This month, as Americans who rely on Affordable Care Act plans opened their first bills of 2026 and experienced sticker shock, President Donald Trump began pitching them on an alternative: his “Great Healthcare Plan,” which would shift government support away from subsidizing insurance coverage and toward putting money directly into accounts that consumers can use to pay for care.
The details, of course, are scant. But the concept of shifting government funds away from an approach that encourages comprehensive coverage to one that might leave many Americans behind is troubling.
Trump has long criticized the Biden administration-era subsidies that allowed millions of Americans to purchase better coverage at more affordable prices, arguing they lined the insurers’ pockets while consumers’ costs rose. Although lawmakers are still exploring potential solutions to extend the subsidies, the president has threatened to veto any deal.
So far, his plan to replace subsidies with Health Savings Accounts (HSAs) — tax-sheltered funds that can be invested and rolled over each year — amounts to little more than a list of bullet points. Among the unknowns are how much money people would receive each year, who would qualify and whether it would expand the utility of HSAs, including whether they could pay for care outside of ACA guidelines (such as plans that can deny coverage based on preexisting conditions or fail to cover certain essential benefits).
Current rules tightly restrict who is eligible for an HSA and how the money can be spent. The only ACA customers who could benefit from the government’s HSA contribution would be those enrolled in the lowest-tier plans, which feature low monthly premiums but high deductibles.
Diverting money to an HSA “is a reasonable approach for 80% of the population, and a terrible approach for 20% of the population,” says Gerard Anderson, a professor of health policy at Johns Hopkins University. Most of us don’t end up in the hospital or needing an expensive drug each year, meaning a savings account would likely cover our health care bills.
But that smaller group — the people who get in a car crash or are diagnosed with cancer — could be much worse off, Anderson says.
In a survey of health policy experts published last month in Health Affairs, 70% said that a plan that diverted the value of the subsidies into an HSA “would measurably worsen the affordability of health care for Marketplace enrollees.” Just 10% believed a shift to HSAs would improve affordability.
The rest of us could be worse off, too. Someone who is underinsured or uninsured still gets emergency care, but the cost is ultimately borne by insured people.
The vast majority of people with HSAs get them through their employer, and typically are wealthier, white or Asian and in very good health, according to a recent analysis by the Government Accountability Office.
Meanwhile, the tax benefits of an HSA have primarily accrued to higher-income Americans, who can afford to put more money into them.
In other words, people with the most disposable income are by far the most likely to put enough money into an HSA to ensure that a health catastrophe doesn’t also lead to a financial one.
“The way HSAs are being marketed and discussed, it sounds a lot like free money to people — it’s not,” says Nicole Rapfogel, a policy analyst at the Center for Budget and Policy Priorities. A 2024 report from the Consumer Financial Protection Bureau found that many funds offered such low interest rates that monthly fees exceeded the gains.
The scenario would change if Trump’s plan involved overhauling the way HSA funds can be used, allowing Americans to use the payout to buy health insurance. Yet too many people might still gravitate toward cheaper, riskier plans — and that could end badly for everyone.