The upcoming midterm congressional elections could determine whether health savings accounts and high-deductible health plans face tough new fights in Washington.
Jeanne Lambrew, a longtime Democratic health policy veteran, has hinted at the battles that might lie ahead by publishing a new opinion article calling for Congress to abandon efforts to encourage employers, insurers and consumers to use HDHPs, or to combine HDHPs with HSAs or flexible spending accounts.
"The problems of high prices and complexity of health care cannot be solved by shifting responsibility to people through high-deductible plans linked to spending accounts," Lambrew writes in the commentary, which was published by Health Affairs, an academic journal that focuses on health care finance and delivery systems. "Evidence suggests going in the opposite direction to solve these problems: replacing deductibles with value-based cost sharing and having the government take on greater responsibility for lowering prices."
Jeanne Lambrew: Lambrew is now director of health care reform at the Century Foundation and an adjunct professor of health policy at the Harvard School of Public Health.
Earlier in her career, she was a senior health policy official in the administration of President Barack Obama.
She was the commissioner in charge of the Maine Department of Health and Human Services from 2019 through 2024.
Lambrew's views: Studies have shown that high deductibles discourage use of obviously necessary care, such as care for people with serious chronic conditions, as well as low-value care, Lambrew writes in the new commentary.
Few people have HDHPs, and "shopping for low-cost services, according to several studies, is no greater among enrollees in high-deductible plans than those in traditional plans," Lambrew adds.
"Accounts are disproportionately used by, and benefit, wealthy people. High-deductible plans also contribute to complexity, confusion, and dissatisfaction," Lambrew says. "Enrollees have to track spending toward the deductible and must guess when coverage will kick in."
Lambrew contends that studies have shown that use of HDHPs and health accounts might increase health system costs.
"Hospitals have to collect from patients 100% of the below-deductible costs, raising their administrative and uncompensated-care costs," Lambrew writes. "High deductibles may also have contributed to growth in direct primary care as physicians and other outpatient providers forgo bill chasing for a fixed-fee model. This balkanizes the system, making access to primary care even more challenging for people without the means to pay for it."
The history: For decades, advocates of using high deductibles, or "giving patients skin in the game," argued that requiring patients to spend some of their own money on care would lead them to shop for care based partly on price.
If patients care about price, that will make the entire health care system more price-conscious, HDHP advocates said.
Most Republicans and some Democrats backed the HDHP advocates. Some Democrats have long questioned the HDHP-based approach.
The Affordable Care Act requires HDHPs to cover checkups and other basic preventive services without imposing deductibles on the patients.
In recent years, Republicans and Democrats have tried to nibble away at the HSA deductible requirement by joining in efforts to expand the ACA preventive services package.
Republicans hit the HSA deductible requirement hard in July 2025, by passing the One Big Beautiful Bill Act.
The act appears to let HSAs get access to no-deductible primary care by using HSA cash to pay for direct primary care memberships, or enrollment in organizations that provide basic medical services with no out-of-pocket costs.
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