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A summary of the articles included in the April 2026 edition:

  • Top HSA Spend Merchants Reflect a New Era of Consumer-Driven Healthcare
  • 2025 Consumer Engagement in Health Care Survey
  • IRS Guidance Could Cripple New HSA Direct Primary Care Access Law
  • Health Insurance Exchanges 2026 Open Enrollment Report
  • HSAs Are Being Touted as a Way to Make Healthcare More Affordable. But It’s More Complicated Than That.


Top HSA Spend Merchants Reflect a New Era of Consumer-Driven Healthcare

Lively revealed their 8th Annual HSA Spend Report. The report reveals that the merchants where consumers spend their HSA dollars are changing — and those changes are redefining how healthcare is accessed, paid for, and experienced.

Based on anonymized 2025 HSA debit card transaction data, Lively identified a growing mix of retail brands, digital health platforms, and direct-to-consumer healthcare companies among top HSA spend merchants. Together, they signal a clear shift toward healthcare that is more consumer-driven, digital-first, and integrated into everyday life.

“The merchants people choose tell us how healthcare is evolving,” said Alex Cyriac, co-founder and CEO of Lively. “HSAs are no longer reserved for hospitals and doctors’ offices — they’re being used across a broad ecosystem of consumer health brands.”

2025 Consumer Engagement in Health Care Survey

EBRI and Greenwald Research released the 2025 Consumer Engagement in Health Care Survey, the 21st annual edition of the study. The survey of 2,001 privately insured adults ages 21 to 64 was conducted between Oct. 13 and Nov. 8, 2025, and tracks consumer-driven and high-deductible health plan behavior, plan choice, affordability, and related healthcare trends.

For HSAs, the report found that employer contributions were the most commonly cited reason for opening an account. It also found that 61% of HSA holders viewed the account as a savings account, while 31% viewed it as an investment account. Two-thirds said they were using the account to pay for current or near-term out-of-pocket healthcare expenses, while 35% reported using it to save for healthcare expenses in retirement and 28% reported investing account funds in stocks, bonds, or mutual funds.

IRS Guidance Could Cripple New HSA Direct Primary Care Access Law

The One Big Beautiful Bill Act seems to create a way for health savings account users to get primary care without worrying about high deductibles, by using HSA cash to pay for direct primary care practice memberships.

But commenters say the Internal Revenue Service may be about to keep OBBBA from letting HSA users have access to no-deductible primary care.

The IRS posted a batch of guidance in December 2025 that suggested how it might interpret the OBBA direct primary care membership provision.

Commenters who support improved direct primary care access for HSA users argue that a batch of IRS guidance showing how the IRS is interpreting the OBBBA provision would keep the OBBBA provision from working the way supporters in Congress intended, by creating confusion about what employers can do.

Health Insurance Exchanges 2026 Open Enrollment Report

The Centers for Medicare & Medicaid Services published its Health Insurance Exchanges 2026 Open Enrollment Report, which summarizes plan selections through the individual Exchanges during the 2026 Open Enrollment Period. CMS reported that 23.1 million consumers selected or were automatically re-enrolled in Exchange coverage during the 2026 OEP, including 15.8 million through HealthCare.gov and 7.4 million through state-based Exchanges.

For HSAs, the most notable finding was that beginning in 2026 all bronze and catastrophic health plans are HSA-eligible under the Working Families Tax Cut law. As a result, CMS said that 43% of consumers with plan selections through the HealthCare.gov platform enrolled in HSA-eligible plans during the 2026 OEP, up from 2% during the 2025 OEP. The report also showed a higher percentage of consumers selecting bronze and gold plans and a lower percentage selecting silver plans compared with the prior year.

HSAs Are Being Touted as a Way to Make Healthcare More Affordable. But It’s More Complicated Than That.

The health savings account, a decades-old tax vehicle that primarily benefits well-off Americans, is being promoted as a solution to today’s healthcare affordability crisis.

The cost of healthcare is soaring for everyone, including people who get health insurance through Obamacare, their employer or even Medicare. And conservative lawmakers including President Donald Trump believe health savings accounts, or HSAs, are key to fixing that problem.