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HSA 2:3 9/30/08 2:22 PM Page 15 Conservatives are pushing health savings accounts to expand insurance for Americans, but experience and research shows they are a losing bet for patients' health and pocketbooks. Just who is really banking off HSAs? by heather boerner photograph by franklin avery UNHEALTHY GAMBLE Jonathan Stein takes his health seriously. But he takes his responsibilities as a father even more seriously. And so it is that Stein, a self-employed 34year-old lawyer living in Sacramento, Calif., decided to risk his future health so that his wife and three boys will have health coverage for their chronic conditions. His wife has two herniated disks. The couple's oldest son is autistic, the middle boy has asthma, and the youngest was born with a congenital heart defect. If his family could afford the exorbitant premiums, he would have joined them on their highbenefit HMO. But on close to $58,000 a year in income (about the U.S. average for taxfilers), he went with what he thought was the next best thing—a high-deductible health plan linked to a tax-advantaged health savings account, or HSA. It's the type of plan that plays a major component in the healthcare platform of Republican presidential candidate Sen. John McCain and is touted by other conservatives and the insurance industry as a way to expand health coverage and contain costs. Stein admits his decision is a huge gamble, one his family cannot afford to lose. He is the sole breadwinner at the moment and his wife acts as his office manager. "I guess I'm more willing to take the risk that I'm not going to have a huge medical bill— knock on wood—every year because I try to do everything right throughout the year," he said. "I do soccer and tae kwon do. I run. I try to stay healthy. I'm not a daredevil. So I take the chance. I figure I've got other things I have to worry about first and I put my needs behind those. [My health] is the last thing on the list." So far, the plan has worked great. Well, that is, W W W. C A L N U R S E S . O R G except when he got kicked in the ribs during his martial arts class. Or when he twisted his ankle after that. Then he caught that cold he couldn't shake. He waited and waited to seek medical treatment for his injuries, resting and putting ice on his ribs, and visiting his mother-in-law, an RN, for advice. Finally, armed with a small laundry list of ailments, he broke down and saw the family doctor for the first time in two years. "I went in and told her, 'In addition to my cold, can you look at my rib, my knee, and my right ankle while you're at it?'" he recalled. Total bill: $350. "That's just ridiculous," he remembered, thinking of the expense. Supporters of health savings accounts don't think so. Indeed, they think the high deductibles and financial barriers of plans like Stein's force patients to act more "responsibly" when weighing whether or not to seek certain kinds of medical treatment, or request tests and procedures. In this way, HSAs are part of what's called the "consumer-driven" healthcare movement. But in reality, insurance programs like HSAs pose a danger to personal and public health, warn critics. Such plans leave the United States ranking consistently among the least healthy of all industrialized nations. Yes, minimal coverage and a high financial bar require patients to make hard decisions about the care they pursue, but research shows patients are notoriously bad at acting in their own best medical interests when they foot the entire bill. Instead, they ration care according to how much they can afford. That's dangerous for any individual. But when the illness is communicable, such as tuberculosis, they put the public at risk as well REGISTERED NURSE 15