HSA growth and the opportunities emerging for investors and start-ups

Health Savings Accounts have become more popular than ever, not only helping consumers save for health-related bills that can be staggering, but also offering a wealth of potential opportunities for entrepreneurs with an eye on investing in healthcare fields.

Look at the numbers and they are staggering.

HSA balances reached nearly $159 billion by the middle of 2025, and recent policy changes brought about by the One Big Beautiful Bill are expected to attract 3 million to 4 million more HSA participants in 2026.

That bill expanded the health services that are HSA eligible and added some health insurance plans that previously weren’t eligible, allowing even more people to save and to pay for healthcare costs through HSAs.

In the process, the bill may have made certain segments of healthcare even more attractive to those who want to invest in or launch businesses that provide a health service.

After all, healthcare is an area that has traditionally drawn interest from entrepreneurs and investors. Private equity firms have long been attracted to healthcare innovation, investing in transformational technologies and new models of care, such as: Medicare Advantage plans, Accountable Care Organisations, primary care, and Pharmacy Benefit Managers.

All of that is simply the result of investors seeing the business opportunities that arise from government policies surrounding healthcare. Paying attention to the intersection of public policy and business opportunity can be a winning strategy for start-ups and disrupters.

The HSA changes brought about by the One Big Beautiful Bill are one more example of that. And, in recent proposed legislation in the Senate, HSAs would have been able to pay for premiums of high-deductible health plans. This appears to be a foreshadowing of a future state when less benefit-rich plans will be offered to consumers at a lower price than the mandated plans on the exchanges.

The HSA changes have plenty of pros and cons as far as public policy and the health of consumers are concerned. But business opportunities definitely could arise as a result of some of the changes, and there are specific areas where start-ups could flourish.

For example, opportunities exist in using technology to help people in rural areas access care. In many cases, those rural communities are a good distance from physician offices or hospitals.

Also, innovations involving devices that can utilise facial recognition patterns can determine the difference between a panic attack and a heart attack.

Innovation in behavioural health and pharmacy benefit management are also a ripe area for entrepreneurs, as are models focused on loneliness and chronic disease care, including high needs ACOs, chronic special needs Medicare Advantage plans, and innovations in population health.

A couple of specific areas that start-ups might begin exploring, which have the added benefit of potentially helping consumers, are:

Direct primary care

One of the more promising areas for start-ups to consider is direct primary care, where the medical practice doesn’t accept insurance and instead charges patients a monthly fee.

In this model, when working with businesses and their employees, local primary care providers essentially become the company doctor. Prior to the recent changes in Washington, though, direct primary care was not an HSA-eligible expense. Now, an otherwise eligible individual enrolled in certain direct primary care service arrangements may contribute to an HSA. They also may use their HSA funds to pay periodic direct primary care fees.

Beyond the opportunities for start-ups, this change making direct primary care an eligible HSA expense represents a significant step in fighting chronic disease. This is because it allows the primary care physician to establish a long-term relationship with a patient and their family over an extended period of time.

Even without HSA eligibility, the direct primary care model has already been working well in select pockets around the country and is growing rapidly, and lawmakers have already been making efforts to try to expand its reach. For example, in late 2024, House of Representatives legislation allowed the model to be included in the Medicaid programme.

With the change to HSA eligibility, the direct primary care model could become even more relevant as the optimum place for start-ups in this new environment.

Telehealth

Telehealth is also an area start-ups could consider because of changes in the way HSAs can pay for these remote-care services.

Previously, consumers were allowed to use their HSA money to cover telehealth expenses, but there was an important caveat to that. They could spend HSA funds on telehealth only after they had met the deductible for their high deductible insurance plan. For 2025, those annual deductibles had to be at least $1,650 for an individual or $3,300 for a family.

Now, HSA money can be used to pay for telehealth regardless of whether the deductible has been met.

Even without this new advantage, telehealth has been a growing market, reaching $94 billion in 2024 and expected to increase to $180 billion by 2030.

More market options for everyone

Even with the expansion of HSA-eligible services, the current HSA landscape isn’t without its problems and investors should be aware of those as well. HSAs are only useful for people who can afford high-deductible health insurance plans and who have the extra cash to contribute regularly to the account.

Also, under one plan being considered in Washington right now, rather than extending enhanced Affordable Care Act tax credits, the government would redirect those funds into HSAs for consumers. That plan says individuals could use HSA money for out-of-pocket expenses (deductibles, co-pays), but not to pay the insurance premium itself.

Proponents argue this would give people more control and flexibility over their health care spending. Critics predict it would dramatically increase premiums, since the subsidy would no longer help cover them, and make coverage unaffordable for many.

Some analysts worry the latest shift may favour higher earners while leaving lower-income or sicker individuals with fewer options.

These are legitimate concerns. HSAs by themselves will not prevent insurance premiums from spiking or healthcare costs from rising.

But HSAs, when paired with structural reforms – such as channeling dollars toward primary care, telehealth, and DPCs – can create a more consumer-directed health reform platform that will provide more market options for all Americans.

Aligning incentives through shared savings models, which tie outcomes to reimbursement, has proven effective in modifying behaviour as physician groups take on more risk.

The move away from transaction-based fee-for-service care to more of a population health model, where the primary care physicians receive an upfront payment per month tied to the acuity of the patient, will drive down high expenses like ER visits, unnecessary hospitalisations, and lower re-admissions, which will bend the cost curve and systematically lower over-spending.

About the author

Gary Jacobs is the author of The Zen Lobbyist: A Mindful Approach to Transforming Healthcare. With over 40 years of experience in healthcare entrepreneurship, consulting, and policy advocacy, he drives bipartisan solutions to expand primary care access and reform public health programmes. A certified meditation instructor, Jacobs combines mindfulness practices with executive strategy to help heal both patients and the people who care for them.