Republicans revive high-risk health plans, risking higher costs for patients

Republicans are again pushing a health insurance model that would make the sick pay more, move higher-cost patients into separate pools, and steer federal subsidies away from standard Obamacare coverage and into tax-advantaged accounts tied to high-deductible plans. The idea is meant to solve a real problem Republicans have long targeted: how to cover people with expensive medical needs without forcing insurers to spread those costs across everyone else.

Donald Trump’s “Great Health Care Plan,” announced in January 2026, would redirect Obamacare subsidies into those accounts, and the White House has said the government should deliver money directly to Americans rather than to insurance companies. But the framework left unresolved the biggest questions in the debate: what premiums would look like, how much patients would pay out of pocket, how much federal spending would rise or fall, and whether people with pre-existing conditions would still be explicitly protected.

That uncertainty matters because the historical record on high-risk pools is mixed at best. Before the Affordable Care Act, 35 states operated high-risk pools for more than 35 years. Traditional pools usually charged premiums at 150% to 200% of standard non-group market rates. Nearly all of them excluded coverage for pre-existing conditions for six to 12 months, and some capped enrollment, imposed lifetime or annual limits, or set deductibles so high that coverage remained unaffordable.

The numbers from the old system were stark. In 2011, the 35 state high-risk pools had net losses of more than $1.2 billion, while roughly 226,000 people were enrolled at a total cost of $2.6 billion. The American Academy of Actuaries said those pools could not make coverage affordable for many of the very people they were supposed to help.

The ACA largely erased the need for that structure by prohibiting medical underwriting and guaranteeing issue in the individual market, forcing healthy and sick people into one risk pool. That arrangement remains politically popular. KFF found in February 2024 that 67% of adults said guaranteed issue was very important and 65% said community rating was very important, including majorities of Democrats and independents and about half of Republicans.

The fight is landing as Washington argues over marketplace subsidies. KFF estimated that if enhanced premium tax credits expire, average premium payments for marketplace enrollees would more than double in 2026. The Congressional Budget Office has said permanently extending those credits would increase coverage by 3.8 million people by 2035, but add $350 billion to deficits from 2026 through 2035.

Republicans tried a similar approach in 2017, when the House Republican Study Committee folded high-risk pools into its ACA replacement vision and the American Health Care Act added an $8 billion late subsidy for potential pools. The question now is whether this is a workable fix for expensive patients or a cleaner political route back to the same costly, incomplete coverage the ACA was designed to replace.