When compared with the medical care patients get in other high-income nations, the U.S. health system often ranks last in access, affordability and outcomes, as we explained here. One reason for that low rank among those 10 nations is that health care is unaffordable for many Americans, according to a 2024 Commonwealth Fund report.
Unlike consumers in those other countries, many Americans are required to have what’s called “skin in the game,” meaning they need to pay their health insurance deductible — often several thousands of dollars — before seeing a health care provider for many services. In practice, that means many consumers often get a lower insurance premium in exchange for a high-deductible health plan (HDHP). These plans usually require enrollees to pay all of the annual deductible, which is usually multiple thousands of dollars, before insurance begins to cover most services, as Healthinsurance.org explained in Facts About High-Deductible Health Plans.
How high-deductible plans make care unaffordable
For journalists, the widespread requirement that Americans have “skin in the game,” meaning they must pay before they can get treated, is a big story nationwide for at least five reasons.
- Patients may delay treatment, cut back on essentials such as food, heat or rent, or take on medical debt — increasing stress and worsening health, as we reported here: Covering how high deductibles lead to poor health.
- Affordability is the most crucial issue Americans face this year, as Ruth Igielnik and Kate Zernike reported for The New York Times last month.
- If health care is already unaffordable, why did the federal Department of Health and Human Services (HHS) propose new rules**?** Consumers buying catastrophic plans for coverage in 2027 under the Affordable Care Act (ACA) would need to pay as much as $15,600. Families could pay up to $31,200 before coverage begins. Both appear to be unprecedented, as Katie Keith, J.D., MPH, explained in Health Affairs Forefront.
- How many individuals have $15,600 — or families $31,200 — set aside for health care when other consumer prices are rising sharply, as Vidya Marni reported for PBS News?
- The out-of-pocket limits for catastrophic plans that HHS proposed in February are much higher than what most HDHPs require today. Some employers offer health plans with deductibles of $7,000 or more for individuals and families, according to the KFF 2025 Employer Health Benefits Survey, still far below the proposed thresholds.
HHS proposes higher deductibles for ACA plans
If approved, HHS’ Notice of Benefit and Payment Parameters rule for 2027, fact sheet and press release explain that catastrophic and bronze health plans would be treated as HDHPs, making them eligible for health savings account contributions, which offer some tax advantages, Keith added.
The proposal would also allow more Americans over age 30 to qualify for catastrophic coverage based on income and allow such plans to operate for one year or as many as 10 consecutive years Keith noted.
The downside of the proposal is that requiring such a steep rise in out-of-pocket costs could cause as many as 2 million people to drop their ACA insurance, explained Julie Appleby for KFF Health News.
Writing in The New York Times, Reed Abelson quoted Keith, who said of the HHS proposal: “It is not going to work as insurance as most people understand it, and what most people are looking for.”
When writing about HDHPs, it’s important to note that many of these plans mean consumers could become underinsured, according to the Commonwealth Fund’s definition. In 2024, the fund reported that almost 25% of U.S. adults have health coverage all year but are underinsured — often facing costs high enough to skip needed care or take on debt.
Another reason high-deductible plans remain in place is that they save money for health insurers, which, along with other financial service companies, have contributed millions to Democrats and Republicans in 2023 and 2024, according to this report from OpenSecrets.org. Of course, health insurers already make enough profit to rank among the top U.S. companies based on annual revenue in 2024, as Molly Gamble reported for Becker’s Hospital Review.
The U.S. health system as an outlier
It’s important for journalists to explain that the United States is one of the few high-income nations that routinely requires significant deductibles, particularly for those who cannot afford to pay for 100% coverage of all health costs each year. The reason? American economists have long promoted the idea that consumers need to have skin in the game.
“That line of thinking has been dogma among U.S. economists, despite decades of evidence to the contrary in the form of successful single-payer systems in Europe and Canada with little or no such ‘cost-sharing,’ and helps explain why (often hefty) copayments and deductibles have been central to U.S. health insurance,” as Adam Gaffney, M.D. and two other Harvard Medical School professors wrote in this article, “The Only Way to Fix US Health Care,” in The New York Review.
For reporters, this context can guide deeper reporting on who benefits from high-deductible plans, who is left behind and how policy changes could reshape affordability.
Resources
- A One-Pager on What’s Wrong with U.S. Health Care, KFF, Drew Altman, Ph.D., April 24, 2026 .
- Listen: Cheap Health Insurance Isn’t Always Cheap, NPR’s Life Kit podcast, Jackie Fortiér and Marielle Segarra, April 21, 2026.
- Curing U.S. Health Care, Part 1, Paul Krugman, Substack, April 19, 2026.
- Affordability Is the Issue Now, But Look for the Uninsured to Make a Comeback, KFF, Drew Altman, Ph.D., April 10, 2026.
- New A.C.A. Plans Could Increase Family Deductibles to $31,000, Reed Abelson, The New York Times, Feb. 26, 2026, updated Feb. 27.
- Trump Team’s Planned ACA Rule Offers Its Answer to Rising Premium Costs: Catastrophic Coverage, Feb. 13, Julie Appleby, KFF Health News.
- HHS Proposes Sweeping Changes For 2027 Marketplace Plans (Part 1), Katie Keith, Health Affairs Forefront, Feb. 11, 2026.
- Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program, The Federal Register, Feb. 11, 2026.
- CMS Proposes Regulations to Lower Health Care Costs, Expand Consumer Choice, and Protect Taxpayers, HHS press release, Feb. 9, 2026.
- The Only Way to Fix US Health Care, Adam Gaffney, David U. Himmelstein, and Steffie Woolhandler, The New York Review, Nov. 7, 2024.
