Open enrollment season is here, and once again the pitch sounds reasonable enough: pay less every month, keep more of your paycheck, and take control of your own health care.
The plan is called a high deductible health plan, and it now covers more than half of American workers in the private sector, according to decades of employer survey data.
What the pitch tends to leave out is who absorbs the risk when you actually get sick.
A typical high deductible plan might carry a deductible of $1,600 for an individual and more than $3,200 for a family, with the deductible often doubling or worse before the plan pays much of anything beyond preventive care.
Premiums on these plans are usually lower than traditional copay plans, which is the entire selling point.
But the savings show up monthly, while the bills show up all at once.
That gap is where households get squeezed.
A 2024 survey from the health policy nonprofit KFF found that roughly four in ten adults with employer coverage carry medical or dental debt, and about half of those owe at least $2,000.
A separate analysis of federal data found that more than half of US adults have less cash on hand than the size of a typical single-person deductible.
In other words, the plan's structure assumes you have savings you may not have.
To pair a high deductible plan with a tax-advantaged health savings account, the deductible must clear an annual threshold set by the IRS.
For 2025, that minimum is $1,650 for self-only coverage and $3,300 for family coverage, with contribution limits of $4,300 and $8,550 respectively.
The accounts offer real tax benefits, and unused money rolls over year to year.
But an HSA only helps if you can afford to fund it, and many people can't, especially in their first year on the plan.
Meanwhile, the entities that benefit most are rarely the ones in the exam room.
Insurers collect premiums whether or not you use care, and lower-premium plans tend to attract healthier enrollees, which improves their claims math.
Employers save on premium contributions, which is why the plans spread so fast after the Affordable Care Act set new rules for them.
And a growing slice of the health care industry now sells "cost transparency" tools and payment plans that exist mainly because patients suddenly owe thousands before coverage kicks in.
Before you enroll, add up the full year: premiums plus deductible plus the out-of-pocket maximum, which can run above $9,000 for family coverage in 2025.
Then ask what happens if someone in your household needs a specialist, an ER visit, or a prescription that isn't generic.
If the answer depends on money you don't have, the cheaper plan isn't actually cheaper.
The people pushing these plans aren't lying about the premiums.
They're just describing a best-case year.
Final Thoughts
The real test of any coverage is what it does on your worst month, not your healthiest one.