Expect modest to no ACA premium impact from expanded pre-deductible coverage, says EBRI

Beginning this year, a new federal policy is reshaping how health savings accounts intersect with the individual insurance market – and fresh analysis from the Employee Benefit Research Institute suggests that more generous coverage for chronic conditions inside HSA-eligible plans may not push premiums as much as some fear.

As of Jan. 1, individuals enrolled in individual-market bronze and catastrophic health plans can contribute to an HSA under a provision in the One Big Beautiful Bill Act. The change lands just as policymakers debate the future of Patient Protection and Affordable Care Act premium tax credits and the broader question of how to keep coverage affordable in the individual market, where HSAs are increasingly part of the conversation.

Against that backdrop, EBRI examined what happens to premiums when HSA-eligible high-deductible health plans extend pre-deductible coverage for chronic disease medications and services.

The research brief released this week pointed to its previous work looking at IRS Notice 2019-45 – which allowed more pre-deductible coverage for certain chronic treatments – noting that it “found little to no impact on premiums." More recent modeling that expanded pre-deductible coverage to 116 drug classes still produced only modest projected premium hikes, in the range of 1.3% to 4.7%, depending on assumptions.

EBRI offered a simple explanation for the muted premium impact: many people using those drugs are already high utilizers of care who would meet their deductibles anyway. Expanding pre-deductible coverage tends to shift when cost-sharing happens rather than driving a large increase in total plan spending.

“In these cases, services that would otherwise be subject to cost sharing after the deductible is met instead remain subject to the deductible once other services are no longer subject to it,” the institute wrote, arguing that the bigger effects show up in out-of-pocket costs rather than in premiums.

The research also speaks to a growing policy push to widen access to HSAs beyond traditional employer high-deductible plans. One bill, the Health Care Freedom for Patients Act, would have replaced enhanced ACA premium tax credits with federal HSA deposits for people in bronze or catastrophic plans. Another, the Health Marketplace and Savings Accounts for All Act, would make HSAs available to all Americans regardless of coverage.

“There is a strong appetite for allowing flexibility around HSA-eligible health plan designs,” the brief said, pointing to a 2021 survey where 76% of large employers increased the number of drugs and services covered before the deductible once the IRS allowed it.

The new analysis lands alongside fresh worker sentiment data from EBRI’s 2025 Workplace Wellness Survey, fielded with Greenwald Research. In that survey of 1,401 workers, inflation, the cost of health care, and the cost of health insurance ranked among the top financial worries, with well over eight in 10 expressing concern.

For roughly three-fifths of respondents, health insurance and retirement savings plans like 401(k)s contribute “a lot” to financial security. Survey findings suggested that HSAs – when offered – were more likely to be treated as a secondary tool, with just 12% suggesting employers make contributions or raise what they put into HSAs in order to boost employees' sense of financial security.

About half of workers reported access to an HSA, and just 5% said they would consider dipping into theirs for a $5,000 emergency expense. When asked how they would allocate a hypothetical $500 monthly employer contribution across several benefit accounts, respondents directed the largest share to retirement savings, with smaller amounts earmarked for HSAs and emergency savings.