By Robert Bazell Chief science and health correspondent
NBC News
updated 2/1/2006 6:49:47 PM ET 2006-02-01T23:49:47

The law allowing Health Savings Accounts took effect two years ago, but so far only about 2 million people have signed up. President Bush sees an expansion of the program as a way to give more Americans access to health care.

Alan McDonald and his wife, Ruby Mason, run a mortgage business. Because they are self-employed, premiums for regular health insurance are prohibitive. So they opened Health Savings Accounts.

“The options that are available to us are very limited,” Mason says.

Here's how it works. For $300 each a month, Mason and McDonald buy high-deductible, catastrophic health insurance. That covers medical bills that exceed $5,000 a year per person.

At the same time, they put pre-tax money into a Health Savings Account and they decide how to use it for doctors' visits, medicines or other medical expenses. It they don't use it, it accumulates year-to-year.

A big argument for Health Savings Accounts is that they bring down costs because people make their own decisions about how they spend health care dollars.

“You have a clear idea of what the cost of your medical care is,” explains Robert Moffit of the conservative Heritage Foundation, “rather than just submitting a claim where you pay a small co-payment.”

But Ron Pollack of the lobbying group Families USA says the accounts do not help people who are not well off financially.

“They don't get a significant tax break,” Pollack says, “because they're in a lower tax bracket. And they're worried that they can't afford to pay the cost in the deductible.”

Ruby Mason and Alan McDonald say the Health Savings Account does not give them the security of regular health insurance.

“We're relatively healthy, and I think that overall, it has been a benefit to us,” says McDonald. “But again, it's taking us some time to come to grips with how it works, and to come to grips about what it actually does cover does take a bit of time.”

But the accounts may be the only option for increasing numbers of Americans.

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