A family paying $26,993 for health coverage in 2025 has a legal worst-case annual out-of-pocket exposure of $21,200. Worker premium contribution plus that cap: $28,050. That is more than the entire premium. The plan costs less than the maximum the plan lets them owe.
The $340 pediatric checkup that goes viral every few weeks is not fraud and it is not a bad plan. It is a high-deductible benefit design working exactly as priced. If the deductible is not met, the insurer pays zero. A hospital-affiliated visit with a facility fee lands right there.
The consumer protection ceiling on out-of-pocket costs is indexed to private insurance premium growth. Not wages. Not CPI. Premiums. So the cap protecting people from rising costs rises at the pace of rising costs. Wages grew 4% last year. The cap grew 15.2%.
Two-thirds of underinsured Americans are in employer plans. Standard W-2 benefits-eligible coverage. This is not a marketplace or gig economy problem. The Commonwealth Fund put the underinsured share at 23% before enhanced subsidies expired January 1, 2026.
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