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Got a high-deductible health plan? The kind that doesn't pay most medical bills until they exceed several thousand dollars? You're a foot soldier who's been drafted in the war against high health costs.

Companies that switch workers into high-deductible plans can reap enormous savings, consultants will tell you — and not just by making employees pay more. Total costs paid by everybody — employer, employee and insurance company — tend to fall in the first year or rise more slowly when consumers have more at stake at the health-care checkout counter whether or not they're making medically wise choices.

Shots - Health News

Many Big Employers Plan To Offer Skimpy Health Options Despite Law

Consumers with high deductibles sometimes skip procedures, think harder about getting treatment and shop for lower prices when they do seek care.

What nobody knows is whether such plans, also sold to individuals and families through the health law's online exchanges, will backfire. If people choose not to have important preventive care and end up needing an expensive hospital stay years later as a result, everybody is worse off.

A new study delivers cautiously optimistic results for employers and policymakers, if not for consumers paying a higher share of their own health care costs.

More U.S. Companies Switch To High Deductible Health Plans

Researchers led by Amelia Haviland at Carnegie Mellon University found that overall savings at companies introducing high-deductible plans lasted for up to three years afterwards. If there were any cost-related time bombs caused by forgone care, at least they didn't blow up by then.

"Three years out there consistently seems to be a reduction in total health care spending" at employers offering high-deductible plans, Haviland said in an interview. Although the study says nothing about what might happen after that, "this was interesting to us that it persists for this amount of time."

The savings were substantial: 5 percent on average for employers offering high-deductible plans compared with results at companies that didn't offer them. And that was for the whole company, whether or not all workers took the high-deductible option.

Shots - Health News

As Big Employers Pinch Pennies, Health Savings Accounts Take Off

The size of the study was impressive; it covered 13 million employees and dependents at 54 big companies. All savings were from reduced spending on pharmaceuticals and doctor visits and other outpatient care. There was no sign of what often happens when high-risk patients miss preventive care: spikes in emergency-room visits and hospital admissions.

The suits in human resources call this kind of coverage a "consumer-directed" health plan. It sounds less scary than the old name for coverage with huge deductibles: catastrophic health insurance.

But having consumers direct their own care also requires making sure they know enough to make smart choices. That means getting vaccines and skipping dubious procedures like an expensive MRI scan at the first sign of back pain.

"What happens five years or 10 years down the line when people develop more consequences of reducing high-value, necessary care?"

- Amelia Haviland

Not all employers are doing a terrific job. Most high-deductible plan members surveyed in a recent California study had no idea that preventive screenings, office visits and other important care required little or no out-of-pocket payment. One in five said they had avoided preventive care because of the cost.

"This evidence of persistent reductions in spending places even greater importance on developing evidence on how they are achieved," Kate Bundorf, a Stanford health economist not involved in the study, said of consumer-directed plans.

"Are consumers foregoing preventive care?" Bundorf asks. "Are they less adherent to [effective] medicine? Or are they reducing their use of low-value office visits and corresponding drugs or substituting to cheaper yet similarly effective prescribed drugs?"

Employers and consultants are trying to educate people about avoiding needless procedures and finding quality caregivers at better prices.

That might explain why the companies offering high-deductible plans saw such significant savings even though not all workers signed up, Haviland said. Even employees with traditional, lower-deductible plans may be using the shopping tools.

The study doesn't close the book on consumer-directed plans.

"What happens five years or 10 years down the line when people develop more consequences of reducing high-value, necessary care?" Haviland asked. Nobody knows.

And the study doesn't address a side effect of high-deductibles that doctors can't treat: pocketbook trauma. Consumer-directed plans, often paired with tax-favored health savings accounts, can require families to pay $5,000 or more per year in out-of-pocket costs.

Three people out of 5 with low incomes and half of those with moderate incomes told the Commonwealth Fund last year their deductibles are hard to afford.

As in all battles, the front-line infantry often makes the biggest sacrifice.

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Updated at 4:50 p.m. E.T.

For millions of cash-strapped consumers, short-term loans offer the means to cover purchases or pressing needs. But these deals, typically called payday loans, also pack triple-digit interest rates — and critics say that borrowers often end up trapped in a cycle of high-cost debt as a result.

Now, the Consumer Financial Protection Bureau is preparing to unveil a framework of proposed rules to regulate payday lenders and other costly forms of credit. The federal watchdog agency is showcasing those proposals Thursday, the same day that President Obama spoke in Alabama, defending the agency and its work.

"The idea is pretty common sense: If you lend out money, you have to first make sure that the borrower can afford to pay it back," Obama said. "This is just one more way America's new consumer watchdog is making sure more of your paycheck stays in your pocket."

The new rules would very likely affect consumers like Trudy Robideau, who borrowed money from a payday lender in California to help cover an $800 car repair. When she couldn't repay the money right away, the lender offered to renew the loan for a fee.

"Ka-ching," Robideau said. "You're hooked. You can feel the hook right in your mouth. And you don't know it at the time, but it gets deeper and deeper."

Before long, Robideau was shuttling to other payday lenders, eventually shelling out thousands of dollars in fees.

Planet Money

The Weird Inner Workings Of The Payday Loan Business

"I was having to get one to pay another," she said. "It's a real nightmare."

When Robideau first spoke to NPR back in 2001, payday lending was a $14 billion industry. Since then, it has mushroomed into a $46 billion business. Lenders have also branched into other costly forms of credit, such as loans in which a car title is used as collateral.

"What we want is for that credit to be able to help consumers, not harm them," said Richard Cordray, director of the CFPB. "What we find is that consumers who get trapped in a debt cycle — where they're having to pay again and again, fee after fee — is actually quite detrimental to consumers, and that's what we're concerned about."

Cordray suggests that one solution is to require lenders to make sure borrowers can repay a loan on time, along with their other monthly expenses.

That kind of review was a "bedrock principle" of traditional lending, Cordray said in remarks prepared for a Richmond, Va., field hearing. But many payday lenders "make loans based not on the consumer's ability to repay but on the lender's ability to collect."

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Because payday lenders have automatic access to a borrower's bank account, they can collect even when a borrower is stretched thin.

"If you're behind on existing bills, for any legitimate lender that's a red flag," said Michael Calhoun, president of the Center for Responsible Lending, a consumer advocacy group. "For the payday lenders, that's often a mark of a vulnerable and profitable customer, because they will be stuck."

Payday lenders say they might be willing to live with an ability-to-pay test, so long as it's not too costly or intrusive.

"It only makes sense to lend if you're getting your money back," said Dennis Shaul, CEO of the Community Financial Services Association of America, a payday industry trade group. "Therefore the welfare of the customer is important. Now, so is repeat business."

In fact, repeat borrowers are the heart of the payday business. Government researchers found that 4 out of 5 payday borrowers had to renew their loans, typically before their next paycheck. And 1 in 5 renewed at least seven times, with the accumulated fees often exceeding the amount originally borrowed.

Planet Money

I Applied For An Online Payday Loan. Here's What Happened Next

Regulators are also considering alternatives to the ability-to-pay standard, including limits on the number of loan renewals, as well as mandatory repayment plans. Other proposed rules would crack down on costly collection practices, requiring lenders to notify borrowers three days before taking money out of their bank accounts and limiting the number of withdrawal attempts.

Wynette Pleas of Oakland, Calif., ended up with hundreds of dollars in overdraft fees after a payday lender repeatedly tried to collect from her account.

"They make it seem like it's so convenient, but when you can't pay it back, then that's when all the hell breaks loose," Pleas said.

The proposed regulations are still at an early stage, and there will be plenty of pushback. The industry managed to evade earlier efforts at regulation, so Cordray says that he wants the rules to be free of loopholes.

"We don't want to go through all the effort of formulating rules and then find people are working their way around them," he said.

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Alabama

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Would you lead a more active lifestyle if it meant lower life insurance premiums? Insurer John Hancock and Vitality, a global wellness firm, are hoping the answer is yes. But there is a condition: They get to track your activity.

The practice is already employed in Australia, Europe, Singapore and South Africa, where Vitality is based.

The companies announced the new plan Wednesday and posted a video on John Hancock's website.

Here's how the program works: Once you sign up, John Hancock sends you a Fitbit monitor as one way to track your fitness. You earn Vitality Points for your activities. As you accumulate points, your status rises — from bronze to silver to gold to platinum. The higher your status, the more you save each year on your life insurance premiums. The points also allow you benefits at stores like REI and Whole Foods as well as hotel chains like Hyatt.

The New York Times, which first reported on the announcement, notes that the most active customers can earn discounts of up to 15 percent on their premiums. The company in a news release says:

"For example, a 45 year old couple (of average health) buying Protection UL with Vitality life insurance policies of $500,000 each could potentially save more than $25,000 on their premiums by the time they reach 85, with additional savings if they live longer, assuming they reach gold status in all years."

But as The Times notes, if customers don't maintain their gold status for any reason, the premiums could increase by 1.1 percent to 1.6 percent each year. Those who reach platinum status will see premiums fall by about 0.30 percent each year, the newspaper adds.

NPR's Chris Arnold tells our Newscast unit that privacy advocates worry that the plan will raise insurance costs for lower-income people juggling two jobs who don't have as much time to get to the gym.

John Hancock and Vitality say the information collected won't be sold and would only be shared with those entities that administer the program, The Times reported, but some of it could be used to create new insurance products.

And for those uncomfortable with sharing some data, Michael Doughty, John Hancock's president, told The Times: "You do not have to send us any data you are not comfortable with. The trade-off is you won't get points for that."

The Times adds that the company hopes the program revitalizes life insurance sales in the U.S., which have stagnated for decades.

The concept of incentivizing behavior, while new in life insurance in the U.S., is not new to other sectors of the insurance industry. As Julie Rovner, who is with our partner Kaiser Health News, reported last December, wellness programs already exist in many workplaces. And, she reported, "There's no real evidence as to whether these plans actually improve the health of employees." (You can see some of NPR's other coverage of wellness programs here and here.)

In the auto industry, Progressive offers its customers a mileage-based tracking device called Snapshot; those who opt-in can save up to 30 percent on their premiums. But as CNET notes, "not just how many miles you drive but also how you're driving them could affect your insurance rates."

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Earlier this week, members of Congress and their staffs were greeted by a makeshift golf expo set up on the Rayburn House Office Building.

The event included golf shot simulators, certified golf instructors and a putting challenge between Democrats and Republicans. It was all part of National Golf Day, an annual event organized by the industry that promotes the economic and health benefits of the sport.

American politicians have had an affinity with golf dating back at least as far as William Howard Taft, the first-known president to hit the links. Since then, Democrats and Republicans alike have enjoyed game. But as hyperpartisan politics have become more commonplace in Washington, bipartisan golf outings have disappeared like a shanked tee shot into a water hazard

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South Carolina Rep. James Clyburn talks with PGA professional Bob Dolan Jr. at the National Golf Day event on Capitol Hill. Clyburn is an avid golfer, and the Democrat says that earlier on in his career, he learned a lot about bipartisanship on the golf course. Emily Jan/NPR hide caption

itoggle caption Emily Jan/NPR

South Carolina Rep. James Clyburn talks with PGA professional Bob Dolan Jr. at the National Golf Day event on Capitol Hill. Clyburn is an avid golfer, and the Democrat says that earlier on in his career, he learned a lot about bipartisanship on the golf course.

Emily Jan/NPR

Rep. James Clyburn, D-S.C., the third ranking Democrat in House leadership, said that when he first came to Washington in the early 1990s, golf was something political rivals did together regularly.

"I really learned bipartisanship up here on the golf course, and it allowed me to develop relationships across the aisle. And sometimes I'd be the only Democrat there — often the only African-American — but it taught me a lot. And I hope the experience taught some of them a lot," he said.

Clyburn, who took part in the event's putting challenge, admits that as years have passed, golf has stopped being used to chip away at bipartisan divides.

One needs to look no further than the closely watched relationship between President Obama and House Speaker John Boehner. Shortly after Republicans regained control of the House following the 2010 midterm elections, many wondered if the two would get together for a round of golf to iron out their differences.

It finally happened in June 2011. According to reports at the time, it was a cordial outing — Boehner clapped when the President sank a putt, and Obama put his hand on Boehner's shoulder as they were exiting a green.

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President Obama points to Vice President Biden's putt as they and House Speaker John Boehner, R-Ohio, golf at Andrews Air Force Base, Md., in June 2011. Charles Dharapak/AP hide caption

itoggle caption Charles Dharapak/AP

President Obama points to Vice President Biden's putt as they and House Speaker John Boehner, R-Ohio, golf at Andrews Air Force Base, Md., in June 2011.

Charles Dharapak/AP

But a month after that golf outing, the negotiations between the two on raising the nation's debt ceiling collapsed.

Sweetness And Light

Golf May Be Too Polite A Sport For Presidential Politics

Rep. Don Young, R-Alaska, is an avid golfer, and still has a lot of power in his swing for an 81-year-old. Like Clyburn, he believes the decline in across-the-aisle golf outings has led to missed opportunities.

"It's still one of the best ways to communicate with one another and solve a problem — on the golf course," Young said.

Young admits there are still some bipartisan outings, but far fewer than there used to be. He said one reason is that members don't stick around Washington on weekends, when Congress isn't in session.

Former Republican Rep. Michael Oxley, who represented Ohio's 4th Congressional District for a quarter-century, said he played golf with many Democrats before his retirement in 2007, including former Speaker of the House Tip O'Neill.

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A staffer participates in the annual Democrats vs. Republicans putting challenge. Emily Jan/NPR hide caption

itoggle caption Emily Jan/NPR

A staffer participates in the annual Democrats vs. Republicans putting challenge.

Emily Jan/NPR

"When I ran for Congress, of course, Tip was the boogeyman among Republicans," Oxley said.

Oxley said the two golfed together and hit it off. He even remembers O'Neill's odd device at the handle end of his putter — a suction cup, so O'Neill didn't have to bend down to pick his ball up out of the hole. He admits there wasn't a whole lot of good golf played, but says it wasn't about that — it was about laying the groundwork for a good working relationship.

"I can't remember one time when I've cut a deal specifically on a specific piece of legislation on the golf course, because it's just generally frowned upon," Oxley said. "But the prearranged relationship that you've developed over time on a golf course gives you that avenue to make deals at a later date."

Any chance current members of Congress can learn something from their predecessors?

Rep. Clyburn will golf in Hilton Head, S.C., this weekend, and his trip suggests the lack of links bipartisanship will persist a bit longer: The list of House colleagues who will join him is all Democrats.

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Eric Werwa, left, Deputy Chief of Staff for Rep. Mike Honda, D-Calif., gets some tips on his swing from a PGA professional at the National Golf Day event on Capitol Hill. Emily Jan/NPR hide caption

itoggle caption Emily Jan/NPR

Eric Werwa, left, Deputy Chief of Staff for Rep. Mike Honda, D-Calif., gets some tips on his swing from a PGA professional at the National Golf Day event on Capitol Hill.

Emily Jan/NPR

Rep. Don Young

House Speaker John Boehner

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