ACA Marketplace: High Costs & Health Savings Account Hurdles

The rising cost of health insurance is prompting many Americans to consider high-deductible health plans (HDHPs) paired with health savings accounts (HSAs). This shift, driven in part by expiring Affordable Care Act (ACA) subsidies, is leaving individuals navigating a new landscape of healthcare financing. NPR and KFF Health News are seeking to understand the challenges people face as they utilize these plans, launching a “Health Care Helpline” series to gather questions and experiences.

A key factor driving this trend is the expiration of enhanced premium tax credits at the end of 2025. These credits, implemented since 2021, significantly lowered the cost of ACA marketplace plans. Without their extension, premiums have increased substantially, pushing more people toward HDHPs, often categorized as bronze or catastrophic plans, which are HSA-eligible. As reported by KFF Health News, Robert Sory in Thompson’s Station, Tennessee, saw his monthly premium jump to $70 for a barebones plan in 2026, leading him to forgo coverage altogether. This situation is becoming increasingly common, with an estimated 4.8 million people expected to lose coverage this year.

Understanding High-Deductible Plans and HSAs

High-deductible health plans, as the name suggests, require individuals to pay a larger amount out-of-pocket before their insurance coverage kicks in. This deductible – the amount you pay for covered healthcare services before your insurance company starts to pay – is typically higher than traditional plans. In exchange for this higher deductible, HDHPs often have lower monthly premiums.

Health savings accounts (HSAs) are tax-advantaged savings accounts that can be used to pay for qualified medical expenses. To be eligible for an HSA, you must be enrolled in an HDHP. Contributions to an HSA are tax-deductible, the funds grow tax-free, and withdrawals for qualified medical expenses are also tax-free. This makes HSAs a powerful tool for managing healthcare costs, but also requires careful planning and saving.

Navigating the Hurdles: What Questions Are Emerging?

The transition to HDHPs and HSAs isn’t always smooth. Individuals are encountering various challenges, and NPR and KFF Health News are aiming to address them through their Health Care Helpline. Some common questions and concerns likely revolve around understanding what expenses qualify for HSA reimbursement, how to maximize HSA contributions, and how to navigate the complexities of cost-sharing within an HDHP.

For example, understanding what constitutes a “qualified medical expense” can be tricky. Whereas doctor’s visits and prescription drugs are generally covered, over-the-counter medications and certain types of care may not be. KFF provides detailed information on qualified medical expenses and HSA eligibility rules.

The Impact of the Government Shutdown and ACA Premiums

The current situation is further complicated by the recent federal government shutdown, which stemmed from a dispute over ACA health care premiums. As NPR reported in October 2025, the disagreement centered on extending enhanced tax credits for ACA plans. Democrats in the Senate blocked a short-term funding bill that didn’t include this extension, leading to the shutdown. This political battle underscores the ongoing debate over the affordability and accessibility of healthcare in the United States.

The expiration of these subsidies disproportionately affects those who don’t receive health insurance through their employer or public programs like Medicare or Medicaid. This group, which reached a record 24 million enrollees in 2025 – roughly 7% of the U.S. Population – includes many small business owners, farmers, and ranchers, according to Cynthia Cox, vice president and director of the Program on the ACA at KFF.

Who is Most Affected by Rising Costs?

The impact of rising premiums and the loss of enhanced subsidies isn’t felt equally across the population. Older adults, aged 50 to 64, are particularly vulnerable. They are more likely to be enrolled in ACA Marketplace plans and face higher premiums due to their age. This demographic may find it increasingly difficult to afford coverage, even with an HDHP and HSA.

Individuals with lower incomes are also significantly affected. While HSAs offer tax advantages, they require having disposable income to contribute. For those living paycheck to paycheck, even a modest increase in premiums or out-of-pocket costs can be a significant burden.

What to Do If You’re Struggling with Healthcare Costs

If you’re facing challenges with your HDHP or HSA, or are struggling to afford healthcare coverage, there are resources available. The NPR and KFF Health News Health Care Helpline offers a platform to share your story and questions, potentially leading to personalized assistance. You can submit your questions here.

it’s crucial to explore all available options, including state-based marketplaces, Medicaid eligibility, and community health centers. Consulting with a qualified insurance broker or financial advisor can also provide valuable guidance.

Looking Ahead: Potential Policy Changes

The future of ACA subsidies remains uncertain. While the House recently passed legislation to extend the expired subsidies, negotiations are ongoing in the Senate. The outcome of these negotiations will have a significant impact on the affordability of healthcare coverage for millions of Americans. Continued monitoring of legislative developments and engagement with policymakers are essential to ensure access to affordable healthcare.