2026年5月20日 / 美国东部时间凌晨5:00 / KFF健康新闻
当梅兰妮·米勒发现自己的健康保险保费今年即将上涨近两倍，达到每月914美元时，她停止了在《平价医疗法案》医保市场的购物。
这位59岁的退休教师最近从俄亥俄州搬到了密歇根州，现在每月为两套计划支付341美元：一套覆盖常规诊疗和急诊护理，另一套为住院治疗支付固定金额。这两套计划均未达到联邦规定的综合医保标准。
尽管她坚持练瑜伽、身体状况良好，米勒仍表示自己感到“脆弱”。如果需要住院，她的保险计划只会支付固定的2000美元，这仅相当于平均住院费用3万美元的一小部分。
“我不赌博，但现在我好像也在赌，”她说，“这就是赌博。”
美国国会去年年底决定不再延长医保市场的额外税收抵免，这提升了综合医保替代品的吸引力——类似米勒购买的这类计划保费更低，但不符合《平价医疗法案》的医保范围和消费者保护标准。与交易所销售的保险不同，这些可选计划——部分由大型保险公司销售，其余由小公司或非营利机构推出——可以拒绝理赔，消费者几乎没有或根本没有上诉的法定权利。这些计划无需覆盖“基本健康福利”，如预防性护理，还可以设置年度或终身赔付限额。
关于这些选择究竟是帮助还是损害患者，业内存在争议。消费者权益倡导者将其斥为“垃圾保险”，而支持者则认为，限制消费者只能选择昂贵的交易所医保计划，可能会推高未参保人数。包括堪萨斯州和佛罗里达州在内的一些州，以及联邦政府本身，已经放宽了对这类计划的监管或出台了参保激励措施；而加州、马萨诸塞州等其他州则试图阻止民众参保替代医保。不过，随着保费大幅超出家庭预算，这些监管护栏如今正受到严峻考验。
替代医保有多种形式，包括原本旨在填补临时医保空白的短期保单，这类计划通常不覆盖既往病症；还有固定赔付计划，无论医疗费用多高，都会按服务支付固定金额，主要用于补充医保。还有一种是人们凑钱互相支付医疗费用的安排，包括基于信仰的“医疗共享事工”，这类计划也为民众提供了比交易所医保更便宜的选择。由于它们在联邦或州法律中不被视为保险，因此即使是符合资格的医疗账单，也没有法律义务支付。
替代医保的参保数据大多保密，但多项指标显示市场正在发生变化。最近的估计显示，交易所医保的参保人数较2025年下降了约20%；去年一项KFF对交易所参保者的调查发现，5%的人转而购买了私人非交易所个人医保，包括不符合《平价医疗法案》标准的计划。加州医保交易所Covered California计划对前参保者进行调查，以了解他们转向了何种保险。
保险业内部人士也报告称，在补贴到期的背景下，替代医保计划正在加大营销力度。科罗拉多州保险经纪人萨曼莎·奥尔布里顿表示，在《平价医疗法案》开放注册期前，她看到固定赔付计划的营销活动比往年更多。其中一家医疗共享计划Zion HealthShare在2月份的会员人数超过7.5万，该公司在一份声明中称，这一数字较去年6月增长了50%。
这些替代医保计划的批评者表示，最大的问题出在人们将其作为主要医保使用，却直到最需要医保时才意识到保障不足。“人总会生病，”乔治敦大学健康保险改革中心助理研究教授艾米·基利利亚说道。
基利利亚和其他健康保险专家表示，这些计划的细则很难理解，参保者也无法像传统保险那样获得保障。2023年的一项同行评审研究发现，在阅读一份短期医保计划的福利摘要和该计划不符合《平价医疗法案》标准的披露后，仅有一半的参与者明白该计划不覆盖处方药。
24岁时，杰德·拉姆齐因雇主提供的保险保费过高而拒绝参保。后来她出现疲劳和不明原因的瘀伤，便通过Southern Guaranty保险公司购买了一份类似固定赔付计划的低价保险。
2021年，参保两周后，住在亚利桑那州的拉姆齐无法行走。急诊就医后她住院六天，账单金额高达143823美元。她被诊断为急性淋巴细胞白血病。她表示，保险公司将癌症认定为既往病症，拒绝赔付此次及其他医疗账单，且在驳回她的上诉后未提供其他救济途径。
这些账单被交由催收机构处理，她的信用评分一落千丈。拉姆齐说，她曾因这笔六位数债务带来的压力而前往急诊室治疗胸痛。她最终符合医疗补助计划的参保资格，信用评分也随之恢复，尽管她从未偿还这笔债务。她说催收机构仍在打电话，但她不予理会。
Southern Guaranty保险公司未回应置评请求。
替代医保的支持者认为，压制这些更实惠的选择只会增加未参保人数。
“人们应该能够按照最适合自己的方式，用自己的钱为医疗保健买单，”保守派智库帕拉贡健康研究所所长布莱恩·布莱斯说道。该研究所曾推动取消医保市场的额外税收抵免，称这些抵免会助长不当参保——不道德的经纪人会在参保者不知情的情况下为其办理参保。
佛罗里达州克利尔沃特市的罗伯特·戈弗雷很感谢有更多选择。当他的月度保费从879美元预计上涨至今年的约1250美元时，这位64岁的沙龙老板转而选择了每月320美元的Zion HealthShare会员计划。由于很少需要医疗护理，戈弗雷认为转投更便宜的计划是务实的选择。“谢天谢地我身体还健康，”他说。
特朗普政府已放宽了对部分替代医保计划的监管。去年，联邦机构不再执行拜登政府时期关于短期医保计划有效期和营销方式的规定，随后还向各州提供了少量竞争优势：若各州效仿放宽监管，将有机会参与瓜分500亿美元的联邦农村医疗资金。
美国医保与医疗补助服务中心（CMS）发言人克里斯托弗·克雷皮奇在一份声明中表示，该政府致力于确保“人们能够获得负担得起的医保选择，加强竞争，减少不必要的监管负担，同时维持适当的消费者保护”。
各州对替代医保的监管各不相同。在美国大部分地区，这类计划几乎不受限制。包括佛罗里达州、亚利桑那州和印第安纳州在内的许多州，在特朗普政府放宽监管后，也放松了对短期医保计划的限制，允许其累计续保最长达三年。
在堪萨斯州，议员们推翻了州长的否决，于3月通过了一项法案，为参保医疗共享事工的民众提供税收减免。民主党州长劳拉·凯利在否决通知中警告称，这类事工不受监管，“为各种欺诈和滥用行为打开了大门”。堪萨斯州众议院议长丹尼尔·霍金斯在一份新闻稿中反驳称，“众议院共和党人认为，家庭应该在医疗决策上拥有更多灵活性和控制权，而不是更少的选择和更高的成本”。
俄克拉荷马州今年早些时候也曾审议过类似法案，但未获通过。
并非所有州都对替代医保计划持欢迎态度。十多个州禁止销售短期医保政策，或制定了足够严格的规则，足以阻止保险公司销售此类产品。加州和马萨诸塞州是监管最严格的州之一，两地均禁止短期医保计划，并要求在特定情况下向考虑参保医疗共享事工的民众提供明确警告。两地还对放弃综合医保的成年人征税，同时补贴交易所医保保费以鼓励参保。
不过，倡导低收入人群获得优质医疗保健的全国健康法律项目主任赫克托·埃尔南德斯-德尔加多表示，保费上涨将对这些监管护栏构成考验。他担心，被低价计划吸引的消费者可能“日后会陷入更糟糕的境地”，背负沉重的医疗债务。
如今病情已缓解的拉姆齐敦促那些考虑购买低价保险的人仔细研究。“确保它能覆盖你需要保障的内容，”她说，“这可能好得不太真实。”
Cheaper, alternative health plans are having a moment, but critics urge caution
May 20, 2026 / 5:00 AM EDT / KFF Health News
When Melanie Miller saw that her health insurance premium payment was set to nearly triple to $914 a month this year, she stopped shopping on the Affordable Care Act marketplace.
The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.
Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the $30,000 price tag of an average hospital stay.
“I don’t gamble. But I may as well,” she said. “This is gambling.”
Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance — plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options — some sold by major insurers, others by small companies or nonprofits — can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.
There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.
Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even eligible medical bills.
Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment declined about 20% from 2025, and a KFF survey of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.
Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February — a 50% increase since last June, it said in a statement.
Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.
Killelea and other health insurance experts say that the fine print on these plans can be difficult to parse and that enrollees don’t have the protections of traditional insurance to fall back on. A 2023 peer-reviewed study found that after reading a summary of a sample short-term policy’s benefits and a disclosure that the plan was not ACA-compliant, only half of participants understood that prescription drugs were not covered.
When Jade Ramsey was 24, she declined insurance from her employer due to the cost of the premiums. After experiencing fatigue and unexplained bruising, she sought low-cost coverage from Southern Guaranty Insurance Company through a policy similar to a fixed-indemnity plan.
Two weeks after enrolling, Ramsey, who lives in Arizona, was unable to walk. An emergency room visit led to a six-day hospital stay and a $143,823 bill in 2021. She was diagnosed with acute lymphoblastic leukemia. Her insurer denied coverage for this and other bills, labeling the cancer a preexisting condition and offering no other recourse after rejecting her appeal, she said.
Those bills landed in collections, and her credit score nose-dived. Ramsey said she once visited the ER with chest pain she attributed to the stress of the six-figure debt. She eventually qualified for Medicaid, and her credit score has since recovered even though she never paid off the debt. She said collections agencies still call, but she ignores them.
Southern Guaranty Insurance Company did not respond to requests for comment.
Proponents of alternative insurance argue that stifling these more affordable options will just increase the ranks of those without any coverage.
“People should be able to spend their own money financing healthcare the way that works best for them,” said Brian Blase, president of Paragon Health Institute, an influential conservative think tank. Paragon pushed for ending the enhanced marketplace tax credits, arguing they fueled improper enrollment by heightening incentives for unscrupulous brokers to sign people up without their knowledge.
Robert Godfrey of Clearwater, Florida, appreciates having choices. When Godfrey’s monthly premium payment was slated to jump from $879 to around $1,250 this year, the 64-year-old hair salon owner switched to a $320-a-month membership with Zion HealthShare. Rarely needing medical care, Godfrey viewed the shift to a cheaper plan as a pragmatic choice. “Thank God I’m healthy,” he said.
The Trump administration has relaxed regulations on some alternative plans. Last year, federal agencies stopped enforcing Biden-era rules on how long short-term plans could last and how they could be marketed, then offered states a marginal advantage in the competition for a share of $50 billion in federal rural health funding if they followed suit.
In a statement, CMS spokesperson Christopher Krepich said the administration is focused on ensuring “access to affordable coverage options, strengthening competition, and reducing unnecessary regulatory burdens, while maintaining appropriate consumer protections.”
State oversight of alternative insurance is a patchwork. In much of the nation, these plans face few restrictions. Many states, including Florida, Arizona, and Indiana, have eased limits on short-term plans in the wake of the Trump administration’s moves, allowing them to be renewed for up to three years in total.
In Kansas, lawmakers overrode the governor’s veto to pass a bill in March providing a tax break for people who enroll in healthcare sharing ministries. In her veto, Democratic Gov. Laura Kelly warned that these ministries are unregulated, “which opens the door to all sorts of fraud and abuse.” Kansas House Speaker Daniel Hawkins countered in a news release that “House Republicans believe families should have more flexibility and more control over their healthcare decisions, not fewer options and higher costs.”
Oklahoma weighed a similar bill earlier this year, though it did not pass.
Not all states are friendly toward alternative plans. Over a dozen ban short-term policies or have rules restrictive enough to deter insurers from selling them. California and Massachusetts are among the states with the most stringent rules, banning short-term plans and requiring clear warnings to people considering a healthcare sharing ministry in certain circumstances. Both also tax adults who forgo comprehensive coverage, while subsidizing marketplace premiums to encourage enrollment.
Still, the higher premiums will test these guardrails, said Héctor Hernández-Delgado, a director at the National Health Law Program, which advocates for quality healthcare for low-income people. He worries that consumers lured by the plans’ low prices could “be worse off down the road,” saddled with burdensome medical debt.
Now in remission, Ramsey urges those considering cheaper insurance to do careful research. “Make sure it’s covering what you need to be covered,” she said. “It could be too good to be true.”