Health Savings Plans and Disparities in Access to Care by Race and Ethnicity


      High-deductible health plans are often touted to motivate patients to become informed healthcare purchasers; however, racial/ethnic minorities report that high deductibles prevent them from seeking the needed care. One proposed way to mitigate the financial burden of high-deductible health plans is the use of health savings plans. This cross-sectional study investigates whether chronically ill Blacks and Hispanics enrolled in high-deductible health plans experience greater access to care difficulties than non-Hispanic Whites and whether racial/ethnic disparities are mitigated by the use of health savings plans.


      Weighted, multivariate, linear probability regression models were estimated (analyses were conducted in December 2020), adjusting for individual attributes and contextual factors that may explain the variation in health care access. Chronically ill, U.S.-born Black, Hispanic, and White adults enrolled in a high-deductible health plan from the National Health Interview Survey in 2011–2018 were included. Associations were tested among 3 independent variables—being Black, being Hispanic, and health savings plan utilization (and their interaction)—and access to healthcare outcomes of interest, including affordability-related access, provider-related access, and delayed care.


      Blacks and Hispanics were less likely to use health savings plans, and Blacks were more likely to experience problems with access to health care. Although the use of health savings plans was found to have a minimal effect on reducing racial/ethnic disparities in affordability-related access, there was also evidence that health savings plans compounded racial/ethnic disparities in provider-related access.


      Understanding how health savings plans function to improve access to care within racial/ethnic minority groups may help to inform policy approaches related to their use.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kullgren JT
        • Galbraith AA
        • Hinrichsen VL
        • et al.
        Health care use and decision making among lower-income families in high-deductible health plans.
        Arch Intern Med. 2010; 170: 1918-1925
        • Bloche MG
        Consumer-directed health care and the disadvantaged.
        Health Aff (Millwood). 2007; 26: 1315-1327
        • Buntin MB
        • Damberg C
        • Haviland A
        • et al.
        Consumer-directed health care: early evidence about effects on cost and quality.
        Health Aff (Millwood). 2006; 25: w516-w530
        • Haviland A
        • McDevitt R
        • Marquis M
        • et al.
        Skin in the game: how consumer-directed plans affect the cost and use of health care.
        RAND Corporation, Santa Monica, CAPublished 2012
        • Cole MB
        • Ellison JE
        • Trivedi AN
        Association between high-deductible health plans and disparities in access to care among cancer survivors.
        JAMA Netw Open. 2020; 3e208965
        • Agarwal R
        • Mazurenko O
        • Menachemi N
        High-deductible health plans reduce health care cost and utilization, including use of needed preventive services.
        Health Aff (Millwood). 2017; 36: 1762-1768
        • Lewey J
        • Gagne JJ
        • Franklin J
        • Lauffenburger JC
        • Brill G
        • Choudhry NK
        Impact of high deductible health plans on cardiovascular medication adherence and health disparities.
        Circ Cardiovasc Qual Outcomes. 2018; 11e004632
      1. U.S. Department of the Treasury, Internal Revenue Service, Health savings accounts and other tax-favored health plans, Published February 11, 2021; U.S. Department of the Treasury, Internal Revenue Service; Washington, DC, Accessed March 30, 2021.

        • Miller GE
        • Vistnes JP
        • Rohde F
        • Keenan PS
        High-deductible health plan enrollment increased from 2006 to 2016, employer-funded accounts grew in largest firms.
        Health Aff (Millwood). 2018; 37: 1231-1237
        • Claxton G
        • Rae M
        • Long M
        • Damico A
        • Whitmore H
        The Kaiser Family Foundation: employer health benefits 2019 annual survey.
        The Henry J. Kaiser Family Foundation, San Francisco, CAPublished 2019
        • Kaiser Family Foundation
        Cost-sharing for plans offered in the federal marketplace, 2014-2021.
        Kaiser Family Foundation, San Francisco, CAPublished January 15, 2021
        • Galbraith AA
        • Soumerai SB
        • Ross-Degnan D
        • Rosenthal MB
        • Gay C
        • Lieu TA
        Delayed and forgone care for families with chronic conditions in high-deductible health plans.
        J Gen Intern Med. 2012; 27: 1105-1111
        • Segel JE
        • Kullgren JT
        Health insurance deductibles and their associations with out-of-pocket spending and affordability barriers among U.S. adults with chronic conditions.
        JAMA Intern Med. 2017; 177: 433-436
        • Abdus S
        • Keenan PS
        Financial burden of employer-sponsored high-deductible health plans for low-income adults with chronic health conditions.
        JAMA Intern Med. 2018; 178: 1706-1708
        • Wharam JF
        • Zhang F
        • Eggleston EM
        • Lu CY
        • Soumerai SB
        • Ross-Degnan D
        Effect of high-deductible insurance on high-acuity outcomes in diabetes: a Natural Experiment for Translation in Diabetes (NEXT-D) Study.
        Diabetes Care. 2018; 41: 940-948
        • Hibbard JH
        • Cunningham PJ
        How engaged are consumers in their health and health care, and why does it matter?.
        Res Brief. 2008; 8: 1-9
        • Patel MR
        • Jensen A
        • Ramirez E
        • et al.
        Health insurance challenges in the post-Affordable Care Act (ACA) era: a qualitative study of the perspective of low-income people of color in metropolitan Detroit.
        J Racial Ethn Health Disparities. 2018; 5: 78-85
        • Blumberg LJ
        • Clemans-Cope L
        Health savings accounts and high-deductible health insurance plans: implications for those with high medical costs, low incomes, and the uninsured.
        Urban Institute, Washington, DCPublished February 3, 2009
      2. Norris L. What is the difference between a medical FSA and an HSA? Accessed March 30, 2021.

        • Claxton G
        • Rae M
        • Long M
        • et al.
        The Kaiser Family Foundation and Health Research & Educational Trust: employer health benefits 2016 annual survey.
        The Henry J. Kaiser Family Foundation, San Francisco, CAPublished 2017 (Accessed May 20, 2020)
        • Lo Sasso AT
        • Shah M
        • Frogner BK
        Health savings accounts and health care spending.
        Health Serv Res. 2010; 45: 1041-1060
        • Ellison J
        • Shafer P
        • Cole MB
        Racial/ethnic and income-based disparities in health savings account participation among privately insured adults: study examines racial.
        Health Aff (Millwood). 2020; 39: 1917-1925
        • Painter II, MA
        • Qian Z
        Wealth inequality among immigrants: consistent racial/ethnic inequality in the United States.
        Popul Res Policy Rev. 2016; 35: 147-175
        • Painter II MA
        • Shafer K
        Children, Race/ethnicity, and marital wealth accumulation in Black and Hispanic households.
        J Comp Fam Stud. 2011; 42: 145-169
        • Gee GC
        • Ford CL
        Structural racism and health inequities: old issues, new directions.
        Du Bois Rev. 2011; 8: 115-132
        • Bailey ZD
        • Krieger N
        • Agénor M
        • Graves J
        • Linos N
        • Bassett MT
        Structural racism and health inequities in the USA: evidence and interventions.
        Lancet. 2017; 389: 1453-1463
        • Feagin J
        • Bennefield Z
        Systemic racism and U.S. health care.
        Soc Sci Med. 2014; 103: 7-14
      3. About the National Health Interview Survey. Centers for Disease Control and Prevention. Updated September 16, 2020. Accessed March 19, 2021.

        • Parsons VL
        • Moriarity CL
        • Jonas K
        • Moore TF
        • Davis KE
        • Tompkins L
        Design and estimation for the national health interview survey, 2006-2015.
        Vital Health Stat 2. 2014; : 1-53
        • National Center for Health Statistics
        2015 National Health Interview Survey (NHIS) public use data release. National Health Interview Survey: survey description.
        National Center for Health Statistics, Hyattsville, MDPublished June 2016
        • Ford ES
        • Croft JB
        • Mannino DM
        • Wheaton AG
        • Zhang X
        • Giles WH
        COPD surveillance–United States, 1999-2011.
        Chest. 2013; 144: 284-305
      4. Federal poverty level (FPL). U.S. Department of Medicaid & Medicare Services. Updated 2020. Accessed June 1, 2020.

        • Fiscella K
        • Franks P
        • Gold MR
        • Clancy CM
        Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care.
        JAMA. 2000; 283: 2579-2584
        • Kullgren JT
        • Cliff EQ
        • Krenz C
        • et al.
        Use of health savings accounts among U.S. adults enrolled in high-deductible health plans.
        JAMA Netw Open. 2020; 3e2011014
        • Buntin MJB
        • Graves J
        • Viverette N
        State Medicaid lessons for federal health reform.
        HealthAffairs, Bethesda, MDPublished June 7, 2017
        • Buntin M
        • Graves J
        • Viverette N
        Developing and implementing health savings accounts in Medicaid: lessons from pioneering states.
        Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TNPublished June 2017
        • Stokes EK
        • Zambrano LD
        • Anderson KN
        • et al.
        Coronavirus disease 2019 case surveillance - United States, January 22–May 30, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 759-765
        • Lopez MH
        • Rainie L
        • Budiman A
        Financial and health impacts of COVID-19 vary widely by race and ethnicity.
        Pew Research Center, Washington, DCPublished May 5, 2020
        • Eisenberg MD
        • Barry CL
        • Schilling CL
        • Kennedy-Hendricks A
        Financial risk for COVID-19–like respiratory hospitalizations in consumer-directed health plans.
        Am J Prev Med. 2020; 59: 445-448
        • Norton M
        • Hamel L
        • Brodie M
        Assessing Americans’ familiarity with health insurance terms and concepts.
        The Henry J. Kaiser Family Foundation, San Francisco, CAPublished November 11, 2014
        • Cunningham PJ
        • Denk C
        • Sinclair M
        Do consumers know how their health plan works?.
        Health Aff (Millwood). 2001; 20: 159-166