In my experience the cost of a low deductible health plan is more expensive than a high deductible health plan + equivalent amount of a pre tax HSA.

I have never known a health care provider that you can’t negotiate a payment plan with. Even if your HSA isn’t funded, they could probably have a payment plan = HSA monthly contribution and then take it out of the HSA.

Yes I understand that a lot of people making $40K would be deftly afraid of doing that. But they would still statistically come out ahead