Yves here. The deadline for stitching up a deal on extending Covid-era ACA subsidies is bearing down on the Trump Administration and Congress like a freight train. No fix means millions of Americans face painful insurance premium increases for 2026, between already-high scheduled increases plus the loss of the extra support. Many, including some podcasters, have said they will probably have to forego coverage.
If there were any hope of the Republicans retaining the House in the midterms, throwing this many citizens under the bus would seem to kill it stone cold dead. Admittedly, Chuck Schumer and his Democrat Senate stooges were the ones who blinked on the shutdown, which had been intended to make the cost to the Republicans of doing nothing to become impossibly high. However, with the Republicans controlling both houses and the Administration, it’s hard to see how they can shift blame.
We are providing a discussion of what Trump tried presenting as an alternative, which is health savings accounts paired with high deductible insurance plans. The idea makes sense at most for the generally healthy well off, who can salt away a lot in the savings accounts and also conceivably stand the risk of a big medical bill. Giving middle and lower income citizens a few thousand dollars for these accounts is a band-aid level solution to the gunshot wound of huge health care costs for anything beyond very routine care.
Proponents claim, without any trace of shame, that patients need skin in the game so they will find good health care at cheaper prices. Please tell me where to find this unicorn. Being a libertarian means never having to say you are sorry.
Hence the lack of uptake on the Trump “old wine in new bottles” scheme.
By Noam N. Levey. Originally published at KFF Health News
Sarah Monroe once had a relatively comfortable middle-class life.
She and her family lived in a neatly landscaped neighborhood near Cleveland. They had a six-figure income and health insurance. Then, four years ago, when Monroe was pregnant with twin girls, something started to feel off.
“I kept having to come into the emergency room for fainting and other symptoms,” recalled Monroe, 43, who works for an insurance company.
The babies were fine. But after months of tests and hospital trips, Monroe was diagnosed with a potentially dangerous heart condition.
It would be costly. Within a year, as she juggled a serious illness and a pair of newborns, Monroe was buried under more than $13,000 in medical debt.
Part of the reason: Like tens of millions of Americans, she had a high-deductible health plan. People with these plans typically pay thousands of dollars out of their own pockets before coverage kicks in.
The plans, which have become common over the past two decades, are getting renewed attention thanks to President Donald Trump and his GOP allies in Congress.
Many Republicans are reluctant to extend government subsidies that help cover patients’ medical bills and insurance premiums through the Affordable Care Act.
And although GOP leaders have yet to coalesce around an alternative, several leading Republican lawmakers have said Americans who don’t get insurance through an employer should get cash in a special health care account, paired with a high-deductible health plan. In such an arrangement, someone could choose a plan on an ACA marketplace that costs less per month but comes with an annual deductible that can top $7,000.
“A patient makes the decision,” Sen. Bill Cassidy (R-La.) said at a recent hearing. “It empowers the patient to lower the cost.”
In a post on Truth Social last month, Trump said, “The only healthcare I will support or approve is sending the money directly back to the people.”
Conservative economists and GOP lawmakers have been making similar arguments since high-deductible health plans started to catch on two decades ago.
Back then, a backlash against the limitations of HMOs, or health maintenance organizations, propelled many employers to move workers into these plans, which were supposed to empower patients and control costs. A change in tax law allowed patients in these plans to put away money in tax-free health savings accounts to cover medical bills.
“The notion was that if a consumer has ‘skin in the game,’ they will be more likely to seek higher-quality, lower-cost care,” said Shawn Gremminger, who leads the National Alliance of Healthcare Purchaser Coalitions, a nonprofit that works with employers that offer their workers health benefits.
“The unfortunate reality is that largely has not been the case,” Gremminger said.
Today, deductibles are almost ubiquitous, with the average for a single worker with job-based coverage approaching $1,700, up from around $300 in 2006.
But even as high deductibles became widespread, medical prices in the U.S. skyrocketed. The average price of a knee replacement, for example, increased 74% from 2003 to 2016, more than double the rate of overall inflation.
At the same time, patients have been left with thousands of dollars of medical bills they can’t pay, despite having health insurance.
About 100 million people in the U.S. have some form of health care debt, a 2022 survey showed.
Most, like Monroe, are insured.
Although Monroe had a health savings account paired with her high-deductible plan, she was never able to save more than a few thousand dollars, she said. That wasn’t nearly enough to cover the big bills when her twins were born and when she got really ill.
“It’s impossible, I will tell you, impossible to pay medical bills,” she said.
There was another problem with her high-deductible plan. Although these plans are supposed to encourage patients to shop around for medical care to find the lowest prices, Monroe found this impractical when she had a complex pregnancy and heart troubles.
Instead, Monroe chose the largest health system in her area.
“I went with that one as far as medical risk,” she said. “If anything were to happen, I could then be transferred within that system.”
Federal rules that require hospitals to post more of their prices can make comparing institutions easier than it used to be.
But unlike a car or a computer, most medical services remain difficult to shop for, in part because they stem from an emergency or are complex and can stretch over numerous years.
Researchers at the nonprofit Health Care Cost Institute, for example, estimated that just 7% of total health care spending for Americans with job-based coverage was for services that realistically could be shopped for.
Fumiko Chino, an oncologist at the MD Anderson Cancer Center in Houston, said it makes no sense to expect patients with cancer or another chronic disease to go out and compare prices for complicated medical care such as surgeries, radiation, or chemotherapy after they’ve been diagnosed with a potentially deadly illness.
“You’re not going be able to actually do that effectively,” Chino said, “and certainly not within the time frame that you would need to when facing a cancer diagnosis and the imminent need to start treatment.”
Chino said patients with high deductibles are often instead slammed with a flood of huge medical bills that lead to debt and a cascade of other problems.
She and other researchers found in a study presented last year that cancer patients who had high-deductible health insurance were more likely to die than similar patients without that kind of coverage.
For her part, Monroe and her family were forced to move out of their house and into a 1,100-square-foot apartment.
She drained her savings. Her credit score sank. And her car was repossessed.
There have been other sacrifices, too. “When families get to have nice Christmases or get to go on spring break,” Monroe said, hers often does not.
She is thankful that her children are healthy. And she continues to have a job. But Monroe said she can’t imagine why anyone would want to double down on the high-deductible model for health care.
“We owe it to ourselves to do it a different way,” she said. “We can’t treat people like this.”
Does the GOP plan even consider adding premiums as a qualified medical expense under HSAs? Nevermind the fact that most HSA plan’s deductible amounts are higher than the yearly contribution limit for HSAs. Part of this is the fact the GOP only has a hammer, and so everything is a nail, where the hammer is “Let people shove tax-free money into a ‘savings account’ that can function as an investment account.” Though in this case, the hammer is not only the wrong tool for the job, but the GOP doesn’t even want to address the job itself, instead using the crisis to benefit themselves.
By benefit themselves, what I mean in this case is that by dumping money to subsidize HSAs, this will increase the pool of money that banks and investment firms who provide HSAs will get to play with and be able to loan or reinvest. More money there means more money chasing the stock market, which means all the GOP lawmakers can get some final juicing and pumping of those stocks before they sell them.
Besides that, this doesn’t actually address the cost growth side of the healthcare equation. If Gremminger wants to talk about ‘skin in the game,’ then maybe he should move to the countryside where hospitals have been closing. Talking about “patients need to take initiative in their healthcare to control costs” is unbelievably crass when hospitals and caregivers are closing around the country, significantly due to the refusal of private health insurance to fully pay out the cost of care. Many people around the country used to only have two options: The rural regional medical center and the hospital system in the nearest city. Now nearly a third of Americans don’t even have one option, where they can’t even get complete primary care. It’s only getting worse.
If remaining healthcare providers and insurance companies gain more market power, than any money the government subsidizes in those accounts is going to be sucked up by the same actors, no differently than how they describe ACA subsidies being sucked up by those actors.
Fellow Chris, as I’m sure you and others on this excellent site are aware, the problem is no one has any idea of what to do with a chronically sick population that has a non zero number of people that needs exceptional care for a range of illness. So our leaders ignore them and offer solutions to problems that don’t exist but appear to be related to the concern.
HSAs are great! As long as you and your kids don’t get sick. The premiums for policies are fine! As long as your employer picks up most of the cost. HDHPs work well! As long as you use them only for simple, basic care.
And all of this requires that we ignore the glaring philosophical and scientific contradictions in our policy. How much influence does a child with leukemia have over their premiums? How hard should one negotiate drug prices for the care of a spouse who is recovering from a stroke? When should you be willing to limp away when haggling over fees for a broken limb? How many hospitals should you interview for their prices when Grandma is suffering a heart attack?
These people are ready to accept every concept of the free market, except the obvious conditions for a market failure that exist in health care.
Being a libertarian means having an infantile view of the world. And they get to run it.
I shudder when I read accounts of USian health care like this. Add a good dose of the revulsion that Yves posted about yesterday. My sister-in-law has been in hospital in Ottawa since early October recovering from a badly done emergency colostomy – not medical error just saving her life was priority over a nicely placed ostomy. She is finally strong enough to undergo surgery again, is in fact in the operating room as I type this. If she and my brother lived in the US they would have lost everything by now. As it is, aside from high parking fees at the hospital they have had no costs of their own. They have had to pay for ostomy supplies up front but most of those costs will be reimbursed. I think of my Mom (heart & dementia) and then my Dad’s (stroke, long term care) health woes back in the day – again, in the US they would have been bankrupt.
US Healthcare Equation:
working/working poor + not healthy = useless cog = just go and die
And further in Canada, one can actually choose their medical providers. Whereas in the US, one is restricted to ‘networks’ as well as the possibility of a provider not accepting one’s insurance. Health care savings plans do nothing to address these weaknesses either.
My initial post was overly optimistic. I don’t know where you live but choosing your own doctor is not a thing in my neck of the woods – eastern Ontario, Kingston is closest big hospital. Our system is not as good as it once was. Yes, we pay little to nothing for care but things are changing. I moved a few years ago knowing that there would be a wait for a doctor. It took 3 years and I didn’t have a choice. My last doctor was more of a choice. She was my husband’s family doctor and when my doc retired, we asked and she agreed to take me on as a patient – that was over 20 years ago. Many, many Canadians don’t have family doctors. The system has been underfunded for decades. The current Ontario (Conservative) government is slowly privatizing things. I hope it doesn’t happen in my life time but privatization is coming. Greatest government failing in this country ever.
> Proponents claim, without any trace of shame, that patients need skin in the game so they will find good health care at cheaper prices.
Many healthcare economists make this claim. Presumably because price discovery in healthcare is famously quick, easy and transparent. I used to think that healthcare economists were cynical grifters, but having read some of their work I’ve realized that they’re actually just really dumb.
If one thinks that old people have been left out of the grift, think again:
https://economicpopulist.substack.com/p/dr-oz-called-prior-authorization
It’s obvious that the trump regime wants old people dead and quickly in order to save money that could go to his slimy corporate overlords.
https://healthcareuncovered.substack.com/p/cassidy-wants-a-new-path-on-aca-affordability
Cassidy Wants a New Path on ACA Affordability. HSAs Won’t Get Us There.
A Senate HELP Committee hearing showed rare urgency to avoid ACA subsidy lapses — but the leading GOP alternative would steer billions into insurer-owned HSA empires.
caps mine
One of the greatest indignities is being referred to as a health care “consumer” .
I recently visited a specialist at a large hospital. My compliment, which was well-received, was that I thought it was the highest compliment that I could give the doctor that I felt as though I had been treated like a human being, and not a ‘health care consumer.’ My doctor was awesome and deserved the high praise for manner and knowledge and thorough exam and understanding of me, the patient who needed her.
On the other hand, I was seen by another, different type of specialist at the same large hospital. I did not directly give feedback to that consultation, but when I found a second opinion, a better specialist who treated me as a human, I commented that I felt like a ‘health care consumer’ when I had been examined by the first specialist and I appreciated having been allowed to feel human in the second exam. Second opinion giver of course said nothing about the first, but was grateful for the positive comment about the care they had given me. Faces light up when you let them know. Many good Doctors are aware of the situation they and many of their colleagues are trapped in and the pressures put on themselves and other physicians.
Lesson is to make it known. When you are fortunate to find a human who is not acting as another cog in the wheel grinding out patient consultations, speak up. I can see the difference it makes when a good physician is appreciated.
A family member of mine was diagnosed with cancer back in the teens. Her deductible then was six grand. I know many people who simply could not come up with this much money in a pinch, including her, so we, her family, funded it thrice in three years. This tale does come with a happy ending, as she did receive effective treatment, she beat it and for the time being is cancer free.
Don’t worry, once the Democrat Party is back in power, they will fix this. Vote Democrat! /sarc
Not to take away from the gist of the story, but something feels off with a description of a homeowning couple in their late 30s making a six-figure income in Cleveland, losing their house and standard of living over $13,000 in debt.
I’m guessing $13k was what they still owed after getting all they could from insurance and then effectively bankrupting themselves.
Possibly so but a $13k leftover debt (about a month’s income for this family) shouldn’t be a blocking point, and the article said that she is still working.
So much effort went into making us feel sorry for the family but then we learn that they had to move out of their luxury accommodations, give up “nice” Christmas, and no more spring break. This is what my American friends might call white people problems, leaving us with the impression that they were overextended already and this medical emergency just forced them to take care of the issue.
I am very sympathetic with the overall argument, but frustrated that it was presented this way.
And then the possibility exists that they simply don’t pay. My wife had $5M in medical billings 2017-2022. One $5K bill went unpaid. It was a hospital administration billing error. Basically no prior approval. We never paid and the hospital never pursued us.
My thoughts exactly.
It boggles my mind how one is expected to shop for medical care when
1. acute issues such as cardiac, neurological, and kinetic events usually have unclear diagnoses until one goes to the friggin’ doctor,
2. treatment options and therefore costs depend on diagnosis, and are therefore unknown during the period where one is supposed to be shopping,
3. rational cognition during this time to be able to shop is questionable, even if one maintains consciousness, and
4. prices, even if posted clearly, will vary with severity of the illness/injury and the individual needs of the victim.
I’ve tried this a few times- calmly call the insurance rep to ask where i should go with [insert affliction here] to keep the cost down and the response is always “OMG to the nearest ER!!!!!” Several times what I thought was wrong wasn’t what was actually wrong. How does that get priced- does truth in advertising apply if you get a quote for an ankle sprain but it’s actually broken? Etc.
The politicians who utter such neoliberal nonsense, let alone believe it, should be thrown into an icy river with the expectation that the ice will help them float.
All very real and serious concerns. These are essentially the potential uncertainties of medicine and some reasons that we have Medicare in the first place.
Kenneth Arrow, a Nobel Prize winner, discusses some of this over 60 years ago:
https://assets.aeaweb.org/asset-server/files/9442.pdf
From Chat
Shareholder payouts: profits flowing to investors. A recent paper (2025) found that among large publicly traded U.S. health-care companies, 95% of net income over the last two decades went to shareholder payouts (dividends + stock buybacks).
Yale School of Medicine
That study estimated total payouts at about US$ 2.6 trillion over roughly 20 years.
A striking detail: in 2001, payouts were ~$54 billion — by 2022 they reached ~$170.2 billion, a ~315% increase.
Takeaway: For large (public) health-care firms, a substantial portion of profits is returned to shareholders rather than reinvested — indicating that for investors, health care has often been financially rewarding.
The source from Yale. The research letter that Yale cites was published in 2025 Apr 1 in JAMA, but PubMed won’t have a publicly accessible version until February 2026.
My employer has offered and I have used the high-deductible health plan coupled with an HSA for at least 6 years. Overall, it’s a top-tier plan (as good as any offered by any employer) so I can’t complain. But here are a few observations on the plan and on offering a comparable Fed Govt sponsored plan.
1) The first year my employer offered it, the employer contribution to the HSA effectively covered the in-network deductible. Six years later, the in-network deductible has roughly doubled; the employer’s contribution is unchanged. I’d anticipate that any federal plan would be exactly the same (apparently generous initially but dwindling as years go by).
2) A push by the HSA sponsor to “invest” – so I can put my HSA into a NASDAQ fund or even Crypto (I’m guessing). Guess what I can’t invest in – a US Treasury Bill. Gravy for the financial services industry.
3) Shopping for care presumes that you (a) know what you need and (b) know how your provider will code. At a recent introductory visit with a PCP, I assumed that it would count as my (free) annual checkup/physical. Nope, coded as some other type so my insurance paid zero and I was stuck with an unanticipated $600 fee.
4) Also presumes that there are alternatives available. Maybe in a major metro; I’m in a prosperous albeit smaller city with about 25,000 people (luckily only 80-100 miles from major metros). I’m on my 3rd PCP in three years – one I really liked went into concierge medicine shortly after my initial visit; the second through the local (and only) hospital was “phoning it in”; my newest is younger but I have to go about 60 miles. We’ll see how she works out. But the majority of PCPs even 30 or 40 miles away weren’t accepting new patients and the ones that were are all part of the same huge hospital group.
5) Finally, the local hospital has an effective monopoly on virtually all medical services; you can’t find an independent practitioner in the area. You can happily drive 50 miles to another hospital but otherwise you’re out of luck. And needless to say, prices are extortionate (spouse’s PT therapy for a broken wrist was $1,000 per 45 minute session – no other provider available).
If you’re young, healthy, don’t have children, and in a major metro a HDHP may be a good choice. You can bank $4,300 per year tax free. Unfortunately, $4,300 doesn’t go very far for health care.
And as others have cited, the solutions offered are for problems that don’t exist (skin in the game?) or of the “assume a can opener” solution set.