target for those saving for retirement. First, you should make sure to get your employer match in your 401k then max out the HSA before returning to the 401k. The HSA functions much like a 401k but offers all the other benefits we’ve discussed already that make it a better choice.

There are some exceptions here and I assume that your HSA does offer investment options that aren’t cost prohibitive(very high expense ratios) versus your 401k and doesn’t have outrageous fees. The 401k also offers some other benefits that an HSA does not like bankruptcy protection(HSA has that as well in certain states) and the ability to take advantage of such things as 72t early withdrawals but those don’t necessarily apply to everyone.

That means that if you’re thinking of retiring early then an HSA does have less options for tax-free withdrawal unless you’re spending the money on medical expenses or using it to cover some past medical expense. Most people who are thinking of retiring early should already be maxing out their 401k so it shouldn’t be a choice of one or the other but both if possible. I just wish the annual contribution limit for an HSA was a bit higher!

The HSA is a no brainer for those who have access to it and are already maxing out their other tax-advantaged account or make too much to be eligible for a Roth or Traditional IRA. Those who aren’t quite maxing their other accounts should still make use of their HSA if available as it offers a lot of benefits that make it better than the other available investment accounts.

I’ve been using my HSA for a few years but only recently started maxing it out every year after reading more about them. Most people don’t see the HSA for the retirement vehicle it is and that’s a mistake because it’s one of the best ones out there and should definitely be at the top of any list for savers. Healthcare expenses are almost guaranteed to be a big part of your expenses in early or late retirement and it is great to have the ability to pay for those expenses with no tax obligation after letting it grow tax-free for decades.

These days a lot of HSA administrators offer fund selections and fee structures that compete with most 401ks making them an excellent choice for your investment dollars. That means that if you’re looking to supplement your tax-advantaged savings account then an HSA is a great choice as long as you can make sense of the premiums and extra risk of an HSA eligible plan against a traditional copay plan.

How many out there are currently using an HSA eligible plan and/or thinking about switching to one? What HSA administrator do you use and what do you think about it? I might do some research on that end and make another post about which ones are the best in the future.

That’s it for HSA guys! Let me know if there are any other questions/concerns I failed to cover here and thanks for reading!

2 thoughts on “The story behind Health Savings Accounts

  1. Hi timeinthemarket,

    Wow I think you covered everything there is to know about HSA's – great post!

    I max mine out and I'm currently paying for medical expenses post-tax while letting my HSA account grow. It's invested in Total Stock Market and I don't plan on touching it for years. Luckily mine has some cheap Vanguard funds and my employer pays quite a bit in on my behalf too.

    My HSA is housed at Bank of America who have, absolutely hands-down, the worst investing website I've used to date. I get to tell them that monthly too as they ask for my opinion just before logging out 😉

    Best wishes,
    -DL

    Like

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