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Consumer-Directed Health Plan Enrollment Rises in All Cities over 10 Years (2008 to 2017)

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Recent analysis by HCCI finds that enrollment in consumer-directed health plans (CDHPs) increased dramatically since 2008. Nationally, nearly a third of commercially insured individuals were enrolled in a CDHP in 2017, up from 7.5% in 2008. Over ten years, enrollment in CDHPs doubled in 85 of the 88 metro areas studied.

High-deductible health plans (HDHPs) have become increasingly common for people covered by employer-sponsored insurance (ESI). HDHPs present a trade-off for consumers, offering lower premiums in exchange for more exposure to out-of-pocket payments. CDHPs are a type of HDHP that typically include a health savings account (HSA) or a health reimbursement arrangement (HRA).

Nationally, the percent of commercially insured individuals enrolled in a CDHP quadrupled between 2008 and 2017, from 7.5% to 31.9%. Although CDHP enrollment increased in all metro areas studied, the magnitude of the increase in enrollment varied. In 2017, CDHP enrollment exceeded 20% in 84 metropolitan areas, compared to only four metropolitan areas in 2008. Manchester, New Hampshire had the largest increase in percent CDHP enrollment over ten years, from 7.2% to 51.9%. Shreveport, Louisiana had the smallest increase, with 5.2% of the commercially insured enrolled in CDHPs in 2008 and 13.3% enrolled in 2017. Use the interactive tool below to see how your area changes in percent CDHP enrollment over time.

Previous HCCI research assessed overall spending among individuals enrolled in CDHPs, including differences between people with and without chronic conditions. 

Methods Note

Using the Health Care Cost Institute claims database, we identified all individuals from 2008 to 2017 who were under 65 years of age, covered by employer-sponsored health insurance. We excluded individuals who moved to different CBSAs within a year or changed insurance plans within the year. Our denominator is total unique individuals within the year to account for changes in year-to-year total enrollment whereas the numerator was unique individuals enrolled in a CDHP plan within the year to represent percent in a CDHP plan out of total enrollment. Individuals' CDHP enrollment was determined by insurers based on plan design and annual deductible.

Our study population is restricted to individuals with employer-sponsored health insurance with a full 12 months of coverage, approximately 25 million distinct individuals per year. From there, we looked at 88 core-based statistical areas (CBSAs) in 39 states and examined the enrollment trends in CDHP and non-CDHP plans from 2008 to 2017. We excluded CBSAs that had large annual changes in total membership in the HCCI data.

National statistics included data from all 50 states and the District of Columbia whereas states that contained CBSAs with minimal enrollment counts were suppressed in the interactive dashboard.  CBSAs were selected based in states where Aetna, Humana, and UnitedHealth Group have operations.

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