An elementary school teacher chose a low-price health insurance plan but soon realized she wasn’t clear about what it would mean for her family’s finances.

“Once I got the insurance card, I compared our old plan to our new plan, and that’s when I really got worried, because I didn’t really understand what a deductible was. It got me thinking, how do I use this insurance?”

— Madison Burgess, 31, of San Diego

When enhanced federal subsidies expired at the end of 2025, a lot of people buying their own health insurance on the state and federal exchanges saw their expected monthly rates jump. To keep costs down, many switched to a high-deductible health plan. These plans offer lower monthly payments, but in exchange patients can face steep out-of-pocket costs when they need care.

The plans are pretty common. In 2023, 30% of people who got insurance through their employer had a high-deductible plan, up from only 4% in 2006.

Madison Burgess, a teacher in San Diego, gets health insurance through her teaching job. But when she investigated adding her husband to her plan, it was just too expensive, so she started shopping on the exchange for a cheaper option for him.

The longer she scrolled through the plan options, the more overwhelming it felt. Insurance jargon made it hard to tell what her family would owe if her husband got sick.

“I didn’t know what a deductible was, so I just went with what was cheap, and now I have regret,” she said.

In exchange for that lower monthly premium payment, her husband’s coverage won’t kick in for most care until they’ve paid $5,800 in medical bills. Burgess didn’t know that the deductible must be met before insurance picks up part of the tab.

Deductible:

The amount you as the patient have to pay before insurance picks up part of the tab

Premium:

The monthly bill for your policy, paid to the insurance company

How do you prepare for thousands of dollars in upfront costs? One option is a health savings account, or HSA, which lets you save pretax money and is now available to people enrolled in lower-tier state and federal exchange plans, including bronze and catastrophic coverage. These plans generally have the lowest premiums on the exchange but the highest out-of-pocket costs when you need care.

Burgess had chosen a bronze plan and didn’t know HSAs were an option.

“I’ve never thought about having to put money away for a deductible,” she said.

Burgess and others are often more worried about socking away money for unexpected car and house repairs or vet bills.

If, like Burgess, you chose cheaper health coverage for this year only to discover you’re on the hook for meeting a high deductible, these tips can help you prepare.

1. You might qualify for an HSA and not know it.

If you’re enrolled in a bronze or catastrophic plan, you qualify to open a health savings account. Think of it as a medical piggy bank with tax perks. You put in pretax money, which lowers your taxable income. The money grows tax-free, and when you spend it on , those transactions are also tax-free. That’s what people call a “triple tax advantage.”

These accounts build a cushion for future health costs, such as doctor visits, prescriptions, and even products like over-the-counter medicine, tampons, and sunscreen.

The money typically can’t be used for monthly premiums, but the account is yours to use for qualified medical expenses for yourself, your spouse, or your dependents anytime in the future. The money in the account is yours, even if you change jobs or health plans.

An HSA is not the same as a flexible spending account, or FSA. FSAs are tax-advantaged too but are offered only through employers. The money expires annually and you lose any remaining money when you leave that job.

2. HSA-curious? Here’s how to open one.

You open a health savings account through a bank or other financial institution. The institution will issue you a debit card so you can make purchases from the HSA.

You can at any point during the year as long as you’re covered by an eligible plan. You can choose where to open the account, but be sure to check for any fees financial institutions charge and shop around.

If you get insurance through your job, your employer may require you to use a specific IRS-approved company.

Many people decide they can’t afford to contribute to an HSA. For some households, the desire to set aside money for medical expenses competes with the need to pay rent and buy groceries.

But there’s a detail that can make it feel more manageable. Contributions don’t have to be large. Just a few dollars a month can get you started.

There is, however, a limit. The IRS sets an annual cap on how much you’re allowed to contribute to an HSA. In 2026, an individual is limited to $4,400, or $8,750 for a family plan. Under that ceiling, the amount is up to you.

3. Preventive services should be covered at no cost to you.

All plans sold on marketplaces must cover at no cost to the patient as long as the care is provided in-network. Those services include routine immunizations and cancer screenings.

Beyond preventive care, understanding what different services cost can help you decide which type of medical appointment works best for your health needs and your wallet. For example, some plans charge less for a telehealth visit than to see your primary care doctor in person.

Check out your for more details.

4. Seek care early in the year.

Most deductibles reset on Jan. 1. Scheduling appointments or surgeries early in the year can be strategic if you discover a condition that requires ongoing care. If you can afford it, meeting your deductible sooner can make the rest of the year significantly cheaper, said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

5. Consider paying cash instead of spending down your deductible.

Some hospitals, clinics, or other providers offer cheaper prices if you pay cash. You have the and explanation of how much a health service would cost if you paid out-of-pocket. Ask for the estimate before you get care. Then, compare that price with what your insurance company tells you it would cost if you used your insurance. If you decide to go with a cash payment, you’ll need to pay while you’re still at the doctor’s office, before charges get submitted to your insurance company.

Paying cash may save you money, but the amount you pay generally won’t count toward your deductible or out-of-pocket maximum.

“If you don’t think you’re ever going to hit your deductible — you’re that young invincible, and your deductible is $10,000 — negotiate the cash price,” Donovan said.

6. On an ACA plan? Update your income and use an HSA to avoid a tax surprise.

If you’re on an ACA plan and you’re eligible for subsidies, be aware: If your and you don’t update your marketplace application, you could owe thousands of dollars at tax time. The . Report raises, new jobs, or side gigs as they happen. If your income goes up, stashing money in an HSA can help because the money you put in the account doesn’t count toward your taxable income.

As soon as you report an increase in your income, that could mean higher premiums (if you no longer qualify for the same subsidy), but experts say it’s better to pay now than owe a big bill that you have to pay all at once.

“One of the biggest problems I see is someone is newly unemployed and they sign up for coverage, they say that they’re not making any money, and then eventually they get a job and don’t report it, and then they have this huge tax bill at the end,” Donovan said.

She advises updating your marketplace profile as soon as your income changes, which could newly qualify you for Medicaid or a plan that contributes more toward your medical bills.

Taylor Cook contributed to this report.

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“I call it the unaffordable care act,” he said. He reprised the line in his address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, , told ºÚÁϳԹÏÍø News that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted , a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said , a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in , but not in . Pennsylvania’s EHBs also don’t include hearing aids, but do.

But the Trump administration’s 2027 regulatory proposal : When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

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Según el gobierno, el objetivo es ofrecer más opciones y primas más bajas.

Sin embargo, la iniciativa también contempla un fuerte aumento de algunos gastos de bolsillo anuales  —que podrían superar los $27.000 en un tipo de cobertura— y podrían hacer que casi pierdan su seguro médico.

Los cambios se producen en un momento en que el costo de la atención de salud es una preocupación clave para muchos estadounidenses: algunos están teniendo dificultades para pagar sus primas de ACA desde que los subsidios mejorados vencieran a finales del año pasado. Las cifras iniciales de inscripción para este año muestran una caída de más de un millón de personas.

La cobertura médica y su accesibilidad se han convertido en de cara a las elecciones de medio término de noviembre.

Los cambios propuestos por la administración Trump forman parte de una extensa norma que modifica distintos aspectos del sistema, incluidos los paquetes de beneficios, los gastos de bolsillo y las redes de proveedores de salud. Las aseguradoras usan estas reglas  como base para fijar las primas para el año siguiente.

Después de un período de comentarios públicos —en el que personas, organizaciones y distintos sectores pueden opinar sobre el proyecto— la norma se oficializará esta primavera.

La propuesta “pone a los pacientes, contribuyentes y estados en primer lugar al reducir costos y reforzar la rendición de cuentas sobre el dinero de los contribuyentes”, dijo Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), en un .

Una de las formas en que lo haría es impulsando un tipo de cobertura —los — que, , el año pasado atrajeron apenas a unos 20.000 asegurados, elevan esa cifra a cerca de 54.000.

“Para mí, esta propuesta indica que la administración ha encontrado su próximo gran objetivo en los planes catastróficos”, dijo Katie Keith, directora de la Iniciativa de Política de Salud y Derecho en el O’Neill Institute for National and Global Health Law del Georgetown University Law Center.

Estos planes tienen costos anuales de bolsillo muy altos para el asegurado, pero suelen ofrecer primas más bajas que otras opciones de ACA. Antes estaban limitados a personas menores de 30 años o a quienes enfrentaban ciertas dificultades económicas, pero el gobierno de Trump permitió que se inscribieran personas de más edad que perdieron la elegibilidad para subsidios para la cobertura de 2026. Aún no se sabe cuántas personas eligieron esta opción.

La norma consolida este cambio porque hace elegibles a quienes tengan ingresos por debajo del nivel de pobreza ($15.650 este año) y a quienes ganen más de dos veces y media esa suma siempre que hayan perdido el acceso a un subsidio de ACA que reducía sus gastos de bolsillo. El texto también señala que una persona que cumpla con estos criterios sería elegible en cualquier estado, un punto importante porque esta cobertura actualmente .

Además, la propuesta exigiría que el límite máximo de gastos de bolsillo en estos planes alcanzara $15.600 al año para una persona y $27.600 para una familia esta semana en Health Affairs.

Actualmente, el tope de gastos de bolsillo para planes catastróficos es de $10.600 para una persona y $21.200 para cobertura familiar. Salvo la atención preventiva y tres consultas cubiertas con un médico de atención primaria, ese monto debe alcanzarse antes de que el resto de la cobertura entre en vigencia.

En el texto presentado, la administración afirma que los cambios propuestos ayudarían a diferenciar los planes catastróficos de los planes “Bronce”, el siguiente nivel, y posiblemente impulsarían una mayor inscripción en los primeros. Según el mismo documento, hoy esa diferencia no siempre es significativa cuando las primas son similares. Elevar el tope de gasto de bolsillo de los planes catastróficos a esos niveles, argumentan, serviría para establecer esa distinción.

“Cuando existe una diferencia tan clara, los consumidores más sanos —que suelen ser los candidatos ideales para inscribirse en planes catastróficos— se sienten más motivados a elegir uno de estos planes, en lugar de un plan Bronce”, señalan.

Sin embargo, como los subsidios de ACA no pueden usarse para pagar las primas de los planes catastróficos, es posible que esto desaliente a los posibles beneficiarios.

La inscripción en los planes Bronce, que actualmente tienen un deducible anual promedio de $7.500, se ha duplicado desde 2018 hasta alcanzar unos 5,4 millones de consumidores el año pasado. Este año es probable que la cifra sea mayor.

Los datos de inscripción en algunos estados muestran un desplazamiento hacia los planes Bronce, ya que los consumidores fueron dejando los planes “Plata”, “Oro” o “Platino”, que tienen primas más altas, tras el vencimiento de subsidios mejorados a finales de 2025.

La iniciativa del gobierno también permitiría que las aseguradoras ofrezcan planes Bronce con niveles de copagos y deducibles que superen lo que hoy permite ACA, pero solo si esa misma aseguradora también vende otros planes Bronce con niveles más bajos de costos compartidos.

En lo que describen como un enfoque “novedoso”, las nuevas regulaciones permitirían que las aseguradoras ofrezcan planes catastróficos multianuales, en los que las personas podrían permanecer inscritas hasta por 10 años. Durante ese período, los límites de gastos variarían. Por ejemplo, los costos podrían ser más altos en los primeros años y luego bajar a medida que el plan se mantenga vigente. La presentación solicita comentarios específicos sobre cómo podría estructurarse un plan de este tipo y qué efecto tendrían los planes multianuales en el mercado en general.

“Por lo que entendemos hasta ahora, las aseguradoras podrían ofrecer la póliza por un año o por períodos consecutivos de hasta 10 años”, explicó Zach Sherman, director gerente de política de cobertura y diseño de programas en HMA, también conocida como Health Management Associates, una firma de consultoría en políticas de salud que trabaja para estados y aseguradoras. “Pero aún estamos analizando los detalles de cómo funcionaría”, añadió.

Matthew Fiedler, investigador principal del Centro de Políticas de Salud de Brookings Institution, advirtió que el paquete regulatorio que propone el gobierno incluye muchas disposiciones que podrían “exponer a los inscritos a gastos de bolsillo mucho más altos”.

Además de los cambios previstos para los planes Bronce y catastróficos, Fiedler señaló otra disposición que permitiría vender en el mercado de ACA planes que no tengan redes fijas de proveedores de salud. Es decir, la aseguradora no habría firmado contratos con médicos ni hospitales específicos para aceptar su cobertura.

En su lugar, estos planes pagarían a los proveedores un monto fijo por sus servicios médicos. Podría ser una tarifa única o un porcentaje de lo que paga Medicare. La iniciativa establece que las aseguradoras tendrían que garantizar “acceso a una variedad de proveedores” dispuestos a aceptar esas sumas como pago total. Sin embargo, los asegurados podrían quedar expuestos a gastos inesperados si un médico o centro de salud no acepta esas condiciones y le cobra al paciente la diferencia.

Debido al amplio alcance de la norma —que incluye muchas otras disposiciones— se espera que reciba cientos, si no miles, de comentarios públicos hasta principios de marzo.

El corredor de seguros de Pennsylvania Joshua Brooker dijo que le gustaría que se exija a las aseguradoras que venden planes catastróficos con gastos de bolsillo muy altos que también ofrezcan otros planes catastróficos con límites anuales más bajos.

En términos generales, agregó, una mayor variedad de opciones podría resultar atractiva para personas en ambos extremos de la escala de ingresos.

Según explicó, algunos consumidores con mayores ingresos —especialmente quienes ya no califican para subsidios para las primas de ACA— preferirían pagar una prima más baja, como la que se espera en los planes catastróficos, y asumir de su propio bolsillo los gastos médicos hasta alcanzar ese tope máximo.

“Están más preocupados por un infarto que cueste medio millón de dólares”, reflexionó Brooker.

La situación es más difícil para quienes están por debajo de la línea de pobreza, no califican para subsidios de la ACA y, , muchas veces tampoco cumplen los requisitos para Medicaid, opinó. “En esos casos, es probable que se queden sin seguro médico”. Al menos un plan catastrófico, dijo, podría permitirles acceder a la atención preventiva y limitar un desastre financiero si terminan en un hospital. “A partir de ahí, incluso podrían calificar para programas de atención caritativa del hospital que ayuden a cubrir los gastos de bolsillo”, dijo.

En general, afirmó: “ofrecer más opciones en el mercado no perjudica, siempre que la propuesta se divulgue de manera adecuada y el consumidor la entienda”.

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The changes come as affordability is a key concern for many Americans, some of whom are struggling to pay their ACA premiums since enhanced subsidies expired at the end of last year. Initial enrollment numbers for this year fell by more than 1 million.

Health care coverage and affordability have in the run-up to November’s midterm elections.

The proposed changes are part of a lengthy rule that addresses a broad swath of standards, including benefit packages, out-of-pocket costs, and health care provider networks. Insurers refer to these standards when setting premium rates for the coming year.

After a comment period, the rule will be finalized this spring.

It “puts patients, taxpayers, and states first by lowering costs and reinforcing accountability for taxpayer dollars,” said Centers for Medicare & Medicaid Services Administrator Mehmet Oz .

One way it would do so focuses heavily on a type of coverage — — that last year attracted only about 20,000 policyholders, , although put it closer to 54,000.

“To me, this proposal reads like the administration has found their next big thing in the catastrophic plans,” said Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center.

Such plans have very high annual out-of-pocket costs for the policyholder but often lower premiums than other ACA coverage options. Formerly restricted to those under age 30 or facing certain hardships, the Trump administration allowed older people who lost subsidy eligibility to enroll in them for this year. It is not yet known how many people chose to do so.

The payment rule cements this move by making eligible anyone whose income is below the poverty line ($15,650 for this year) and those earning more than 2.5 times that amount who lost access to an ACA subsidy that lowered their out-of-pocket costs. It also notes that a person meeting these standards would be eligible in any state — an important point because this coverage is in only 36 states and the District of Columbia.

In addition, the proposal would require out-of-pocket maximums on such plans to hit $15,600 a year for an individual and $27,600 for a family, Health Affairs. (The current out-of-pocket max for catastrophic plans is $10,600 for an individual plan and $21,200 for family coverage.) Not counting preventive care and three covered primary care doctor visits, that spending target must be met before a policy’s other coverage kicks in.

In the rule, the administration wrote that the proposed changes would help differentiate catastrophic from “bronze” plans, the next level up, and, possibly, spur more enrollment in the former. Currently, the proposal said, there may not be a significant difference if premiums are similar. Raising the out-of-pocket maximum for catastrophic plans to those levels would create that difference, the proposal said.

“When there is such a clear difference, the healthier consumers that are generally eligible and best suited to enroll in catastrophic plans are more motivated to select a catastrophic plan in lieu of a bronze plan,” the proposal noted.

However, ACA subsidies cannot be used toward catastrophic premiums, which could limit shoppers’ interest.

Enrollment in bronze plans, which currently have an average annual deductible of $7,500, has doubled since 2018 to about 5.4 million last year. This year, that number will likely be higher. Some states’ sign-up data indicates a shift toward bronze as consumers left higher-premium “silver,” “gold,” or “platinum” plans following the expiration of more generous subsidies at the end of last year.

The proposal also would allow insurers to offer bronze plans with cost-sharing rates that exceed what the ACA law currently allows, but only if that insurer also sells other bronze plans with lower cost-sharing levels.

In what it calls a “novel” approach, the proposal would allow insurers to offer multiyear catastrophic plans, in which people could stay enrolled for up to 10 years, and their out-of-pocket maximums would vary over that time. Costs might be higher, for example, in the early years, then fall the longer the policy is in place. The proposal specifically asks for comments on how such a plan could be structured and what effect multiyear plans might have on the overall market.

“As we understand it thus far, insurers could offer the policy for one year or for consecutive years, up to 10 years,” said Zach Sherman, managing director for coverage policy and program design at HMA, also known as Health Management Associates, a health policy consulting firm that does work for states and insurance plans. “But the details on how that would work, we are still unpacking.”

Matthew Fiedler, senior fellow with the Center on Health Policy at the Brookings Institution, said the proposed rule included a lot of provisions that could “expose enrollees to much higher out-of-pocket costs.”

In addition to the planned changes to bronze and catastrophic plans, he points to another provision that would allow plans to be sold on the ACA exchange that have no set health care provider networks. In other words, the insurer has not contracted with specific doctors and hospitals to accept their coverage. Instead, such plans would pay medical providers a set amount toward medical services, possibly a flat fee or a percentage of what Medicare pays, for example. The rule says insurers would need to ensure “access to a range of providers” willing to accept such amounts as payment in full. Policyholders might be on the hook for unexpected expenses, however, if a clinician or facility doesn’t agree and charges the patient the difference.

Because the rule is so sweeping — with many other parts — it is expected to draw hundreds, if not thousands, of comments between now and early March.

Pennsylvania insurance broker Joshua Brooker said one change he would like to see is requiring insurers that sell the very high out-of-pocket catastrophic plans to offer other catastrophic plans with lower annual maximums.

Overall, though, a wider range of options might appeal to people on both ends of the income scale, he said.

Some wealthier enrollees, especially those who no longer qualify for any ACA premium subsidies, would prefer a lower premium like those expected in catastrophic plans, and could just pay the bills up to that max, he said.

“They’re more worried about the half-million-dollar heart attack,” Brooker said. It’s tougher for people below the poverty level, who don’t qualify for ACA subsidies and, in . So they’re likely to go uninsured. At least a catastrophic plan, he said, might let them get some preventive care coverage and cap their exposure if they end up in a hospital. From there, they might qualify for charity care at the hospital to cover out-of-pocket costs.

Overall, “putting more options on the market doesn’t hurt, as long as it is disclosed properly and the consumer understands it,” he said.

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Su prima mensual de $435 por la cobertura familiar es casi igual a la del seguro de su trabajo anterior. Pero el plan de salud de su empleo actual tiene un deducible anual de $4.000, que debe pagar de su bolsillo antes de que el seguro comience a cubrir los gastos médicos de su familia cada año.

“Ahora todo es el precio total”, dijo este hombre de 53 años, que trabaja en un almacén al sur del área de Dallas-Fort Worth. “Ha sido un poco difícil”.

Para reducir sus gastos, Garza cambió su medicamento para la diabetes por otro más económico y dejó de usar el monitor continuo de glucosa que controlaba sus niveles de azúcar en sangre. Desde que empezó en este trabajo hace casi dos años, comentó, su nivel de hemoglobina A1c ha ido subiendo: pasó del 7% o menos —el objetivo recomendado— a un 14% en su visita médica más reciente, en noviembre.

“Mi A1c está por las nubes porque técnicamente ya no estoy usando el medicamento correcto como antes”, lamentó Garza. “Estoy tomando lo que puedo pagar”.

Los planes con deducibles altos —es decir, la cantidad que los pacientes deben abonar por la mayoría de los servicios médicos antes de que el seguro se haga cargo— se han vuelto cada vez más comunes.

En 2024, la ofreció este tipo de cobertura, comparado con el 38% en 2015, según datos federales. Estos planes también están disponibles a través del mercado de seguros de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Con los para el próximo año y la posible finalización de varios subsidios a fin de 2025, más personas enfrentan decisiones difíciles al comparar el costo mensual de las primas con los deducibles. Para poder pagar un seguro, algunas personas optan por planes con primas bajas pero deducibles altos, apostando a que no tendrán crisis médicas.

Pero estos planes representan un reto particular para quienes viven con enfermedades crónicas, como los que tienen diabetes tipo 1 o tipo 2 en Estados Unidos.

Según un estudio publicado en 2024, los adultos con diabetes que, involuntariamente, pasan a un plan con deducible alto enfrentan un 11% más de riesgo de hospitalización por infarto que quienes tienen otro tipo de cobertura. También tienen un 15% más de peligro de derrame cerebral y de probabilidad de quedar ciegos o desarrollar enfermedad renal en etapa terminal.

“Todas estas complicaciones son prevenibles”, señaló , autora principal del estudio.

Atención vs. costo

El objetivo inicial de los planes con deducibles altos era fomentar mejores decisiones al buscar atención médica, explicó McCoy, profesora asociada en la University of Maryland School of Medicine, en College Park.

Pero mientras que alguien con un dolor de oído insoportable buscará atención médica, dijo, quienes tienen niveles de azúcar en sangre fuera de control tal vez no sientan la misma urgencia —a pesar del posible daño a largo plazo— debido al fuerte impacto financiero.

“No hay síntomas hasta que ya es demasiado tarde”, dijo. “Y en ese punto, el daño es irreversible”.

En promedio, la atención médica para personas con diabetes cuesta , según un análisis de datos de 2022. La diabetes tipo 2, que es la forma más común, se diagnostica cuando el cuerpo deja de producir suficiente insulina o no la utiliza de forma adecuada, lo que dificulta controlar el nivel de azúcar en la sangre.

En la diabetes tipo 1, el cuerpo no produce insulina. Las personas con esta enfermedad deben cubrir no solo el costo de la insulina y otros medicamentos, sino también el de los equipos necesarios para su atención.

Mallory Rogers calcula que gasta unos $1.200 al mes en el tratamiento de su hija Adeline, de 6 años, que tiene diabetes tipo 1. Ese monto incluye insulina, una bomba de insulina y un monitor continuo de glucosa. No están contemplados los suministros de emergencia que se requieren si alguno de estos dispositivos falla: otro tipo de insulina, tiras para medir la glucosa en sangre y dos frascos de un aerosol nasal que cuesta casi $600 y debe reponerse al menos una vez al año.

“Si no tuviera insulina, estaría en una situación de emergencia en menos de dos horas”, explicó Rogers, consultora en tecnología que vive en Sanford, Florida. La mujer ha estado ahorrando para cuando su hija tenga que usar el plan de salud con deducible alto que ofrece su empleador, que alcanza los $3.300 para la cobertura familiar.

Decisiones impositivas

Muchos planes de seguro vienen con deducibles cada vez más altos. Pero para que un plan se considere oficialmente de “deducible alto” —y así pueda ofrecer una cuenta de ahorros para gastos médicos (HSA)— el deducible en 2026 tiene que ser de al menos , según las reglas del IRS.

En 2026, quienes tienen acceso a una cuenta de ahorros para la salud (HSA) a través de su plan o de su empleador pueden obtener beneficios fiscales aportando hasta $8.750 por familia o $4.400 por persona, si es que pueden pagarlo. El empleador de Rogers aporta $2.000 a lo largo del año, y el de Garza contribuye con $1.200.

Rogers reconoce que ha tenido suerte: ha logrado ahorrar $7.000 en su cuenta HSA para cuando el seguro de su hija se transfiera a su plan.

“Agregar una carga financiera a una condición médica ya de por sí estresante, me parte el corazón”, dijo al pensar en quienes no pueden ahorrar lo mismo. “Nadie pide tener diabetes, ya sea tipo 1 o tipo 2”.

En 2024, el deducible promedio en los planes de empleadores fue de $2.750, pero pueden superar los $5.000, según George Huntley, director ejecutivo del y de la

Cuando los deducibles son demasiado altos, aseguró Huntley, lo primero que la gente empieza a recortar es el tratamiento básico: “No toman el medicamento que deberían tomar para controlar la glucosa. Racionan la insulina, si ese es su caso. Toman las pastillas día por medio”.

Garza sabe que debería hacer más para controlar su diabetes, pero su situación económica no se lo permite. Su seguro anterior cubría un tipo más novedoso de medicamentos para la diabetes, conocidos como agonistas de GLP-1, por $25 mensuales. También cubría sin costo sus otros medicamentos, como los de la presión arterial y el colesterol, y su monitor continuo de glucosa.

Con su nuevo seguro, paga $125 mensuales por la insulina y otros medicamentos. Solo ve a su endocrinólogo dos veces al año.

“Quiere verme cada tres meses”, comentó Garza. “Pero le dije que no es posible a $150 la consulta”.

Además, generalmente necesita exámenes de laboratorio antes de cada visita, los que le cuestan otros $111.

El año próximo, el deducible promedio de un plan Plata en el mercado de ACA será de $5.304, sin reducciones de costos compartidos, según un análisis de KFF. Para un , el promedio será de $7.476.

Una visita médica anual y algunos exámenes preventivos, como una mamografía, estarán cubiertos sin costo para el paciente.

Además, quienes —ya sea a través de su empleador o del mercado de seguros— deben tener en cuenta cuál es su gasto máximo de bolsillo anual, que se sigue aplicando incluso después de cubrir el deducible, explicó Huntley.

Por ejemplo, el plan familiar de Garza requiere que él pague el 20% de los costos hasta llegar a los $10.000.

Dado que sus niveles de azúcar están tan elevados, el doctor le recetó una insulina de acción rápida para usar con las comidas, que cuesta $79 adicionales al mes. Garza planeaba surtir esa receta en diciembre, cuando solo debería pagar el 20% del costo: ya cumplió su deducible pero aún no alcanzó su máximo de bolsillo.

A Garza le gusta su trabajo a pesar del plan de salud, y dijo que nunca ha faltado ni un día, ni siquiera recientemente, cuando tuvo un virus estomacal. Hacia finales de 2025, seguía sin decidir si inscribirse o no en el seguro médico cuando llegue el período de afiliación de su compañía, a mediados de 2026.

Le preocupa que dejar el seguro ponga en riesgo a su familia si se presenta una emergencia médica. Sin embargo, comentó, podría usar el dinero que ahora paga en primas mensuales para cubrir directamente su atención médica y así controlar mejor su diabetes.

“Para serle honesto, me siento atrapado”, concluyó.

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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 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 that can top $7,000.

“A patient makes the decision,” Sen. Bill Cassidy (R-La.) said . “It empowers the patient to lower the cost.”

In a 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 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 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, 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 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 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.”

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His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said , the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of the disease, according to an analysis. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be , according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the and .

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. For a . An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people , whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.

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The agency that oversees the ACA that it would expand eligibility for “catastrophic” plans sold in Affordable Care Act online marketplaces. The plans require people to spend more than $10,000 a year on deductibles before the policies pay most medical costs but carry lower monthly premiums than other Obamacare policies.

The move reflects growing concern among Republicans about political backlash if Congress doesn’t extend larger tax credits put in place during the covid-19 public health emergency to help consumers pay their premiums. The extra subsidies are set to expire at the end of the year, resulting in an in the amount people pay for coverage, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

A small, bipartisan group of House lawmakers introduced legislation to extend the enhanced covid-era subsidies for one more year, which would keep them in place through midterm congressional elections in fall 2026.

But , with many Republicans opposed to extending the extra tax credits, with a permanent change costing . Without an extension, tax credit amounts would revert to pre-pandemic levels.

“They spent the last 15 years against the ACA, so a lot will be steadfast, but others are worried about the effect of massively spiked premiums on their constituents,” noted a Democratic Senate staffer who asked not to be identified because they weren’t authorized to speak to the media.

Republicans currently control Congress by slim margins, raising the stakes if voters who lose their ACA tax credits blame them at the ballot box.

Catastrophic plans are a little-known type of Obamacare policy that have previously been limited mainly to people under age 30. While they come with lower monthly premiums than other types of ACA plans, the coverage has higher annual deductibles, which are set at the out-of-pocket maximum for the year: $10,600 for individuals in 2026 or $21,200 for families.

A deductible is the amount patients must spend on health care before insurance plans pay for most services. Catastrophic plans do cover three primary care visits a year without having to pay the full deductible and, as with other ACA policies, policyholders pay nothing for preventive services such as some cancer screenings and vaccines.

The catastrophic plans will automatically show up on the federal marketplace, healthcare.gov, for consumers who lose tax credit coverage entirely next year due to their household income. Another category of consumers — people who continue to qualify for tax credits but not for subsidies that reduce out-of-pocket costs — may also be eligible but would have to send in paperwork.

“By expanding access to catastrophic plans, we are making sure hardworking people who face unexpected hardships can get affordable coverage that protects them from devastating medical costs,” Centers for Medicare & Medicaid Services Administrator Mehmet Oz .

It isn’t clear whether the policy changes will make the plans more attractive to consumers. Catastrophic plans aren’t available in all states, and the size of the deductibles can be off-putting.

“It’s a ton of money,” , a health insurance analyst and broker who writes regularly about the ACA. “A full-price catastrophic plan is still more expensive than some people can afford, but they’re doing this to offer a slightly more affordable option.”

Catastrophic plans have had limited appeal, with 24 million enrollees currently opting for the coverage, according to government data, Norris said.

“Uptake has always been quite low,” said Katie Keith, director of the O’Neill Institute’s Center for Health Policy and the Law at Georgetown University. “It’s not a bad option if it is the only option you have. I question whether consumers are looking for this kind of coverage.”

CMS plans to grant people a “hardship” designation to enroll in catastrophic plans if they lose eligibility for ACA tax credits next year. Most likely to qualify are people earning more than four times the federal poverty rate ($62,600 for an individual this year, or $106,600 for a family of three), who will lose access to all premium subsidies if Congress does not extend the current enhanced tax credits. It’s also unclear how much premiums will cost. Insurers, reacting to the new administration guidance, might seek to recalculate their rates based on what they estimate may be an influx of older people into the plans, Norris said.

AHIP, the insurance industry lobbying group, is pushing hard for the larger tax credits to be extended. It did not comment specifically on how the new guidance might affect catastrophic health plan premiums. Still, AHIP spokesperson Chris Bond said that “while catastrophic plans can provide important coverage for specific needs, they are not a replacement for affordable comprehensive coverage.”

There are other hurdles. Norris said insurers don’t offer plans at all in 10 states: Alaska, Arkansas, Indiana, Louisiana, Mississippi, New Mexico, Oregon, Rhode Island, Utah, and Wyoming. And where they are available, options are few. This year, for example, a 25-year-old in Orlando, Florida, had a choice of 61 “bronze” plans, the cheapest level of coverage available to all ACA shoppers, but just three catastrophic plans.

Policy experts say the expanded eligibility for catastrophic plans makes it more important than ever for consumers to consider all options when shopping for ACA coverage during the annual open enrollment period, which starts Nov. 1. In addition to the catastrophic and bronze plans, there are also “silver” and “gold” plans, each with varying premiums and deductibles.  

Bronze plans have the lowest premiums but the highest deductibles; the , which is still lower than the catastrophic plans, according to KFF.

Catastrophic plan deductibles, while high, are comparable to some bronze plans, Norris noted. People who choose catastrophic plans are not eligible for any ACA tax subsidies to help pay monthly premiums.

A pending court battle may provide lawmakers concerned about voter pushback on Obamacare changes an unintended reprieve.

In late August, a federal judge in Maryland temporarily put on hold some changes the Trump administration had ordered for next year. Those changes, included by the administration, would have added additional verification paperwork requirements for some people enrolling in ACA plans, and were challenged by several cities, which cited government estimates that the changes could to lose their insurance in 2026.

The court ruling including income verification requirements that would affect people below the poverty level and those without tax return information. The move also paused verification requirements affecting people who apply outside the annual open enrollment period and blocked a $5 monthly charge for people who are automatically enrolled into plans in which subsidies cover the entire premium — unless they contact the marketplace and confirm their selection.

The Trump administration is appealing the decision, but the case may not be settled until next year, said Keith at Georgetown University.

That makes it likely that the pause of the new requirements will stay in place for this year’s open enrollment season.

Keith said the ruling was a “bigger deal” than expanding eligibility for catastrophic plans. “Consumers all across the country won’t have to deal with red tape the Trump administration rushed to put into place ahead of the new plan year,” and the ruling also “helps people keep their coverage.”

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Millions of people are expected to lose health insurance in the coming years as a result of the tax cut legislation Trump signed this month, leaving them with fewer protections from large bills if they get sick or suffer an accident.

At the same time, significant increases in health plan premiums on state insurance marketplaces next year will likely push more Americans to either drop coverage or switch to higher-deductible plans that will require them to pay more out-of-pocket before their insurance kicks in.

Smaller changes to federal rules are poised to bump up patients’ bills, as well. New federal guidelines for covid-19 vaccines, for example, will to stop covering the shots for millions, so if patients want the protection, some may have to pay out-of-pocket.

The new tax cut legislation will also raise the cost of certain doctor visits, requiring copays of up to $35 for some Medicaid enrollees.

And for those who do end up in debt, there will be fewer protections. This month, the Trump administration secured permission from a federal court to that would have removed medical debt from consumer credit reports.

That puts Americans who cannot pay their medical bills at risk of lower credit scores, hindering their ability to get a loan or forcing them to pay higher interest rates.

“For tens of millions of Americans, balancing the budget is like walking a tightrope,” said Chi Chi Wu, a staff attorney at the National Consumer Law Center. “The Trump administration is just throwing them off.”

White House spokesperson Kush Desai did not respond to questions about how the administration’s health care policies will affect Americans’ medical bills.

The president and his Republican congressional allies have brushed off the health care cuts, including hundreds of billions of dollars in Medicaid retrenchment in the mammoth tax law. “You won’t even notice it,” at the White House after the bill signing July 4. “Just waste, fraud, and abuse.”

But consumer and patient advocates around the country warn that the erosion of federal health care protections since Trump took office in January threatens to significantly undermine Americans’ financial security.

“These changes will hit our communities hard,” said Arika Sánchez, who oversees health care policy at the nonprofit New Mexico Center on Law and Poverty.

Sánchez predicted many more people the center works with will end up with medical debt. “When families get stuck with medical debt, it hurts their credit scores, makes it harder to get a car, a home, or even a job,” she said. “Medical debt wrecks people’s lives.”

For Americans with serious illnesses such as cancer, weakened federal protections from medical debt pose yet one more risk, said Elizabeth Darnall, senior director of federal advocacy at the American Cancer Society’s Cancer Action Network. “People will not seek out the treatment they need,” she said.

Trump promised a rosier future while campaigning last year, and “expand access to new Affordable Healthcare.”

Polls suggest voters were looking for relief.

About 6 in 10 adults — Democrats and Republicans — say they are worried about being able to afford health care, according to , outpacing concerns about the cost of food or housing. And medical debt remains a widespread problem: As many as 100 million adults in the U.S. are burdened by some kind of health care debt.

Despite this, key tools that have helped prevent even more Americans from sinking into debt are now on the chopping block.

Medicaid and other government health insurance programs, in particular, have proved to be a powerful economic backstop for low-income patients and their families, said Kyle Caswell, an economist at the Urban Institute, a think tank in Washington, D.C.

Caswell and other , for example, that Medicaid expansion made possible by the 2010 Affordable Care Act led to measurable declines in medical debt and improvements in consumers’ credit scores in states that implemented the expansion.

“We’ve seen that these programs have a meaningful impact on people’s financial well-being,” Caswell said.

Trump’s tax law — which will slash more than $1 trillion in federal health spending over the next decade, mostly through Medicaid cuts — is expected to leave 10 million more people without health coverage by 2034, according to the from the nonpartisan Congressional Budget Office. The tax cuts, which primarily benefit wealthy Americans, will add $3.4 trillion to U.S. deficits over a decade, the office calculated.

The number of uninsured could spike further if Trump and his congressional allies don’t renew additional federal subsidies for low- and moderate-income Americans who buy health coverage on state insurance marketplaces.

This aid — enacted under former President Joe Biden — lowers insurance premiums and reduces medical bills enrollees face when they go to the doctor or the hospital. But unless congressional Republicans act, those subsidies will expire later this year, leaving many with bigger bills.

Federal debt regulations developed by the Consumer Financial Protection Bureau under the Biden administration would have protected these people and others if they couldn’t pay their medical bills.

The agency issued rules in January that would have removed medical debts from consumer credit reports. That would have helped an estimated 15 million people.

But the Trump administration chose not to defend the new regulations when they were challenged in court by debt collectors and the credit bureaus, who argued the federal agency had exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

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The charge was a “facility fee” for the hospital, though the treatment entailed only a six- to seven-minute consultation with a doctor. Because Swami had a high-deductible health plan and had not yet met his deductible for the year, he was on the hook for the entire amount. 

Swami’s attempt to dispute the charge led him to battle the hospital, then his insurer, a bill-mediation service provided by his employer, and finally the debt collector. He didn’t win, but learned valuable lessons about advocating for hospital discounts. 

“An Arm and a Leg” host Dan Weissmann speaks with Swami about the experience. He also interviews Kaelyn Globig, head of advocacy for the , about how to find out what Medicare pays for a given procedure, and April Kuehnhoff, an attorney with the , for advice on filing a dispute with a debt collector. 

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

You know, sometimes experiments fail. And when we’re lucky,

• Nothing life-changingly awful happens, and
• We learn stuff.

That’s the kind of story we’ve got today. It starts with a note from a listener named Sandeep Swami, who was in a fighting spirit.

Sandeep: the facilities are doing nothing but taking advantage of a vulnerable situation, right, which the patient is already in.

Dan: He was fighting a medical bill. And he had a question I didn’t know the answer to. But I WANTED to know. And I knew exactly who I wanted to ask. It wasn’t an academic researcher, or a lawyer, or whatever. It was somebody whose credentials were a lot more … informal. One of my favorite people I’ve ever talked with for this show. I wanted to put her together with Sandeep. In the end, Sandeep’s experiment didn’t work out the way he’d hoped. He was disappointed, but he’ll be OK. Meanwhile,  we did get the answer to that question, we had a great conversation with that expert… and we learned some useful lessons.

This is An Arm and a Leg– a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

Sandeep lives in the Bay Area, works in software, came to this country from India fourteen years ago.

Sandeep: I’m basically an immigrant. And so the whole system over here was kind of completely new to me.

Dan: He was used to something a little more basic, but adequate– and way more affordable. The last few years, he’s had a high deductible insurance plan, and it’s gotten him VERY interested in learning more about how to avoid getting ripped off.

Sandeep: you start seeing those big numbers being billed to you and you kind of get uncomfortable paying those large amount.

Dan: He’s been listening to our show, and he’s been reading a book we’ve talked about here: Never Pay the First Bill, by reporter Marshall Allen. I wouldn’t say it had all left him itching for a fight, but…

Sandeep: I had this in mind that, hey, the next time I have a situation where I had to walk into a facility, uh, I’m kind of better prepared

Dan: Then, last spring his daughter wasn’t feeling well — she was eleven at the time. Just a cold, a cough at first. But her usual medicine– an inhaler– wasn’t working like it usually did. And the cough– it was keeping her awake

Sandeep: about four or five in the morning. She was still not able to sleep with coughing

Dan: It got to be like 4 or 5 in the morning, and Sandeep was like, OK. I guess we better get her seen. Now. The trip to the ER was uneventful, and short.

Sandeep: the whole consultation lasted probably about six, seven minutes.

Dan: The doc said, she’s gonna be OK. Maybe up the frequency with the inhaler. That was it. Sandeep’s daughter gets better.

A few weeks later he gets a bill: One thousand three hundred thirty-nine dollars. And this bill doesn’t include the doctor’s services. That was a separate bill– maybe sixty bucks, which he says he paid right away.

This is from the hospital. And what did they do for him, exactly?

Sandeep: there was no IV, no injection, nothing. There was nothing which was given to us from the emergency facility. And the only recommendation we got, hey, use over the counter medication.

Dan: So, Sandeep’s like, OK, I’m gonna fight this.

Sandeep: I think I can afford to pay this amount. There’s no questions that I, I won’t be able to but I think it’s more like a principle thing

Dan: I’m not gonna go through all the work Sandeep had already done before we talked. But it was a LOT.

First, he checked:  Was this charge even correct?

He got an itemized bill, looked up the billing codes, found out he was being charged a “facility fee” — like a cover charge just for walking into the ER.

It’s legal.

In fact, hospitals will tell you:  This is how they keep the lights on. And all the life-saving machinery running. And how they keep the nurses and other staff paid. All the people and equipment they need to keep at the ready for WHATEVER walks through the door.

In any case, Sandeep was like, thirteen hundred bucks?

He made all the phone calls: to the hospital, to his insurance, to a bill-mediation service from his employer.

They all told him the same thing:

Sorry, man. 13 hundred bucks is the amount your insurer pays for that code. 

Sandeep: you haven’t met your deductible. You had to pay, and this is the amount.

Dan: He was like, yeah but it’s ridiculous.

Sandeep: I said, even if I rent a hotel for a day, with all the facilities, it’s not going to come to this price at all.

Dan: So even if there’s no error, he wants to put up a fight. He goes looking for ammo: data that could show the price he’s being charged is unfair.

And because Sandeep has really been following stuff, he knows:  A federal order that went into effect last year requires hospitals to lay out a lot of pricing information for certain services.

Like, what they actually charge different insurers.  And what they charge people who don’t have insurance.

He finds the file. And it’s a good thing for him that he’s a software engineer. Because this file?

Sandeep:  it’s not in a readable format. It’s like the binary

Dan: Yeah, it’s a binary file– pure code. Readable by machines, but not people. And yes, it’s legal for them to post it in that format.

Sandeep puts his work skills to use, decodes the file. And he learns this hospital charges people who don’t have insurance about a thousand dollars less than what they want from him.

And he wrote to me because he wanted to know: How could he find out what they accept from Medicare?

And I was like, ooh, wait. I actually don’t exactly know. I know you CAN. And I know it’s a really good thing to do: If you’re negotiating a medical bill, that could be a good data point to have.

It’s a price the other side definitely accepts, that’s gonna be a lot lower than what they’re charging you.

Medicare prices are set by the government, and they tend to be a lot lower than the rates hospitals and other providers negotiate with insurance companies. Because with Medicare, they don’t get to negotiate.

The government does its studies, decides on what it thinks is reasonable, and says: Here, take it or leave it. Actually, take it or leave Medicare.

Now, hospitals sometimes say they get screwed on Medicare rates … but they all accept them.

They might not accept that rate from you, but if you’re gonna try to negotiate a bill — or fight it– it seems like a data point you might want.

So I wanted to know how to find it too.

And it seemed like an opportunity to re-connect with one of my favorite sources ever.

That’s the behind the scenes star of one of the first stories I ever did for this show — and its’ a story I especially enjoyed making. Partly because I got to report it at a Renaissance Fair.

Rennie 1: Have you gotten the chance to speak with Robin Hood yet? Robin, come forward.

Dan: That’s right after this.

This episode of An Arm and a Leg is a co-production with Kaiser Health News–

That’s a nonprofit newsroom covering health care in America.

KHN is not affiliated with the giant health care outfit, Kaiser Permanente.

We’ll have more information about KHN at the end of this episode.

OK, this very early Arm and a Leg story starts with me at the Renaissance Fair.

Robin Hood: And you’re having fun

Dan: for sure.

Yeah, I’m talking to Robinhood.

Robin Hood: Awesome. Yes

Dan: If you’ve heard the story, you may remember: The people who work at these fairs, Rennies, have developed a kind of hand-crafted medical-bill safety net.

They need one. They don’t all earn a lot of money. The gig doesn’t come with insurance. And they’re handling swords and flaming torches, and what-not.

Part of the Rennie system is, they pitch into a kitty to help cover each other’s medical bills. Like half a million bucks over a five year period.

But the other part of their system is what’s really impressive. Because in that same five-year period, they made more than two million dollars worth of medical bills disappear.

The wizard responsible for that trick is Kaelyn Globig. She’s a former Rennie herself, and she does all this part time — she also works as a real estate agent.

My first interview with Kaelyn may be the single most educational, influential conversation I’ve ever had in reporting for this show. This especially stuck with me.

Kaelyn Globig: I love this job because I am so appalled at the way it, they try to work our medical system. Um, I like to be on this side of it. The one that’s kind of fighting for the, you know, for the little guy.

Dan: That’s it right there, the direction our whole show has taken. Kaelyn’s the person who introduced me to the whole idea of using negotiation, and advocacy, and our wits to defend ourselves– and others — against wild medical bills.

Including by getting an itemized bill, with billing codes. In fact, here’s what she said:

Kaelyn Globig: I look up those codes and I see how much Medicare will pay for those.

Dan: This, I think, is what gave Sandeep the idea to call me. So I was EXTREMELY PLEASED to introduce them. I got the three of us together on Zoom, and Sandeep told his whole story.

Kaelyn definitely loved meeting him.

Kaelyn Globig: well first of all, give them held Sandeep. I am so happy to hear, that you have tried to exhaust every avenue.

Dan: And she was ready to show us how to find out what Medicare pays

Kaelyn had sent us a cheat sheet ahead of time. Including a link to a special page on CMS dot gov– that the site for the Centers for Medicare and Medicaid Services.

It was like she led us to a secret door. Now it was time to go through it.

Kaelyn Globig: So what you wanna do is scroll down, um, in the first page here,

Dan: I am not gonna make you listen to our whole journey.

Kaelyn Globig: Just scroll down and click

Accept

or read it if you’d like. I’ve never read that.

Dan: I am going to refer you to Kaelyn’s cheat-sheet– a how-to document. We’ll post that wherever you’re listening, and to arm and a leg show dot com.

For now, I’ll just tell you: about four and a half minutes after we found that secret door, we landed here.

Kaelyn Globig: Yeah. So as you see that $1,339 service , our government has deemed a fair price for the service that you received is,

SANDEEP: Wow.

KAELYN: 40…

Dan: it

Kaelyn Globig: did it say? 45

Dan: $45 and 91 cents?

Kaelyn Globig: That’s it. Yep.

Dan: Holy

Kaelyn Globig: They are charging you two to 10 times more usually than the fair price.

So this is our

Dan: This is more like, more like 20 or 30 times more.

Kaelyn Globig: right? Right. Yeah. I mean, just astronomical.

SANDEEP:  It’s so crazy.

Dan: Sandeep said seeing this did strengthen his resolve to fight

Sandeep: I mean, you look at the Medicare price , it’s not even two times, not even three times.

It’s like several times the amount. So it just not right.

Kaelyn Globig: Nope, you’re right.

Dan: Now, a hospital might say:  That 46 dollar medicare rate is the REASON we demand such high rates from insurance companies like Sandeep. We’re getting killed, and we’ve gotta make it up somehow.  It’s an argument I hear a lot. Kaelyn has a different caution.

Kaelyn Globig: I Love what a hard time you’re giving them. Sandeep. This is so great. Um, unfortunately you are wrestling with a giant,

Kaelyn says, that’s not something she tends to take on. When she looks up Medicare prices, it’s not for fighting with a hospital, arguing that their rate is too high.  

She uses Medicare prices when she’s advocating for someone who doesn’t have insurance.  It’s a way of making an offer of something they can pay, even though they can’t pay the amount on the bill.

°­²¹±ð±ô²â²Ô:Ìý I write them a letter and just let them know  I cannot afford to pay this amount. I’ll ask them to please consider accepting Medicaid prices from me.

Dan: Actually, Kaelyn means Medicare, government insurance primarily for folks age 65 and up. Medicaid is government insurance for low-income folks.

It pays even LESS than Medicare — — and a lot of providers don’t take Medicaid at all.

So Kaelyn asks them if they’ll consider taking Medicare prices, for someone who just doesn’t have insurance. She writes a letter, asking please.

Kaelyn:  And a lot of times they’ll say yes.

Dan: And usually, she’s not approaching big hospitals this way.

Kaelyn: Um, these are smaller, you know, this is the doctor’s offices, the radiologists, you know, the smaller businesses, and service providers, hospitals a little more difficult and every hospital’s different.

Um, but it’s worth trying. I mean, I, I’d still write a letter and send it to somebody who I hope would look at it , yeah, my, my experience, it’s, it would be difficult to get them to agree to negotiate lower prices,

 (Sandeep laughs)

Dan: Sandeep was not exactly sure what would happen next, or what he was gonna do.

Sandeep: time is running out for me, so I think I still have maybe about two weeks time before it goes to collections.

Dan: That was a few months ago. About a week after we talked, Sandeep heard from the hospital. They were offering him half off. He said he’d think about it.

And he did. A week later, he was just about ready to say yes. And then he got a letter from a collection agency, demanding the whole thing. 

Sandeep: I was really upset. I was thinking about, okay, let me get over this. Let settle this amount. , and then the next day I see this letter I was totally kind of pissed off uh, by looking at it,

He sent them back a very firmly worded letter, told them he was disputing the debt. Demanded a bunch of information from them, before he would consider paying, the details of their state license as a debt collector.

Sandeep: , provide the date of the license, the name on the license, the license number,

Dan: He sent it certified mail, called to confirm that they had it.

That was two months ago. And that’s it so far. He hasn’t heard from them, or from the hospital.

Sandeep: nothing. Zero. Zero letter. Zero communication.

Dan: He wondered: Where does that leave me?

I mean, I have to say, I wondered for a minute: Is he off the hook?

And I called another great pal of the show, who happens to be an expert.

April Kuenhoff: my name is April Koff and I’m a staff attorney at the National Consumer Law Center.

Dan: She said, basically, Sandeep’s not really in the clear.

For one thing, the law doesn’t say he’s entitled to all the information his letter demands, and that if he doesn’t get it, the debt’s not valid.

April Kuenhoff: and, you know, just because somebody stops contacting you doesn’t mean that the issue has gone away, unfortunately.

Dan: Saying you dispute a debt doesn’t mean you win.

Which, April says, doesn’t mean you shouldn’t do it! Especially when the other side might actually be in error.

April Kuenhoff: there’s so many reasons you could have. Questions about whether you owe the money is this the right amount? Should my insurance have covered more? You know, was I billed the wrong rate? Was I billed for services not received? and, if you have those questions, then absolutely file a dispute.

Dan: We’re on to a whole nother topic: Dealing with debt collectors. But I’ll note: NCLC has sample letters –editable templates — that you can use. We’ll link to them from wherever you’re listening to this.

Meanwhile, Sandeep’s in a kind of limbo, after all his fighting.

Sandeep: it didn’t turn out the way I wanted. Not to even a minimum, uh, degree,

Dan: He may go back to the hospital and see about settling for half. And if he could do it all over again, he probably wouldn’t do it the same way.

Sandeep: it’s a lot of time, effort. Um, it’s unnecessary stress, I should say.

Dan: Yeah.

So, I’m saying: Sandeep’s experiment — just duking it out when a bill struck him as ridiculous — did not pan out. But he’ll be …OK.

And he says did take a lesson from the experience — he calls it a silver lining: If or when he has to go to the ER again for something that’s not huge and life-threatening:

SANDEEP: I wouldn’t share my info, uh, insurance information. I would insist on the cash pricing.

DAN:  That seems worth considering, as long as you’re sure you COULD give them insurance later, like if they say, “Actually we need to check you into the hospital right now.” 

… because they need to treat you for something where the charges might blow way past what you could pay cash for– and way past your deductible.

And because Sandeep shared his story with us, we learned a few things.

We learned about the limits of just duking it out— of trying to wrestle with a giant.

We learned a little about certain tools — finding the Medicare price, sending a dispute letter to a debt collector— about where they are and aren’t likely to be useful.

And we pulled in tools and guides for when they ARE handy:

Kaelyn Globig’s cheat-sheet for finding out what Medicare pays for something, plus those sample letters from April’s organization.

And, we reconnected with Kaelyn, who was awesome.

On the way out, I’ll share a couple of bonus tips from her that could come in handy next time you’re calling somebody about a stupid medical bill.

The first one? We’ve heard it Ph abefore, but it’s worth repeating: If the person you’re talking to is a total pill, just end the call, and try getting someone else.

Kaelyn Globig: I’ve gotten the most unhelpful, rude. um, just stonewalled people. Um, and I just, I, I politely hang up and call back, uh, because there a good chance that there are more than one operator manning that, um, that department.

And sometimes it’s just the biggest difference is just getting the right person, um, that’s willing to help and listen.

And Kaelyn’s second bonus tip, I especially loved: Bring an advocate with you to the call. It can be anyone. Here’s how it came up.

Kaelyn Globig: somehow even just being, you know, I say I’m a patient advocate, um, and just saying that sometimes they like straighten up a little bit.

Dan: I wonder if it would be a good tactic to kind of try in general. You know, to be each other’s ad to kind of recruit somebody to play that role…

Kaelyn Globig: it’s me and my patient advocate’s on the phone right now, and

Dan: yeah. Right. Which, you know, my patient advocate could be like my spouse. Um, they don’t have to know that

Kaelyn Globig: yeah. , your friend, your neighbor,

Dan: Ya know what I mean? I’m definitely taking that one with me.

Meanwhile, I’m headed to Houston, to meet Dr. Ricardo Nuila. He says we talk about how, what if we had a medical system that didn’t revolve around money, around billing?

And he says, actually we have one. It’s just not evenly distributed. But that’s where he works.

He practices at Ben Taub Hospital — a publicly-funded safety net hospital in Houston. He says it’s not perfect, but it’s where he wants to work. And he’s just written a book about it, called The People’s Hospital. 

That’s next time, on An Arm and a Leg. 

Till then, take care of yourself.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” . You can also follow the show on Ìý²¹²Ô»åÌý. And if you’ve got stories to tell about the health care system, the producers .

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And subscribe to “An Arm and a Leg” on ,Ìý,Ìý,Ìý,Ìýor wherever you listen to podcasts.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).