By Megan R. Wilson

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• The HSA double down: GOP lawmakers are continuing to push a swap of the enhanced ACA tax credits for pre-funded health savings accounts, a gamble that could reshape coverage for nearly 20 million people.
• Rebate checks as backup plan: The Washington Post reports on alternatives to the enhanced tax credits, including sending some Obamacare enrollees rebate checks funded by insurer fees — an idea shelved for now but still in the mix as costs climb.
• Short-term plans could surge: With premiums rising, more Americans may turn to cheaper short-term policies, but the skimpy benefits risk leaving patients exposed to massive bills.

Good afternoon! Welcome to the Health Brief newsletter. Hope you had an excellent weekend. Conversations around the insurance industry — and cost of coverage — will be dominating most health care conversations in the coming weeks. Let’s get into the continued push to avert a health insurance “death spiral.” (More on that below.)

Send the best health policy tips and scoops you’ve got to megan.wilson@washpost.com or message me securely on Signal at megan.434.

This newsletter is published by WP Intelligence, The Washington Post’s subscription service for professionals that provides business, policy and thought leaders with actionable insights. WP Intelligence operates independently from the Washington Post newsroom. Learn more about WP Intelligence.

Sen. Bill Cassidy (R-Louisiana), who leads the Senate's health panel, is urging Congress to unify behind a plan to fund health savings accounts for people on Obamacare. (Ricky Carioti/The Washington Post)

	The Lead Brief

Republicans are plowing ahead with trying to push a proposal to give people money in tax-advantaged accounts to spend on doctors’ visits and prescriptions. It has gained the support of many Republicans, including President Donald Trump, in recent weeks.

Last week, Trump touted the idea in the Oval Office: “They’re gonna go out and buy their own health care, and we’re gonna forget this Obamacare madness,” he said.

→ The race is on to find a solution to help more than 20 million Americans whose insurance premiums are set to spike next year without an extension of the enhanced Affordable Care Act premium tax credits that expire at year’s end.

Senate Majority Leader John Thune (R-South Dakota) promised Democrats a vote by mid-December on legislation to extend the tax credits. While a bipartisan contingent is working on a compromise, hurdles — including opposition from Trump — could imperil the effort.

THE HSA PLAY

Republicans have latched on to the idea of providing people with the subsidies that would have offset their premiums in health savings accounts, or HSAs, that could allow them to pay for care out of pocket.

A key issue with those accounts, however, is that the money can’t be used on a person’s monthly insurance premium — so if that’s increasing more than they’re able to afford, analysts say that people may opt out of getting insurance entirely. Health economists warn this could create a “death spiral,” wherein healthier people — who are cheaper to cover — drop coverage, raising premiums for those who remain.

Sen. Bill Cassidy (R-Louisiana), who leads the Senate’s health panel, told me during a roundtable with other reporters on Monday that his newly favored proposal surrounding health savings accounts, or HSAs, would mitigate the departure of people from the marketplaces by lowering overall costs.

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Here’s how he tells it: There are existing ACA tax credits already in the law to help lower-income Americans buy insurance, which are based on the cost of mid-tier silver plans that are the most popular. If people take those subsidies and purchase a high-deductible bronze plan — which Cassidy argues would be much less expensive — they would be able to pair that with a HSA that’s funded with an amount similar to the enhanced premium tax credit.

→ The enhanced premium tax credits, originally passed during the pandemic, bumped up the subsidies for everyone and expanded them to people with incomes above 400 percent of the poverty level — which is about $62,600 for a single person and $106,600 for a family of three.

“Most people will never go beyond $1,000 worth of expenditures per year. So you would cover that with the [HSA] balance,” he said. “That's something that should appeal for everybody, whether a Democrat or Republican.”

→ In the Republicans’ sprawling tax and spending package that passed this summer, GOP lawmakers expanded the availability of tax-free HSAs to people buying bronze or catastrophic plans. Therefore, he told reporters, it would be easy to implement for 2026.

Cassidy had previously floated using flexible spending accounts, or FSAs, which have different rules around how they can be used.

→ But HSAs aren’t helpful to people who can’t also afford to contribute more of their own money into them or should they require more expensive care — due to an accident or chronic condition.

The average deductible — the amount a person needs to pay before coverage kicks in — for bronze plans next year is nearly $7,500, according to KFF. Meanwhile, the average enhanced tax credit amount in 2024 was $705 per year, according to government data. Although a pre-funded account could shield people from their initial care costs — and lower-income people also benefit from the ACA’s existing subsidies, sometimes paying very little each month in premiums — it wouldn’t be helpful beyond that.

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The ACA tax credit amounts depend on a number of factors, including how much a person makes, their age and where they’re located.

Although he hasn’t yet introduced legislation, Cassidy said he’s been reaching out to Democrats to get them on board — a crucial step, as the proposal would need 60 votes in the Senate.

“The president's not going to sign a straightforward extension of the premium tax credits. So if you actually want something which can pass — and get a vote on the House floor — then, what the president is proposing is actually a better way,” Cassidy said.

What to watch: Cassidy has not yet announced any hearings in the Senate Health, Education, Labor, and Pensions Committee; but, expect the debate to play out on Wednesday in a Senate Finance Committee hearing set to tackle the issue. There’s also an effort playing out in the House to move the HSA proposal forward.

	From our notebook

The Washington Post’s Dan Diamond and Paige Winfield Cunningham have a story that’s a great primer laying out the various options policymakers are mulling for the more than 20 million Americans who buy insurance through the Affordable Care Act marketplaces.

It goes into more depth on the various proposals around extending the enhanced tax credits and expanding health savings accounts — but their story also has some new revelations and ideas:

• The White House at one point had asked Peter Nelson, who oversees the Affordable Care Act marketplaces at the Centers for Medicare and Medicaid Services, to formulate a way to send rebate checks to people with Obamacare coverage to help cover the costs, two CMS staffers who spoke on the condition of anonymity to discuss internal operations told my colleagues.

The idea has been tabled for now, Dan and Paige report, but is still on the list of options to revive amid the overall health care debate on coverage costs. The checks would be funded by fees that are paid by insurers that sell their health plans on Healthcare.gov, the federal marketplace.

• On Capitol Hill, Sen. Ron Johnson (R-Wisconsin) is working on a legislative proposal focused on issuing rebate checks to people.

→ Another key point to keep in mind: The issue is one that polls well with voters, including among some Republicans. Allies of the president, including his pollster Tony Fabrizio, have also warned Trump about the political backlash of ending the subsidies, saying it could hit Republicans during next year’s midterm elections.

	Market Moves

While millions of Americans are expected to drop insurance coverage amid rising premium costs, others could move into short-term insurance plans being promoted by the Trump administration as a cheaper alternative to the offerings available on the Obamacare marketplaces — but they come with a catch.

In his latest piece, Peter Whoriskey in the Washington Post newsroom explored these plans, which offer such spotty coverage that five states have banned them.

Why this matters: People, including the individuals Peter talked to, may mistake them for traditional insurance — but they often don’t cover preexisting conditions, outpatient prescription drugs, or services including mental health and maternity care, leaving patients with high out-of-pocket costs.

Some insurance agents argue that the plans — which were originally designed to last a few months — could be useful to people who are healthy, need it temporarily between jobs or before they reach 65 and can enroll in Medicare yet have incomes too high to qualify for ACA subsidies. In 2018, the Trump administration ruled that a short-term policy could last as long as three years.

	Document Drop

The Advisory Committee on Immunization Practices posted the schedule for its two-day meeting next month.

→ I reported in Health Brief last week that the ACIP, the federal panel of vaccine advisers, will be kicking off its next meeting on Dec. 4 to talk about the childhood and adolescent immunization schedule, ingredients in the shots, and potential new recommendations on hepatitis B vaccines.

	What We’re Reading

“Federal cuts upended clinical trials. A new study reveals the toll,” Allyson Chiu reports for The Washington Post.

“First U.S. case of human bird flu in 9 months confirmed in Washington state,” reports Lena H. Sun at The Washington Post.

“What Would Happen To Americans In A Bird Flu Pandemic?” Stephanie Psaki and Beth Cameron write in Health Affairs.

“The surprising new use for GLP-1s: Alcohol and drug addiction,” The Washington Post’s David Ovalle writes.

“RFK Jr. Discussed Curbing FDA Head’s Role After Complaints About Management Style,” Liz Essley Whyte writes at the Wall Street Journal.

“Congress’ Obamacare subsidy vote could set off state scramble,” according to Robert King at Politico.

“Health Insurance Claim Denied? See What Insurers Said Behind the Scenes,” reports ProPublica’s Maya Miller, with reporting from ProPublica’s David Armstrong and the Capitol Forum’s Patrick Rucker.

“The trend of unproven peptides is spreading through influencers and RFK Jr. allies,” Matthew Perrone reports at the Associated Press.

“NIH abruptly places outspoken critic of Trump administration on leave,” according to Anil Oza at Stat.