A Bitter Pill?

I’ve never had very healthy eating habits – even as a child.

And while this wasn’t a concern of mine at the time, my parents were quite insistent that either I start taking vitamins or improve my eating habits. Figuring that it was the lesser of two “evils,” I went for the pill.

Well, until I saw THE PILL.

Mind you, this was no kid-friendly Flintstones chewable – no, it was some big, ugly black monstrosity – a real “horse pill.”  And just looking at it I was sure that there was no way it could possibly make it down my poor 5-year old throat (I wasn’t altogether sure it would even fit in my mouth).

However, and despite my vehement protestations, my parents were determined that I would ingest it. And, for the next 15 minutes or so (it felt like forever) I was as close to being waterboarded as I will ever want to be – as my parents proceeded to hold me down, tilt my head, and attempt to flush the pill down my throat with copious amounts of water. But sure enough – and as I had tried to tell them, that darned pill just wouldn’t go down. 

I wonder sometimes if that isn’t how workers view the admonitions about how much they are supposed to be saving, and/or how much they are supposed to have accumulated in order to retire. And, as if that weren’t overwhelming enough, there are a handful of ginormous projections about how much more you’ll need to take care of health care expenses.

How much? Well, Milliman projects that a healthy 65-year-old couple[i]retiring in 2019 is projected to spend $369,000 in today’s dollars ($551,000 in future dollars) on health care over their lifetime. Fidelity puts the number for a 65-year-old couple at $285,000 in health care and medical expenses throughout retirement, up from $280,000 in 2018. The Employee Benefit Research Institute (EBRI) says that some couples could need as much as $400,000. You get the picture.

That’s no small thing – particularly when survey after survey suggests that it’s health care costs that loom largest as a concern – not just for those for whom retirement awaits, but for those already in retirement (who, most surveys still find to be pretty comfortable with their other retirement expenses).

Several weeks back I stumbled across an interesting report aptly titled “A New Way to Calculate Retirement Health Care Costs.” The report, authored by T. Rowe Price’s Sudipto Banerjee, acknowledges that while health care costs are a significant retirement expense, it may be more practical to look at health care as an annual expense incurred over the 20-30 years you’ll actually incur those expenses, rather than as a lump sum.

The paper offers an eye-opener that says that if you were to view that $150/month cable bill as a retirement lump sum, you’d want to have $86,000 set aside.

Closer to the subject of retirement, the paper takes the example of a 65-year-old couple – a couple that has saved $400,000, and now has a combined monthly Social Security benefit of $2,000. How are they going to afford that $300,000 for health care costs? Well, as Banerjee points out, that $2,000/month Social Security benefit actually (with a 2% annual cost-of-living adjustment), that adds up to approximately $583,000 in Social Security benefits in the next 20 years.[ii]

Let’s face it, the costs of health care in retirement – or retirement overall – can look like a big pill to swallow as a lump sum – but it can go down a lot easier when you can take it in smaller pieces.[iii]   

- Nevin E. Adams, JD

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[i]Of course, those are averages – and for some context, you might check out “Why an Average 401(k) Balance Doesn’t ‘Mean’ Much.” 

[ii]It’s not just that that approach puts things in an apples-to-apples light – the paper explains that since fixed monthly premiums make up the bulk of annual costs, most of those costs are predictable – and can be budgeted, and paid for, from monthly income. It’s the out-of-pocket expenses that can vary widely, from month to month and from individual to individual.

[iii]Oddly, my parents never thought to cut that pill into smaller pieces. And I certainly wasn’t going to suggest it…

Consumer "Driven?"

Over the last several years, the trend in employment-based retirement plans has been to put in place structures to make more decisions for workers through the expansion of automatic enrollment plan designs.(1) At the same time, the trend in employment-based health plans has been to look for ways to better manage costs, while providing workers more choice, and flexibility in those choices, by looking to so-called consumer-driven health plans, or CDHPs.(2)

In the case of the former, the shift has been to help workers make better decisions, to boost savings by not only increasing plan participation, but to direct contributions to more diversified investment options than many seem to choose on their own accord. In the case of healthcare plan designs, the expansion of choice is similarly rooted in a desire to help workers make “better” decisions, albeit with a slightly different emphasis.

The addition of CDHP designs (and in many cases it is an addition, rather than a replacement for, traditional health plan designs) has arguably been motivated in no small part by a desire to constrain the costs of employment-based health care programs by giving workers some “skin in the game” beyond whatever premiums may be associated with the benefit. A recent EBRI report notes that, by 2012, 31 percent of employers offered some version of a CDHP (either a health reimbursement arrangement or health savings account-eligible plan), with about 25 million people (about 14.6 percent of the privately insured market) covered by these type plans.

The concept is relatively straightforward: CDHPs combine high deductibles with tax-preferred savings or spending accounts (that can be funded by employer and/or employee contributions, or both) that workers and their families can use to pay their out-of-pocket health care expenses. The theory is that individuals may spend money from their own account(s) more judiciously. However, there have been concerns that individuals may prove to be too frugal, choosing to defer needed and perhaps even necessary healthcare just to avoid spending money.

Additionally, while the theory that consumerism would lead to less (and perhaps better) spending appeared sound, and while prior research in this area has generally found low-to-moderate reductions in measures such as services used, conclusions have also been limited by the potential for selection bias, in that workers were often given a choice between CDHPs and more traditional options—and it was possible that individuals of a particular profile might be more inclined to opt for the CDHP.

A recent EBRI study, published in the June issue of Health Affairs,(3) was able to examine healthcare services utilization trends by using data from two large employers—one that adopted a CDHP in 2007 and another with no CDHP. That research(4) found that after four years under an HSA plan, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, although there were 0.018 more emergency department visits, and the likelihood of receiving recommended cancer screenings was lower under the HSA plan after one year and, even after recovering somewhat in later years, still lower than the baseline at the study’s conclusion. While small numbers, these figures are considered statistically significant.

Ultimately, the longer-term impact of CDHPs on health status, outcomes, and spending remains to be established. On the other hand, and as the research paper notes, if CDHPs succeed in getting workers to make decisions that are more cost-sensitive, employers may well want to ensure not only that the plan designs work to incentivize the right choices, but that their work force is educated on the expanded choices that lie ahead.

Nevin E. Adams, JD

(1) See “The Impact of PPA on Retirement Savings for 401(k) Participants,” online here.

(2) CDHPs combine high deductibles with tax-preferred savings or spending accounts that workers and their families can use to pay their out-of-pocket health care expenses. These accounts allow people to accumulate funds on a tax-preferred basis—the funds may include contributions from the employer, the employee, or both, depending on the plan’s structure. Employees can choose between using the funds for their health care cost sharing or saving the money for the future. Employers began offering CDHPs in 2001 when a handful started offering health reimbursement arrangements (HRAs). They then started offering health savings account (HSA)-eligible plans after the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included a provision to allow individuals with certain high-deductible health plans to contribute to an HSA. See also “What Do We Really Know About Consumer-Driven Health Plans?”  and “Characteristics of the CDHP Population, 2005–2010.”

(3) See “Consumer-Directed Health Plans Reduce The Long-Term Use Of Outpatient Physician Visits And Prescription Drugs,” online here.

(4) This work was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI). The following organizations provided the funding for EBRI CRHBI: American Express, BlueCross BlueShield Association, Boeing, CVS Caremark, General Mills, Healthways, IBM, John Deere & Co., JP Morgan Chase, Mercer, and Pfizer.