The effort in the senate for repeal and replace ended up in delay and depart for recess week and perhaps more to come. Let me just tell you todays forum is called unbundling the benefit for Better Health from a broader role Health Savings accounts. More on that in just a moment. In light of the senate efforts, what i was thinking of this in older competition that used to be held for Young Athletes between the ages of six to 15 to show their skills in the nfl. It was called the front kick competition. It appears that its actually been discontinued after more than 56 years of it. It looks like the senate is up to the task in terms of the kicking approach and how much more the competition remiss in the senate is back next week and i have to be a little careful with this. The nfl is rather aggressive on the trade name protection. This is a news shot besides, they are leaving it behind because they want to get everybody a certificate for being out in the field i guess, kind of like soccer or elongated scales. We are starting today a different series of Health Policy events. Everybody has been caught up in the politics of what has been going on and i thought i would try something different, which is fleshed out and people are doing in Real Research as opposed to always one place to another. Interesting articles appeared in some of the policy journals. What we want to do is talk about giving no matter what you are spending, we could do a better job in the health care and the health we deliver by perhaps taking apart what is conventionally considered current benefit and maybe reassembling it in a somewhat more creative way. Pay attention to the people receiving those benefits is saying what works for them. Todays version of unbundling the benefit talks about how Health Savings accounts can be used. Well have other events later on the spot which talk about how to reengineer and restructure primary care, which would combine using a different mix of services, but in some cases for certain types of patients or individuals with high cost, high risk divisions, more of an intensive care unit type approach in things that might go one further. That is probably coming up on september 5th. We will also take a look at how to move around the dollars including the medicaid benefit and and prioritize to make a different way in order to ideally get some better results and also maybe look at the distinction between what is said to be equal benefits, everything the same for everybody is supposed to what might be apple benefits for people get what they need in different amounts in different situations. I think about what it produces. Today we are looking at some new ways to deal with Health Savings accounts. At the end of the day, Health Savings accounts have a long history and we will hear from us because im not are essentially tax Advantage Health benefits. You can move data around. Some people have talked about using hsa is in so many ways you could say its almost like a Swiss Army Knife. It doesnt just do this. It does five or six other things. If you dont have any money in your Health Savings account, its a good hypothetical tool but it might be a little bull in terms of a working part. I think that victor e. Nor is the only manufactured Swiss Army Knife. Unless i missed that. Or macgyver, perhaps a chewing gum that takes care of our entire health care system. So, the idea of the Health Benefits is to move around tax advantage dollars so they produce more bang for their bucks in one form or another with Health Insurance. You will hear from our speakers the current proposals as to how to change the contours of hsa, but also some more creative and thoughtful ways to reach beyond even tweeting here and there on the margins. We had three speakers today, our first well talk about how to have a more Precision Approach to hsas. An early way to think about it. Warren roth, has just begun a new appointment Teaching Health and law and legal writing at st. Johns University School of law, what is know as the redmond because now they are adjusted on the campuses. Warren is also served as associate or the program and assistant professor at nyu school of law, earned phd in Political Science from columbia university. Previously law degree from harvard, dan Legal Research and writing work. Seton hall and as a hometown connection i suppose because she graduated from George Washington university. I ran across a fascinating article by warren thinking about a different way to think about health. Had some of those thoughts in the past. Its a combination of how we can produce Better Health with a broader array of tools including investments in some of the social services and ways to improve in order to get the results we want as opposed to just paint the people along the way who have health care bills. Appearing in the cornell journal of law and public policy, basically determined as they always say. Lets talk about a different way to look at hsa in a number of layered approaches to getting it. Okay, thank you. And thank you for having me here because i will say that typically i am talking on the academics. They have a broader i wrote this article immediately following the election thinking what are some areas where there is potential bipartisan support and hsa seems to me to be an obvious one. I think the conversations were urgently needed right now given what is going on. A little bit of background on the hsa, hopefully not stepping on the toes of the other presentations. I expanded the amount of Background Information is going to give because last night as the dinner at a friend from college and he said to me, you know, i think i might have a Health Savings account. After one question for me, it turned out he did not in fact have a Health Savings account, yet flexible savings account. I think this person is one of the smartest people i know. Hes a lawyer. I think people i can dont understand in my guess is a lot of other people have no idea and dont really understand how to use them if they do have them. So, theres been a lot of talk about hsas in the media, you know, following politicians. Health savings accounts are part of the movement for Consumer Directed Health plans, a whole lot of acronyms involved in the movement, fsa, hma, maybe thats why people have trouble distinguishing between them because they get lost a little bit in the alphabet soup. It is all part of the generalship that started with tensions from a defined benefit paradigm for Employee Benefits to a defined contribution paradigm. What do i mean by that . With the definedbenefit paradigm, your employer basically promises you a benefit now or in the future. Youll get 2000 a month for retirement income. I will pay for all your Health Care Expenses and maybe some copayments. To a shift where the employer will pay some amount of money if youre lucky into account and youll really have the control and freedom to figure out what to do with that. What are your benefit priorities now of course the problem we talk about is if theres not enough money in the account, which ill return again throughout my presentation and its not all that much help to you. If you dont have the money to purchase benefits and provide Means Committee accounts which have a lot of potential are not that useful. So there is a big divide, a political divide about the individual accounts. Republicans, including president bush who enacted the legislation for hsas tend to really love the individual account. It goes along with the american ibos of individuality and control and ownership. The idea that people can decide for themselves what their needs are and act on those neat that you dont have this paternalistic employer telling you what to do in providing benefits in the way they think is appropriate. Democrats on the other hand tend to think that individual accounts shift the risk to people who are least able to parent a democrats are focused on the fact theres not enough money in the accounts. Maybe in. Good idea if they were fully funded, but they are not. Democrats see it as a way of cutting back on businesses. So talking a little bit about the basics of hsas. The way it works is that hsas must be combined with a High Deductible Health plan, not to add. Instead of traditional private Health Insurance that covers all of your medical care needs with an exception for some copayments , that covers your medical needs starting from day one with your traditional Health Insurance coverage doesnt start until you reach a pretty high threshold. Before that time come either responsible for paying outofpocket or you can use your hsa that has money in it to cover the costs. I remember when i graduated from law school in 2004 he spent my whole first year working with employers to put in place these hsas. At the time, people were up in arms, you know, about the hsas and thinking this wont be good enough. People wont have enough other expenses covered. Today people are lucky if they have the hsas. But if they want to or not, most people have been shifted towards higher deductible Health Insurance plans and frequently they would love to have an hsa that has money in it. So i will talk about the High Deductible Health plans dont kick in except for an exception for Preventive Care. They require some Preventive Care. But beyond that, there is this whole before your insurance kicks in where you have to pay for the expenses. On the next flight i will talk about the numbers. The professor is going to talk a little bit about the Tax Advantages of hsas and mention in her article, it isnt writable Savings Vehicle, triple tax savings. Your contribution to the hsa are deductible from income. Earnings grow taxfree and with ross from the account are not taxed if they are used for qualified medical expenses. That is the focus of the article ive written is what our account holder is allowed to spend their money on and how i think it should be different. Money can only be used for medical care is defined under section 213 d. Of the Internal Revenue code. This is a definition that originally applied to a deduction in the tax code for people who have excessively high Health Care Expenses. Right now the threshold of 10 of income, which is an extraordinary high amount before the deduction kicked in. But no ocd hp movement kickstand, the definition was expanded to apply to the whole alphabet soup. Individual accounts are using the definition which is pretty out of date and will talk about how scholars beyond traditional medical care. What you see now, these are the 2017 numbers for hses comment hps hehp must have 3600 for family coverage and there is a new outofpocket expense of deductibles, copayments. But its a pretty high maximum. 13,000 for a family is for most people, you know, they list are rationing their health care far before they got to that point. Employers and employees can contribute up to the maximum aggregate limit, which is the congressional proposal work on expanding right now 3400 for singles, 6750 for families and a contribution for people 55 and over. So, right now roughly 19 of employees are enrolled in an hsa qualified trained for. Thats very qualified language. That doesnt necessarily mean theres any money in the hsa if they have opened it up. So, it makes it, you know, you can see from the numbers below that 25 receive no employer contributions at all. The average employer contribution of 1200 per family is to be balanced against the current average annual deductibles for a family of over 4300. Theres about a 3000 gap between what the average employer is contributing to the hsa and the specific deductible where the insurance really kicks in. As people have discussed and continue discussing, theres a lot of drawbacks. Obviously i dont think are insurmountable or it would have written the paper i wrote. The biggest drawbacks which we mentioned before as you need to have money to fund them. Sarah rosenbaum is a professor, nonstarter for people with low income. I think that is true right now in terms of the amount of money going into hsas. I dont think it needs to be true. Just another vehicle for getting money allocated for health care to people. That is really all these accounts are. So it has Great Potential in my view. The great risk shift which i talked about before, done a lot of research on that, you know, employees now if they could switch from a traditional Health Insurance plan to in hehp, they are paid more of their medical expenses than they used to. This is where professor yoos work will come in. Not everyone is being switched. Some are gaining new coverage. But obviously, employees are bearing the cost they were before. The idea is it may not be such a bad thing. Health care expenditures are pretty tremendous. We want to limit them and people to think more carefully. Are they using the Necessary Services . Are there ways this could force people to think more carefully about their medical needs. The problem with is studies have shown consumers are not rational when it comes to health expenditures. Theres a lot of reasons for this. First of all, unlike other goods, you may do some shopping around, its pretty hard to shop around and look for competitive prices when you are sick. Obviously if you are in a hospital in need of Emergency Services this is difficult. The idea of calling five pharmacies to find the best price on a medication is pretty unappealing to most people and you can imagine this would add virgins to the system that are not currently they are in the Insurance Company severn had to be there answering individual questions. Services may not be comfortable. How do you value cancer treatments versus the same treatment at a local hospital. How do you deal with the fact that people have a very subjective attachment to their doctors and may be willing to pay more than irrationally shed to see a particular doctor. A couple other reasons, hard to know if the services are even necessary. Forgetting that it may be hard to compare prices, people are relying on experts and doctors to know more about medical care than they do to understand if they even need these treatments. So it is a little bit hard for individuals about a medical degree to second guess the doctors and health to ration their own health care. The final point i wanted to make is studies are showing and they list a couple here that people are rationing their own health care and avoiding needed medical treatment because they dont have enough money in their account. The idea is that you want people to feel traditional Health Insurance. People have no skin in the game. They have no incentive at all to limit their services that they consume. Maybe there is a little too much skin in the game and people are choosing to spend the money on other things, which is where my research comes in and been complicated, this comes back to my friend if youre not even sure you have an hsa, the learning curve with making contributions, making sure you have enough money to meet your needs and then getting reimbursed. Its all pretty difficult. Current legislative proposals and i wont say too much here because it is in such a state of flux. Beyond the most recent proposal i heard from senator cruz, the hca and the senate will that i knew about were really focused on doubling the contribution limit to hsas to 5000 for single coverage and 10,000 for family coverage. Again, this is a nice idea, but if a lot of people dont have money in the account, upping the contribution limit which people are not getting any way doesnt help that much. Focus on more flexibility. Some other things i mentioned, the most important one when money is not used for qualified medical care. The reason for that is you may have some people avoiding money in the savings accounts because of them predict bull. They see figures in retirement you need 200,000 for medical care, but you dont know that. If people are going to have a really large penalties if they pull the money out and use it for Something Else, they may be reluctant to say that. Now to my proposal which ill spend the rest of my presentation talking about. My proposal is for something im calling precision and hsas. These are funded by employers, employees, but also the government. In making these for a broader array of goods and services, depending on the account holders family income. Ill go back in detail in a minute, but i list the steps in the notice that step one is to fund the accounts because its hard to experiment in years the money for interesting things that only the wealthiest americans can afford to fund their account. Step two is allow physicians or other Health Workers because they are huge cost to the system from having better housing for a broader good of the race and services. This is where they catch phrase social determinants of health comes in and ill explain more about that in a minute. Step three i really dont believe my proposal requires under the tax code. I think it is more about having agencies reinterpret what the medical care and the impact of the social determinants of health. Com. The medical care is that you are allowed to use your hsa for the diagnos