Fund work also has evaluated the potential of health savings accounts (HSAs), which were created as part of the Medicare Modernization Act of 2003. Used in combination with high-deductible health plans, HSAs allow people to save pretax dollars for deductibles and other out-of-pocket costs. The accounts are part of an overarching philosophy that maintains greater personal responsibility for health care costs will lead to more prudent use of health care services. Policymakers favoring HSAs also hope that they will attract uninsured individuals and families into the individual insurance market with the promise of lower premiums and tax-preferred savings. Yet, an April 2005 Fund issue brief by grantees Sherry Glied, Ph.D., of Columbia University and Dahlia Remler, Ph.D., of Baruch College estimated that this new tax incentive would cover fewer than 1 million previously uninsured people.⁽⁶⁾ The authors found that more than half of the uninsured have incomes so low that they do not owe income taxes and thus would not realize tax benefits from HSAs. In addition, to the extent that HSAs encourage well-compensated healthy workers in small firms to abandon job-based coverage, they threaten to destabilize the small group insurance market.

Glied and Douglas Gould examined how insurance expansion policies initiated at the federal level would affect coverage in each of the 50 states, finding wide-ranging variability in the number of newly insured. In a June 2005 article in Health Affairs, the authors showed that the uninsured rate in some states could be reduced by as much as 20 percent under various policies, including refundable tax credits for the non-group market, tax credits for small-firm workers, and expanding eligibility for Medicaid or the State Children's Health Insurance Program.

The Future of Health Insurance program also tracks changes in employer-sponsored health coverage—the backbone of the U.S. system of health insurance—and considers the implications of these changes for the extent and quality of coverage. Since 2000, the number of uninsured climbed by 6 million to nearly 46 million Americans, with nearly all of the increase attributable to a decline in employer-sponsored coverage. ⁽⁷⁾ In an article published in Inquiry, Fund staff documented the cost burden to businesses, workers, and the health system when employers fail to offer coverage to their employees.⁽⁸⁾ The authors found that 22 million workers do not have coverage through their jobs because their employers do not offer it to them. Employers that offer health coverage to their employees' dependents spend an estimated $31 billion a year insuring workers who are employed elsewhere.