Nevertheless, the effectiveness of CDHC still generates debate. Several studies point to a lack of impact on the uninsured. CDHC supporters say there hasn't been sufficient time to analyze long-term data and draw solid conclusions.

Others argue, often heatedly, that many consumers with high-deductible plans forgo needed care. Some of the numbers back that up. The Commonwealth Fund Biennial Survey found that 44 percent of privately insured adults with deductibles of $1,000 or more avoided getting necessary health care or prescriptions because of the cost. Only 25 percent of adults with deductibles under $500 make those same decisions. UnitedHealth conducted a three-year study that found individuals covered under a CDHC plan were 5 percent more likely to seek preventive care and 14 percent less likely to make unnecessary visits to the emergency room. The UnitedHealth study also suggests that 90 percent of employees would open HSAs if their employers offered one.

That number is higher than other studies out there, but a couple of things become abundantly clear: Consumer-driven health care is here, and it likely will continue to grow as long as carriers keep developing plans and employers keep embracing the move toward employees taking charge of their own health care.

Growth

According to the National Center for Policy Analysis in Dallas, 6 million people have high-deductible plans with no attached savings account. Those with HSAs tied to an HDHP number 3.2 million, and those with an HRA total 3 million. Due to the relative novelty of the consumer-driven health care movement in general and HDHPs in particular, health savings accounts, and health reimbursement accounts specifically, the numbers don't look imposing.

But proponents see promise. "I've seen numerous surveys that say participation will increase," says Devon Herrick, an economist and senior fellow at NCPA. "Given that HSAs and HRAs are still so young, I think the numbers are good right now."

Employers will likely comprise the group most interested in HDHPs with either HSAs or HRAs attached. Their costs will fall substantially. Among firms offering benefits but not offering an HSA-qualified HDHP, the Kaiser Family Foundation survey says 4 percent say they are very likely to offer one in the next year, and an additional 19 percent say they are somewhat likely to offer one in the next year. That's a good number of employers looking at morphing to the CDHC model in the next year. If the UnitedHealth study is correct and 90 percent of employees would enroll in an HSA if it were offered, a lot of people would switch from traditional coverage to the new model. Kaiser Permanente introduced HSA-based products in Colorado in January 2005. Interest has grown since then, and the company expects that to continue.

"When we first introduced the HSA-based plans, there was a fair amount of interest among smaller groups," says Ted Wise, senior vice president for health plan strategy and product innovation. "Now there is large group interest, as well. A lot of the recent activity has been with the large groups." That development makes sense because large groups have a larger variety of employees and a big need to cut premium costs, so they have employees who fit the CDHC mold and they want to take advantage of any cost savings the plans provide. Great-West Healthcare has about 7 percent of its commercial membership in CDHC, a good portion of that in the company's Consumer Advantage plan, a tiered PPO.

While Consumer Advantage doesn't carry the low premium and high deductible of other plans, it is a bridge between traditional plans and HDHPs. "We have a lot of interest in Consumer Advantage," says Megan Spicer, Great-West's director of product specialists. "Employers see it as a step toward consumer-driven health care [and high-deductible plans]."

Education

Most workers probably don't understand everything in their health plans. Employees attend the annual enrollment, sign up for a plan and don't think about it again until they need care. Even then, their only concern is the copay. With something as new as CDHC, the learning curve is even steeper. Consumers shoulder more and more responsibility for managing their own care, and that can lead to problems. "The concept of helping consumers anticipate the cost of their health care is the right concept," Wise says. Problems arise in the delivery and execution, however.

"To expect consumers to jump in and understand everything about the new products [and how to manage their own care] is unreasonable," Spicer says. To that end, carriers must ensure employers have the information employees need and the means to deliver it to them. Workers will have to know where they can access the best information possible. Herrick says there is a fair amount of information out there, and while that may be true, more can be done. Carriers will have to help employers provide large amounts of information without eating into the cost savings the employers want from the plans in the first place. Spicer and Julie McCarter, vice president of product development for Denver-based Great-West, say the educational process needs to be a partnership between plan providers and employers. Spicer and McCarter say that for participation to grow in the future, employers need to offer more education, whether that comes from carriers, employers or consultants.

As plans gain more traction and availability, educational materials will get better and be more readily available, which helps everyone involved, from the carrier to the consumer. At bottom, consumers must know what they are getting and what they are going to pay for it.

Transparency

If the ultimate goal of CDHC is to make better health care consumers of Americans, transparency has to increase. "Transparency in quality and price is lagging," Herrick says. "Most hospitals can't even tell you what something costs." That is because everything is coded, baffling consumers who try to decipher their hospital bills. Without knowing what those coded charges mean, consumers cannot make informed decisions.

Spicer agrees. "If we are going to ask consumers to be more engaged, we have to provide the information for them to do that."

"It's about cracking open the cost and quality information at the consumer level," McCarter adds, saying that carriers like Great-West are looking into Web tools and asking questions like, "How do we deliver information in a meaningful way at the individual level?" Unfortunately, the answer to transparency in health care isn't as simple as posting a cost-per-service board. Experts at both Kaiser and Great-West say they are looking for input right now from employers, employees and brokers about how to increase transparency in a way consumers can understand and then apply that information to managing their health care costs, in much the same way they manage budgets for groceries, housing, entertainment and education.

A big part of future growth and effectiveness relies on strategies for improving transparency, and few would argue differently. But it's going to take a team effort to get there.