Maryland is the first state to tap into an old fund connected to the Affordable Care Act to help solve a new problem: helping pay the expenses of patients who travel to Maryland for an abortion.

With abortion now restricted or illegal in 22 states, jurisdictions like Maryland have become a destination for patients from as close as neighboring West Virginia to as far as Texas.

With a staff of six, the Baltimore Abortion Fund helps patients who need to travel pay for bus or plane tickets, lodging in Maryland, and sometimes meals. The fund spends about a million dollars a year on that support. Calls to its confidential helpline have increased by 50%-60% every year since Roe v. Wade was overturned, said Lynn McCann-Yeh, the fund’s co-director.

The fund disburses aid as people call in. Often, the weekly allotment is depleted after just one or two days.

“Sometimes that means that our helpline is closing within 24 to 48 hours at the start of the week, because there’s just too much demand for the amount of resources that we have,” McCann-Yeh said. “There are many, many more dozens of callers each week that are just getting a voicemail message saying that we’ve run out of support.”

To help, the Maryland Legislature turned to a pot of money established under the 2010 Affordable Care Act. Under the law, states could decide to require insurance plans sold on the ACA “marketplaces” to cover abortion. The plans were required to charge a minimum fee of $1 a month on every plan bought through the marketplace.

That money was then put into an account that would help pay when insured patients received abortion care.

The state accounts were necessary because of the federal Hyde Amendment, which restricts the U.S. government from paying for abortions, except in cases involving rape, incest, or severe medical risk to the patient.

Because the federal government partially subsidizes insurance plans sold through the ACA marketplaces, commercial insurers had to use their money to pay the monthly fee for each policyholder.

“Insurers have quietly complied with the ACA special rules resulting in these segregated accounts that have millions of dollars in them intended for abortion coverage,” said Cat Duffy, a policy analyst for the National Health Law Program.

Over time, the accumulated fees in such accounts have outstripped the withdrawals for abortion care for women on those insurance plans. Maryland’s account has grown to $25 million and takes in about $3 million each year.

Maryland passed a new law that allows the state health department to tap those funds and allocate up to $2.5 million a year in grants to organizations operating in Maryland that offer abortion assistance. Those groups can use the money for traveling patients, low-income patients in Maryland, or people without insurance.

“We know that we will be able to use those funds wisely and to make sure that we’re not turning away any patient due to their inability to pay,” said Ramsie Monk, the director of development at the Women’s Health Center of Maryland on the border with West Virginia.

Without assistance from abortion funds, many of the patients would not be able to pay for their care, says Diane Horvath, an OB-GYN at Partners in Abortion Care, in College Park, Maryland. Unlike some other health centers, which offer abortion only up to 16 weeks of pregnancy, Partners in Abortion Care can provide an abortion later in pregnancy. Those procedures are more complicated and more expensive.

More than 90% of the patients at Partners in Abortion Care receive financial assistance through various abortion funds.

“I would say a typical patient that we see probably every week is somebody who’s already got at least one child, they’re working a job that doesn’t offer substantial leave for medical care, it may not offer health insurance, or the insurance it offers doesn’t cover abortion, particularly when they’re coming from out of state and they’re struggling and living paycheck to paycheck,” Horvath said.

The new law passed this spring and took effect July 1. The first tranche of money is set to be transferred from the ACA fund to the state health department by the fall.

Since the Supreme Court overturned Roe in 2022, states where abortion remains legal, like Maryland, have seen an increase in abortion procedures, including for patients who can’t get a legal abortion in their home state. Many need financial assistance for the procedure or to cover travel costs from other states, lodging, and related expenses while they recover.

That financial aid is often provided by local and regional abortion funds, such as the nonprofit Baltimore Abortion Fund.

As more patients travel to Maryland, and some abortion funds exhaust their resources, clinics that provide abortions in Maryland are feeling financial pressure to serve traveling patients, as well as uninsured and low-income Marylanders seeking care.

Clinicians in Maryland performed about 39,000 abortions last year, a 28% increase from 2020, according to the Guttmacher Institute, a nonprofit focused on sexual health research.

Maryland’s move to tap the ACA fund represents an innovative solution for states that have opened their doors to out-of-state patients but are grappling with the logistics and costs of the increased clinical demand in a post-Roe landscape.

“This bill is super important for Maryland; we’re making sure our clinics stay open,” said Maryland state Del. Lesley Lopez, a Democrat who sponsored the bill. “Maryland has been a leader on a lot of reproductive bills for the past 30 years, and so in that way, this bill fits into that legacy. It’s also nationally significant, because there’s 25 or 26 other states that can take this model and run with it. We’re looking for California, Illinois, New York, those bigger states that are sitting on potentially hundreds of millions of dollars to take what we’ve done here in Maryland and implement it there.”

Anti-abortion groups in Maryland opposed the bill, saying that the new law will force some insurance consumers to pay for procedures they may disagree with.

“This bill uses insurance premiums from insured women to abort the children of uninsured women,” Laura Bogley, executive director of Maryland Right to Life, told the state legislature on March 6.

“Many of those uninsured women are non-Maryland residents who are trafficked into the state for late-term abortions that are restricted by other states.”

The bill’s supporters deny that traveling patients are being trafficked when they are traveling of their own volition in search of health care.

This article is from a partnership with WYPR and NPR.

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In southern Colorado’s San Luis Valley, clouds billow above the towering mountains of the Sangre de Cristo range. A chorus of blackbirds whistle as they flit among the reeds of a wildlife refuge. Big, circular fields of crops, interspersed with native shrubs, give it a feel of bucolic quiet.

But amid the stark beauty in one of the state’s most productive agricultural regions, there was a sense of unease among the community’s leaders as Congress debated a budget bill that could radically reshape Medicaid, the government health program for low-income people.

“I’m trying to be worried and optimistic,” said Konnie Martin, CEO of San Luis Valley Health in Alamosa, Colorado, the hub for health care services for 50,000 people in six rural counties.

Martin said Medicaid is vital to rural health care.

“I think in Colorado right now, nearly 70% of rural hospitals are operating in a negative margin,” in the red, Martin said.

The health system’s annual budget is $140 million, and Medicaid revenue makes up nearly a third of that, according to Shane Mortensen, chief financial officer for SLV Health.

The operating margin is razor-thin, so federal cuts to Medicaid could force difficult cuts at SLV. “It will be devastating to us,” Mortensen said.

The region is one of the state’s poorest. In Alamosa County, 2 in 5 residents are enrolled in Health First Colorado, the state’s Medicaid program.

It’s a lifeline, especially for people who wouldn’t otherwise have easy access to health care. That includes low-income seniors who need supplemental coverage in addition to Medicare, and people of all ages with disabilities.

Envisioning a future with deep Medicaid cutbacks leaves many patients on edge.

“I looked into our insurance and, oh my goodness, it’s just going to take half my check to pay insurance,” said Julianna Mascarenas, a mother of six. She said Medicaid has helped her cover her family for years. Mascarenas works as a counselor treating people with substance use disorders. Her ex-husband farms — potatoes and cattle — for employers that don’t offer health insurance.

Across the state, Medicaid covers 1 in 5 Coloradans, more than a million people.

That includes children in foster care.

“We’ve had 13 kids in and out of our home, six of which have been born here at this hospital with drugs in their system,” foster parent Chance Padilla said, referring to SLV’s flagship hospital in Alamosa.

“Medicaid has played a huge part in just being able to give them the normal life that they deserve,” he said. “These kids require a lot of medical intervention.”

Chris Padilla, Chance’s husband, said: “At one point, we had a preteen that needed to be seen three times a week by a mental health professional. There’s no way that we could have done that without Medicaid.”

Staff and administrators at SLV Health wonder whether federal cuts will make it hard for the system to keep its cancer center running.

“It could be pretty dramatically affected,” said Carmelo Hernandez, SLV’s chief medical officer.

The hospital in Alamosa has its own labor and delivery unit, the type of service that other rural hospitals across the U.S. have struggled to keep open. About 85% of the hospital’s labor and delivery patients are covered by Medicaid, Hernandez said.

“If we don’t have obstetric services here, then where are they going to go?” said Hernandez, whose specialty is obstetrics and gynecology. “They’re going to travel an hour and 20 minutes north to Salida to get health care. Or they can travel to Pueblo, another two-hour drive over a mountain pass.”

Tiffany Martinez, 34, was recently forced to think about that possibility after giving birth to her fourth child.

Her pregnancy was high-risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She’s enrolled in Medicaid.

“Everything down here is low-pay,” Martinez said. “It’s not like we have money to just be able to pay for the doctor. It’s not like we have money to travel often to go to the doctor. So it’s definitely beneficial.”

Providing Health Care — And Jobs

With 750 workers, the health system is the valley’s largest employer. Clint Sowards, a primary care physician, said having less Medicaid funds will make it harder to attract the next generation of doctors, nurses, and other health care workers.

Certain medical specialties might no longer be available, Sowards said. “People will have to leave. They will have to leave the San Luis Valley.”

Kristina Steinberg is a family medicine physician with Valley-Wide Health Systems, a network of small clinics serving thousands in the region. She said Medicaid covers most nursing home residents in the area. “If seniors lost access to Medicaid for long-term care, we would lose some nursing homes,” she said. “They would consolidate.”

Audrey Reich Loy, a licensed social worker and SLV Health’s director of programs, said the system utilizes Medicaid “as sort of the backbone of our infrastructure.”

“It doesn’t just support those that are recipients of Medicaid,” she said. “But as a result of what it brings to our community, it allows us to ensure that we have sort of a safety net of services that we can then expand upon and provide for the entire community.”

Seeking More Efficiency

Republicans in Congress who pushed for the big spending and tax law, which estimates suggest will result in large cuts to Medicaid, say they want to save money and make the government more efficient.

Many in the Alamosa County region voted for Donald Trump. “He’s potentially affecting his voter base pretty dramatically,” Hernandez said.

He said Medicaid cuts could give President Trump’s supporters second thoughts, but he noted that politics is a sensitive topic that he mostly doesn’t discuss with patients.

Sowards said he understands that some people believe the Medicaid system is ailing and costly. But he said he has grave doubts about the proposed cure.

“Losing Medicaid would have drastic repercussions that we can’t foresee,” Sowards said.

Cuts Would Create Ripple Effect

SLV Health’s regional economic impact is more than $100 million a year, with Medicaid accounting for a major part of that, Martin said.

Any Medicaid cuts would hit the health system hard, but they would also affect small businesses and their employees. The region is feeling economic stress from other changes, like recent cuts the Trump administration made to the federal workforce.

The San Luis Valley is home to the Monte Vista National Wildlife Refuge, Great Sand Dunes National Park, and other federally managed lands.

Joe Martinez, president of San Luis Valley Federal Bank, said that recently laid-off federal workers are already coming to banks saying: “‘Can I find a way to get my next two months’ mortgage payments forgiven? Or can we do an extension?’ Or: ‘I lost my job. What can we do to make sure that I don’t lose my vehicle?’”

Ty Coleman, Alamosa’s mayor, traveled to Washington, D.C., in April to talk to Colorado’s congressional delegation. He said his message about Medicaid cuts was straightforward: “It can have a devastating economic impact.” Coleman put together a long list of possible troubles: More chronic disease and higher mortality rates. Longer wait times for care. Medical debt and financial strain on families.

“It’s not just our rural community but the communities, rural communities, across Colorado as well, and the United States,” Coleman said. “And I don’t think people are getting it.”

This article is from a partnership that includes CPR News, NPR and KFF Health News.

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Dan Weissmann

When a New York couple purchased a health insurance plan from a telemarketer, they thought it covered everything they wanted: doctor visits, tests, and medicine. But then came the unexpected bills for thousands of dollars, forcing them to skip crucial medical care. 

In their series “Health Care Hustlers,” Bloomberg reporters Zachary Mider and Zeke Faux revealed how this couple and thousands of other people signed up for health plans by unknowingly agreeing to work fake “jobs.”  

Mider and Faux join “An Arm and a Leg” host Dan Weissmann to peel back the surprising layers of this story, from a TV-sitcom-writer-turned-investor who masterminded the idea to the legal gray area that allows these plans to proliferate.

Dan Weissmann

@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: A Wild Health Insurance Hustle

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there—

This story’s outline may sound familiar, but what’s underneath — what we unravel here: It’s a new kind of thing. And it’s weird. 

And it could become huge.

So: A couple from New York, Sarah and Joe Strohmenger started new businesses, so they needed to buy their own health insurance for the first time..

And Sarah says the New York state marketplace, with Obamacare plans, seemed a little risky: If they got a subsidy, and then their new businesses did well, they might have to pay that subsidy back.

Sarah Strohmenger: As new business owners, we had not a clue of how much we were gonna make in the year.

So we were nervous about. How much we were gonna have to back pay. 

Dan: Looking elsewhere seemed like a cautious thing to do. Google led them to a site that offered quotes for insurance policies — just enter your phone number. They started getting calls from telemarketers, a lot of them, and eventually they picked a plan one of them offered. 

Sarah and Joe thought they were being reasonably careful. After all, Insurance is a regulated business. 

Sarah Strohmenger: We’re thinking it’s monitored. We had no clue that this was kind of like a free for all.

Dan: So as you’ve probably already guessed: Pretty quickly, and very painfully, Sarah and Joe figured out that they’d been hustled. 

But it took a pair of reporters from Bloomberg News to uncover the nature of that hustle. 

Zach Mider: There’s this kind of new breed of people offering health plans to the public that are not, um, not insurance companies at all, 

Dan: That’s one of those Bloomberg reporters, Zach Mider. As Zach and his reporting partner Zeke Faux revealed, this telemarketer had — on paper — made Joe an employee of a company he’d never heard of until those reporters told him about it.

And according to the legal theory underneath all of this, making Joe a certain kind of employee allowed the salesman to sell Joe an insurance plan so skimpy that— as Zach and Zeke’s story says — it would “normally be illegal.”

Zach Mider says these kinds of plans currently operate in a legal grey area, with nobody regulating it — not states, not the feds. 

Zach Mider: So it really is just kind of this weird legal vacuum where, you know, market actors are free to kind of jump in and start trying to do this.

Dan: Which, Zach says, they seem to be doing, more and more. 

Zach Mider: It looks like the numbers are shooting up

Dan: In their Bloomberg story, Zach and Zeke cite hundreds of complaints to the FTC from people who were sold these kinds of health plans.

They also write about meeting the guy who seems to have invented these plans — a former TV sitcom writer who they say actually believes he’s solving an important problem.

Their reporting — in a series called “Health Care Hustlers” — shows something else too: 

How each hustle gets created by a chain of legally-distinct operators — some of them truly operating completely independently of each other — and how, by being just one link in a chain, each operator can say:

“I was just doing a totally legit thing. It’s not my fault if some other guy is shady.”

Basically: These stories are showing us, more clearly than I’ve ever seen, what we’re up against when we take a call from somebody who says they’ve got a great insurance plan for us.

And it’s a totally wild ride. Here we go.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen here is to take on one of the most enraging, terrifying, depressing parts of American life — and bring you something entertaining, empowering and useful.

To start, here’s how bad things got for Sarah and Joe Strohmenger.

As they knew: They needed good health insurance. They’ve got pre-existing conditions.

For instance, Joe takes medicine that Sarah says costs 1500 dollars a month. And he’s got a benign brain tumor and has a doctor monitoring it. 

Sarah Strohmenger: That doctor was the most important doctor because it’s a doctor you can’t afford without health insurance.

Dan: Sarah says the monitoring includes periodic bloodwork and MRIs.

So she says when they were picking this plan, they asked about the doctor, about the tests, about the medicine, all their providers.

She says the sales rep for this plan told them, Yes. That is all covered.

Sarah Strohmenger: You know, it sounded great, covered everything that we needed.

Dan: Joe and Sarah paid about 87 hundred dollars upfront— a discount for a full year’s coverage. 

But Sarah says once they tried actually using the plan, things went south. She says their pharmacist told her Joe’s medicine wasn’t covered, and Joe’s doctor said his visits weren’t covered either.

And she says bills arrived that she did not expect.

Sarah Strohmenger: We were getting blood work bills back in the mail, for like $4,000 at a pop at a time, 3000.

Dan: According to the Bloomberg story, Joe called the company they’d bought the policy from— and reached a guy who said upgrading their plan would fix everything. They ultimately paid 20 thousand dollars for insurance that still didn’t cover what they needed.

Sarah says she thinks they also ended up on the hook for 10 to 15 thousand dollars in medical bills. 

Sarah Strohmenger: Within like six months, we stopped going to doctors.

Dan: They couldn’t afford to.

Sarah Strohmenger: We just were like, if we end up in the hospital, we’re basically screwed, you know? So Joe stopped going to all of his doctor’s appointments, he stopped taking his medication, and it was bad.

Dan: Meanwhile, Sarah says they also complained to state regulators about the company that sold them this policy.

The regulators wrote back, saying: We’ve never licensed or approved this entity. So… sorry. Sarah was like, Wait, WHAT? 

Sarah Strohmenger: I lived in a paradox that I didn’t know existed for a year. My mind was blown. 

Dan: I’m telling you — it’s REALLY weird. I’ve seen the letter, that’s what it says. And no: It’s not like there’s some other state office Sarah was supposed to write to. I checked.

Sarah says she and Joe took legal action against the marketing company, but they haven’t recovered any money. She says they paid off all the bills. And she says they signed up for a plan on New York’s Obamacare marketplace, which has been covering what they need. 

But she never understood what the heck had happened — the nature of the hustle — until she sent her story as a tip to Bloomberg News, and Zach Mider got in touch.

As it happened, he’d been digging into exactly this kind of hustle. 

Which has, I have to say, just an amazing number of layers and twists. Starting here:

When Zach looked at Sarah and Joe’s insurance cards, he noticed something that they had missed.

The name of a GROUP at the top — like as if this was a group plan, like you’d get from your job. 

And that was a key to the whole arrangement. That group — Outreach Data Partners Limited Partnership — is not an insurance company.

As Zach puts it, their legal stance is: They haven’t sold insurance to Sarah and Joe — or anybody else. That’s not the relationship.

Zach Mider: They’re claiming they have an employer-employee relationship with the people who buy health plans from them, and therefore, all of the state insurance laws don’t apply. 

Dan: Now, first: It’s actually true that for most people who get health benefits from their employer — like two-thirds — state insurance laws don’t apply. Lots of employers operate plans regulated by the federal Department of Labor.

Which Zach says is how Outreach Data Partners set up the plan Sarah and Joe bought.

All of which was news to Sarah and Joe.

Zach Mider: They just thought they were buying health insurance. 

Dan: And if they’re workers here, what was the JOB supposed to be?

Zach Mider: Yeah, that’s a great question. So, there is some work that is supposed to be done.

Dan: OK, strap in: Zach says to start with, in theory, the company gives you a special browser to use on your phone.

Zach Mider: The idea is if you want to go do something on the internet, you use this special browser and they’re collecting data about people’s browsing habits which then they can turn around and sell that information to advertisers.

Dan: So that’s the “job”: By using this browser, you’re producing value for the company— you’re working for them. Joe and Sarah told Zach they never got any special browser. And of course there’s another thing they might have expected to get from a job, ANY job: A paycheck.

And here’s how Zach says that absence gets explained.

Zach Mider: These data companies have been described to me as sort of, they’re startups, right?

Dan: And here’s where the full name of this company comes into play: ?Outreach Data Partners Limited Partnership. On paper, Joe and Sarah aren’t mere employees, they’re … limited partners— part owners. But in a company that hasn’t started making money yet. 

Zach Mider: Maybe they have a millionth share of the company. And so if the company starts making a lot of money, they will get a check. 

Dan: I don’t think Joe and Sarah are holding their breath for a check from Outreach Data Partners.

According to the Bloomberg story the company doesn’t have a public-facing website, and LinkedIn doesn’t list any employees. But the story also says that in a government filing the company claims 4,800 workers.

Zach and Zeke checked out the company’s headquarters: Box 371 at a UPS store in an Atlanta strip mall — between a dry cleaner and a Vietnamese restaurant. 

They found more than a dozen other companies using the same mailbox as their address — companies with names like Consumer Data Partners. All told, their story says these companies claim more than 30,000 employees.

And when Zach and Zeke started calling people connected to those companies, they ended up talking with the guy who seems to have invented what they call this fake-jobs healthcare setup.

A guy named Bill Bryan.

Zach Mider: Bill Bryan, was a pretty successful sitcom writer in the eighties and nineties. He wrote for Night Court

Judge from Night Court: What’s up Mac?

Mack from Night Court: A little case of disturbing the piece at a Star Trek convention, sir.

Zach Mider: And Coach

Craig Nelson: I didn’t lose the game. The team lost the game. I didn’t.

Zach Mider: And he wrote for a bunch of others. And then he does some real estate deals. He gets involved in some other investments. He ends up being a fairly wealthy guy and looking for new things to invest in, and comes across the idea of doing something with health plans.

Dan: ?Zach says, the idea was this: Obamacare had imposed standards on a lot of health insurance. Minimum stuff that had to be covered. Hospitalization. Mental health services. Prescription drugs. But covering all that stuff is expensive. It means premiums can be high, even with subsidies. And deductibles can be super-high: Thousands of dollars.

So Bill Bryan thought… 

Zach Mider: maybe if there was a way of designing a product that was legal. That covered less stuff than Obamacare, but still gave people what they wanted. You know? Um, it’s a free country. Maybe people should be able to decide what kind of healthcare they wanna buy and not have to meet all these minimum standards that maybe they’re not interested in.

Dan: So the plan that Sarah and Joe got sold, Zach says it does not meet those minimum standards. He says it covers like three doctor visits a year, a couple of lab services, and not a lot else.

Zach Mider: No coverage for hospitalization, no cover for emergency room visits. There is a prescription or there is a pharmacy benefit, but it only covers generics. 

Dan: Zach says Bill Bryan really thinks: that’s a product somebody might prefer to an Obamacare plan with a high deductible. Under the Affordable Care Act, you can’t sell that product as insurance. Actually, if you have a lot of employees, you can’t offer it to them either. 

But as a health-insurance law expert at Georgetown told me: You could maybe offer it to OWNERS of your company.

So by making people like Joe and Sarah LIMITED PARTNERS, maybe you could offer them this kind of super-stripped-down health plan legally.

Zach says: Bill Bryan thinks of this as a way to fix a problem he sees with Obamacare: Full coverage is too expensive for some people. 

Zach Mider: He’s a very smart guy, and so over the years he’s had to fight a lot for this, and I think that’s only kind of strengthened his conviction that it would be a corrective to the Obamacare system to have something that’s more affordable and more accessible for people to get.

Dan:Of course, that’s not what Joe and Sarah wanted – price wasn’t their top concern. They needed insurance that covered their providers, their treatments, their tests, their meds. That’s what they thought they were paying for.

I asked Zach and Zeke, what does Bill Bryan say about the kind of thing that happened to Joe and Sarah? 

Zach Mider: So it, it’s really important to point out here that like Bill Bryan didn’t sell the plan to Joe and Sarah. You know, he doesn’t do the call centers, right? These salespeople are all kind of independent operators who are essentially just selling this stuff for a commission. And so, he certainly doesn’t defend anybody misleading a customer.

Dan: According to Bloomberg’s story, Bryan said he had cut ties with the agency that sold Joe and Sarah their plan — years ago. 

And when he was told that the agency had sold the couple one of his plans much more recently, Bryan said, “That is absolutely news to me. I just don’t have anything more to say about any of these motherfuckers.” 

Zeke Faux: When we were talking with Bryan, though…

Dan: That’s Zach’s reporting partner, Zeke Faux.

Zeke Faux: …he and his colleagues were pretty evasive about exactly how these plans are sold.

Dan: Zeke says the way the plans are sold — specifically, the big commission rates for salespeople — was one of the reasons he and Zach got interested in this story in the first place.

Zeke Faux: Basically, the percentage of whatever the customer’s paying that is going to the salesman and the various middlemen involved is so high that it’s kind of hard to imagine that the customer could be getting a good deal. 

Dan: Even if the plan was cheap. Zach had pulled some data, crunched some numbers. The Bloomberg story says— at least in some cases— all those commissions and fees added up to 74 percent of what people like Joe and Sarah paid for these plans.

Zach Mider: If a person’s paying a dollar almost 74 cents is gonna go to commission to other various middlemen and whatever and only 26 cents is left for actually going into the pool from which medical care is paid out of. 

Dan: 26 cents for medical care. So, just to compare. Obamacare requires insurance plans to spend at least 80 cents of every dollar on medical care.

Everything else — your sales operation, all your admin costs — including the people who deny claims— and your CEO’s pay, and your profits — has to come out of that remaining 20 cents. 

With Bill Bryan’s plans, Zach’s numbers show that ratio can get almost flipped: 26 cents for medical care. 74 cents for commissions, fees, everything else

Zeke says: They brought these issues up to Bill Bryan. 

Zeke Faux: And when we tried to ask about that, Bryan and his colleagues pleaded ignorance, as if it was not really their business how the salesmen got paid.

Dan: And this is a big, big theme in this story: There’s no SINGLE entity doing all of this. It’s a chain of different players, and each one can blame the others.

Bill Bryan blamed the sales outfit for what happened to Joe and Sarah. 

And that company? Their CEO told Zach and Zeke that Outreach Data Partners screwed up, denying claims for the Strohmengers that should’ve been paid. And as the Bloomberg story reports: Bill Bryan dismissed that notion.

But there are more links in this chain than that. For instance, Outreach Data Partners — the company that theoretically made Joe and Sarah limited partners?

Bill Bryan does not run it. He doesn’t run ANY of the companies that employ 30,000 people from a mailbox in an Atlanta strip mall.

Which isn’t to say that he has nothing to do with them. That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues.

So, Bill Bryan seems to be the mastermind behind what Bloomberg calls these 30,000 fake-jobs, and the health plans they offer.

But no, he doesn’t run the data companies behind those jobs. That would be illegal. 

Zach Mider: The data companies themselves wouldn’t be allowed under federal labor law to turn a profit on these health plans.

Dan: I mean, that sounds like a good law: Your boss isn’t supposed to make money by selling you a health plan. 

Zach Mider: So it’s all very segregated. They’re very careful to say these data companies are separate from us. The data companies are employing these people and they are sponsoring these health plans. And Bill Bryan’s role is he runs a series of vendors which provides services to the data companies.

Dan: Services like … running a health plan! Which, for a normal company, is a normal arrangement.

Remember how we said: Lots of employer health plans — ones tied to normal jobs— are exempt from state insurance laws?

The way those plans are set up, the employer normally hires a vendor — typically a big insurance company, like Blue Cross or Aetna — to run their health plan.

These data companies, instead of hiring Aetna to administer a health plan — for their 30 thousand “limited partners” — they’re hiring a company that Bill Bryan happens to run.

Zach Mider: I think he’s done a pretty good job of keeping these things formally separate, right? So he’s not formally in control. He doesn’t own the data companies, doesn’t formally direct their activities.

Dan: But Zach says: Bill Bryan seems to have had a hand in getting them set up. So they could offer health plans. That he could run.

Zach Mider: I think it’s fair to say that this was his and his partner’s idea, this whole kind of construct. But he’s tried pretty hard to, as a formal matter, make it compliant with federal labor law.

Zeke Faux: I feel like we should call the data companies and be like, hey, I can see that you have a lot of complaints about your health plan. It might be hurting recruiting. You know, would you like to switch to Aetna? Then we could find out if, uh — how independent they are.

Dan: That’s Zeke again, and yeah: He and Zach wrote in their story that they found HUNDREDS of complaints to the Federal Trade Commission, and the Better Business Bureau, and Apple’s App store about health plans tied to fake jobs.

A graphic that goes with their story shows dozens of quotes, like: This whole thing feels like a big scam that I fell for.

And: I can’t imagine I am the only person who has been lied to and basically stolen from.

And: Stay away at all costs.

Which raises a big question: Is any of this really legal? Isn’t there someone regulating it?

Zach says Bill Bryan wants answers to those questions too. 

Seven years ago, a data company the Bloomberg story describes as “allied with Bryan” went to the Labor Department for clarification— and validation. Basically, they said:

Zach Mider: We want you to sign off on this and confirm to everyone in the marketplace that this is legit. That these are real employees, these limited partner employees who are downloading the web browser are real employees, and that therefore we can sell ’em, these health plans without any problem. And the Department of Labor when push came to shove said, no, these aren’t employees. You’re just trying to sell insurance.

Dan: Bryan’s allies went to court to fight back. 

Zach Mider: And they’re still fighting over it all these many years later. That was 2018 when they were first trying to get this opinion. And um, now it’s 2025 and it’s still unresolved. 

Dan: ?Here’s what’s happened so far: A district judge ruled against the Labor Department, calling its opinion “arbitrary and capricious.” An appeals court later agreed with that conclusion, but sent the case back to the district court to reconsider other details, including: what should happen next.

Zach Mider: So the way it stands, it’s really in a kind of strange limbo, where the Department of Labor really doesn’t get to say, these are legit, or these are not while we wait for the litigation to play out. But it does open the door for other people like Bill Bryan to come into the marketplace and start selling this kind of stuff. 

Dan: And it looks like they have. The Bloomberg story has a chart, showing the number of households enrolled in “fake jobs” plans. After the appeals court ruled against the labor department, the numbers more than doubled.

And meanwhile, NOBODY is regulating these plans. They’re not traditional insurance plans, so state insurance departments don’t have jurisdiction. So with the federal case on hold, people like Sarah and Joe have no one to turn to.

In a letter to the editor that Bloomberg published, Bill Bryan blames what happened to people like Sarah and Joe on the Labor Department, for not validating his model.

“If the department stepped up and played its proper role,” he wrote, “the fraud reported in your story could have very well been prevented.”

He added: “At a minimum, it would give victims someplace to seek recourse.”

So: everybody’s got somebody else to blame. 

Which is one of the themes that connects Bill Bryan’s story with a totally WILD tale that Zeke traced to Florida. One that doesn’t start out sounding like it has anything to do with health insurance.

In 2024, he writes, “if you were poor and online, certain ads were everywhere you looked.”

These ads featured celebrity deepfakes — promising 6 thousand four hundred dollars, if you call a certain phone number. 

Zeke Faux: I mean, it looks like it’s Taylor Swift, and she’s saying…

Fake Taylor Swift: Remember those stimulus checks? Well, there’s a new thing going viral. 

Zeke Faux: Or it’s Dr. Phil and he’s saying..

Fake Dr. Phil: They’re giving out $6,400 to anyone who makes the call 

Zeke Faux: Or Andrew Tate saying…

Fake Andrew Tate: If you don’t act now, you’re basically throwing away $6,400. That’s just stupid.

Zeke Faux: And these ads didn’t even, they might briefly mention health insurance or maybe they don’t say health insurance at all.

Dan: But if you called that number, you’d end up talking with someone ready to sign you up for health insurance. 

Sign you up so quickly that… you might not have any idea that’s what had just happened. 

Or, for that matter, that no, you would not be getting 64 hundred bucks to spend.

This story goes in some WILD directions, but here’s how Zeke describes the connection with the fake-jobs saga. 

Zeke Faux: in reporting both of these stories, I think what we learned is that there is kind of a subculture of call center operators who have turned what seems like a pretty boring business selling health insurance into a get rich quick kind of operation.

Dan: The call centers, the telemarketers. That’s the connection— Bloomberg paired these stories under the heading “Health Care Hustlers.”And those hustlers are always looking for a new angle. 

Which is to say: Zeke and Zach’s stories reinforce a big Arm and a Leg rule: 

If the internet leads you to a phone call with someone who says they’ve got a GREAT health insurance deal for you… be very, very suspicious.

And a lot of people will be looking for deals on health insurance. 

During the Biden Administration, Congress added more-generous subsidies to Obamacare plans, which made them more affordable. 

Unless Congress re-ups them soon— which seems unlikely— those extra subsidies will expire this year. 

People will look for alternatives, and these call centers will offer them.

In a way, it’s back to the future: 

The first Trump Administration loosened certain rules, making it easier to sell short-term plans that didn’t meet Obamacare standards. Zeke says he reported on the results back then.

Zeke Faux: I spoke with people who had bought these plans and then had medical emergencies and been stuck with 50 or a hundred thousand dollar bills, so we’ll be — we’re kinda watching to see what new products emerge or what these call centers start selling. 

Dan: And meanwhile, just — look:  Don’t buy insurance over the phone from somebody you’ve never met. Don’t bother with google. Healthcare dot gov. That’s basically it. 

What you’ll find there, I’m not saying you’ll love it. It’s probably gonna cost more than you want to pay, and deductibles will likely be high. 

But even though subsidies for Obamacare plans aren’t AS generous this year, they still exist. And these policies are regulated. Anything else… like Sarah Strohmenger said, it’s a free-for-all. And there are some hustlers out there. 

Meanwhile: the Trump Administration and Congress have both set up changes to the ACA marketplaces — administrative hassles that will make it harder to get, and keep, your coverage.

The time to start planning for it is now. And we’re gonna have some help for you, starting with next week’s First Aid Kit newsletter. 

My colleague Claire Davenport has been digging into those changes, what they mean for all of us, and how we can start preparing. 

You can sign up on our website at armandalegshow dot com, slash, first aid kit.

By the way: We just launched a new version of our website — with a brand new feature: Starter Packs. 

Here’s where we bring together our best reporting on questions you need answers to, like: How do I shop for health insurance? 

We’ll have a link wherever you’re listening, 

and we’ll be back with a new episode in a few weeks.

Until then, take care of yourself.

This episode of An Arm and a Leg was produced by Emily Pisacreta and me, Dan Weissmann — with help from Lauren Gould—

And edited by Ellen Weiss.

Claire Davenport is our engagement producer. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.

Bea Bosco is our consulting director of operations.

Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show.

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support.

Thanks! And thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

Se suponía que iba a ser más fácil.

Cuando la Ley de Cuidado de Salud a Bajo Precio (ACA) se aprobó en marzo de 2010, el objetivo era ayudar a que más personas en el país obtuvieran seguro médico. Y, de hecho, la creación de mercados en línea y la ampliación de los criterios de elegibilidad para Medicaid lograron ese propósito.

Sin embargo,15 años después, el sistema dista mucho de ser fácil de usar.

A los jóvenes que buscan seguro médico pueden ayudarlos los navegadores que trabajan para los mercados en línea. Pero si prefieres hacerlo por tu cuenta, aquí tienes algunos consejos para buscar un plan, en base a laexperiencia de expertos.

Abróchate el cinturón.

Comienza aquí

Inicia tu búsqueda por lo menos dos meses antes de tu cumpleaños 26 (la edad en la que los jóvenes adultos deben salir del plan de salud de sus padres). En algunos casos, puedes inscribirte en un plan con anticipación para que entre en vigencia el día de tu cumpleaños.

Primero, averigua si tu plan familiar termina el día de tu cumpleaños o al final de ese mes. Algunos estados permiten que los jóvenes permanezcan en el plan familiar hasta los 29 años, bajo ciertas condiciones y, por lo general, con costos más altos.

Un navegador podrá darte más detalles.

Podrías mantener el seguro familiar a través de COBRA, un plan federal que permite extender el tiempo bajo este plan. Pero es imporante saber que puede ser muy costoso porque se debe pagar el total de la prima.

Quienes declaran una discapacidad generalmente pueden permanecer en el plan familiar después de los 26, dependiendo del tipo de seguro que tenga la familia.

Si estás en tratamiento médico y no puedes cambiar de hospital o de doctor, pagar esta prima podría ser tu mejor opción. No tendrás esta alternativa si tu familia tiene seguro a través de un plan de ACA.

Antes de empezar a buscar, haz una lista de los medicamentos y doctores de los que dependes, y destaca aquellos que son imprescindibles para ti. Incluso puedes jerarquizarlos.

Es muy probable que tengas menos opciones en el mercado que las que tenías en el plan de tus padres. Prepárate para hacer cambios y concesiones.

Encuentra tu mercado

Treinta y dos estados adoptaron el mercado federal como el lugar al que sus residentes pueden comparar y comprar cobertura. El resto administra sus propios mercados en línea. Puedes averiguar aquí dónde comprar seguro de slaud en tu estado.

Asegúrate de entrar a un sitio oficial de ACA. Hay muchas páginas que parecen oficiales pero que en realidad las operan corredores privados. El mercado federal está en cuidadodesalud.gov y en ningún otro lugar.

Ten en cuenta que los mercados estatales oficiales a veces tienen nombres poco comunes. Ejemplos son New York State of Health, Kynect (Kentucky), Covered California y CoverMe (Maine).

En los estados que usan el mercado federal, puedes encontrar ayuda aquí. En los mercados estatales, suele haber un botón o pestaña de “find local help” (buscar ayuda local) que te dirige a alguien que puede ayudarte a encontrar un buen plan.

Generalmente, te pedirán elegir entre un corredor, que recibe comisión si te inscribes, o un “asistente” que ofrece el servicio sin costo. Los asistentes han recibido capacitación especial en el mercado donde trabajan y, al no recibir comisión, no tienen incentivos para dirigirte hacia un plan que les genere ingresos.

Los asistentes suelen ser navegadores contratados por el mercado, pero a veces trabajan para hospitales, planes de salud u organizaciones sin fines de lucro. Tendrás que preguntar.

Aunque los navegadores suelen ser una fuente confiable de asesoría, podrían ser más difíciles de encontrar ahora que la administración recortó su financiamiento en los estados que dependen del mercado federal (los estados con mercado propio no han sido afectados).

Muchas organizaciones sin fines de lucro y estados ofrecen excelentes programas de asistencia gratuita. Estos expertos te guiarán paso a paso y sabrán qué opciones seleccionar para asegurarte la mejor cobertura posible al mejor precio disponible.

Inscríbete

Una vez en un sitio oficial que ofrezca planes de ACA, te pedirán ingresar tu información personal y una estimación de tus ingresos.

Cuarenta estados y el Distrito de Columbia ofrecen Medicaid a jóvenes solteros sin hijos si sus ingresos son lo suficientemente bajos para calificar. Si cumples con los requisitos, elsitio te redirige a la plataforma de Medicaid para iniciar el proceso de inscripción, o podrías inscribirte directamente desde el mercado.

Sin embargo, debes saber que la nueva ley aprobada por los republicanos ha aumentado los requisitos y la cantidad de trámites necesarios para obtener y mantener la cobertura de Medicaid.

Medicaid, un programa conjunto federal y estatal que ofrece seguro médico a personas con bajos ingresos, no cobra prima y cubre medicamentos a bajo costo o gratis. El inconveniente es que quienes están inscritos tienen menos doctores y hospitales dentro de la red para elegir.

Si tus ingresos superan el límite para Medicaid, tendrás que buscar una póliza en el mercado.

En la mayoría de los sitios, hay una herramienta para verificar si tu doctor u hospital están dentro de la red de un plan. Pero cuidado: estos directorios suelen tener errores, pese a las leyes federales que exigen su exactitud.

Por eso, antes de seleccionar un plan, llama al doctor o hospital para confirmar que aceptan el seguro que estás considerando.

Haz números

Para los cálculos, es mejor usar una computadora que un teléfono. Generalmente, puedes comparar los costos y la cobertura de solo tres planes a la vez.

Debes considerar:

• La prima (teniendo en cuenta cualquier subsidio que recibas según tus ingresos) y otros gastos que deberás pagar, llamados “gastos compartidos”.
• Deducible: lo que debes pagar de tu bolsillo antes de que el seguro comience a cubrir los gastos. (Algunos planes incluyen ciertas visitas al médico de atención primaria sin que cuenten para el deducible).
• Copagos: cantidad fija que pagas por una visita al médico o a la sala de emergencias.
• Coseguro: porcentaje de la factura total, comúnmente entre 10% y 30%, que puede ser muy alto. Por ejemplo, con el esquema común 80-20, tú pagas el 20%. Una estancia hospitalaria puede costar decenas o cientos de miles de dólares, y el 20% de eso es mucho dinero.
• Límite de gastos de bolsillo: lo máximo que pagarás en un año, siempre que uses proveedores de la red y cumplas con el deducible.

Hacer números implica evaluar de manera integral lo que puedes pagar en primas frente a lo que puedes cubrir de los gastos mencionados antes. Si el deducible supera los $3.000 y el máximo anual de gastos es de $9.200, ¿tienes ese dinero?

En general, cuanto más baja es la prima mensual, mayor es la parte de los costos que deberás pagar si necesitas atención médica. Una misma aseguradora puede ofrecer planes muy distintos en el mismo mercado, con diferentes políticas de pago y redes.

Las personas con ingresos de hasta 2,5 veces el nivel de pobreza pueden obtener alivio en los gastos compartidos, pero solo si se inscriben en planes “Plata”. Los planes suelen clasificarse como Bronce, Plata, Oro y Platino; cada nivel refleja el porcentaje de gastos médicos que cubre el plan. Los planes de Bronce ofrecen la cobertura más baja.

Elige con sabiduría

Cuando reduzcas la lista de opciones a unos pocos planes, examínalos a fondo.

Un plan con deducible bajo podría requerir un copago diario de $1.000 o un coseguro del 50% en hospitalizaciones. Un plan que enumere tu sistema hospitalario como parte de la red podría solo incluir algunas de sus sedes, y no necesariamente las más cercanas o las que ofrecen el tipo de atención que necesitas.

Revisa el “resumen de beneficios y cobertura” para ejemplos concretos de lo que cubre el plan. Pon atención a los servicios que requieren autorización previa y, por ejemplo, cuántas visitas de fisioterapia cubren al año. La autorización previa puede ser un proceso largo y complicado.

En general, las primas más bajas implican más requisitos de autorización previa y menos cobertura. También revisa el listado de medicamentos cubiertos (llamado formulario) y confirma si tus doctores están en la red del plan.

Los planes del mercado suelen ofrecer menos opciones que los que ofrecen los empleadores: no hay tantos doctores u hospitales para elegir.

Verifica si la póliza cubre algo fuera de la red. Algunos planes pagan, por ejemplo, el 60% o 70% de los cargos aprobados, algo útil si necesitas ver un especialista fuera de la red o si la espera para una cita es muy larga.

Un estudio comprobó que las personas con planes del mercado tienen acceso, en promedio, a solo el 40% de los doctores cercanos, y en algunas zonas el acceso baja al 25%. Es probable que la cifra sea aún menor para especialistas en salud mental.

Recurso adicional

Si intentas elegir un plan y aún tienes dudas, busca uno de “precios fáciles” o estándar. Estos cumplen con ciertos requisitos básicos establecidos por los Centros de Servicios de Medicare y Medicaid (CMS), que supervisan los mercados federales. Estos planes incluyen algunas citas de atención primaria antes de que tengas que pagar el deducible.

El gobierno indica que en el mercado federal deben aparecer con la etiqueta “easy pricing”, aunque en los mercados estatales pueden identificarse de otra manera. En Nueva York, por ejemplo, se marcan simplemente con las letras ST (por estándar).

Por ahora, el financiamiento para subsidios a las primas está garantizado al menos este año, y sigue habiendo asistencia experta gratuita, así que no lo dejes pasar. Hay buenas ofertas disponibles, siempre y cuando te tomes el trabajo de encontrarlas.

Que tengas suerte.

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People thinking about starting a business or retiring early — before they’re old enough for Medicare — may want to wait until November, when they can see just how much their Affordable Care Act health insurance will cost next year. Sharp increases are expected.

Premiums for ACA health plans, also known as Obamacare, which many early retirees and small-business owners rely on for coverage, are going up, partly due to policy changes advanced by the Trump administration and Congress. At the same time, more generous tax subsidies that have helped most policyholders pay for coverage are set to expire at the end of December.

After that, subsidies would return to what they were before the covid-19 pandemic. Also being reinstated would be an income cap barring people who earn more than four times the federal poverty level from getting any tax credits to help them purchase coverage. Although Congress potentially could act to extend the credits, people weighing optional life changes should factor in the potential cost if lawmakers fail to do so.

“I would hate for people to make a big decision now and then, in a few months, realize, ‘I’m not even going to qualify for a tax credit next year,’” said Lauren Jenkins, an insurance agent whose brokerage helps people sign up for coverage in Oklahoma. “Coupled with the rate increases, that could be significant, especially for someone at or near retirement, when it could easily cost over $1,000 a month.”

Still, how things play out in the real world will vary.

The key factor is income, as the subsidy amount people receive is primarily based on household income and local insurance costs.

People experiencing the biggest dollar increase in out-of-pocket premiums next year will be those who lose subsidies altogether because they earn more than 400% of the federal poverty level. This year, that’s $62,600 for a single person and $84,600 for a couple.

This “subsidy cliff” was removed in the legislation first enacted during the covid pandemic to create enhanced subsidies, but it will be back next year if they expire. About 1.6 million people who earn more than 400% of the poverty threshold bought ACA plans this year, many of them getting some tax credits to help with the premiums, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

“A lot of small-biz owners fall around that level of income,” said David Chase, vice president of policy and advocacy for the Small Business Majority, a Washington, D.C.-based advocacy group, which is urging Congress to extend the credits.

And a good chunk of ACA enrollment consists of small-business owners or their employees because, unlike larger firms, most small businesses don’t offer group health plans.

In the Washington metropolitan area, “seven out of 10 people who qualify for lower premiums [because of the tax credits] are small-business owners,” said Mila Kofman, executive director of the DC Health Benefit Exchange Authority.

Congress must decide by the end of December whether to extend the subsidies a second time. Permanently doing so could cost taxpayers $335 billion over the next decade, but not acting could cause financial pain for policyholders and pose political repercussions for lawmakers.

Because new premiums and smaller subsidies would take effect in January, the potential fallout has some Republican lawmakers worried about the midterm elections, according to news reports.

Republican pollsters Tony Fabrizio and Bob Ward warned the GOP in a memo that extending the enhanced credits could mean the difference between success and failure in some midterm races, because support for the premium help “comes from more than two-thirds of Trump voters and three-quarters of Swing voters.”

While supporters credit the enhanced subsidies for a record 24 million sign-ups for this year’s ACA plans, critics have blamed them for instances in which sales brokers or consumers engaged in improper enrollment.

“The expanded subsidies were a temporary covid pandemic policy enacted by congressional Democrats on a party-line vote and scheduled to end after 2025,” said Brian Blase, president of the Paragon Health Institute, a conservative think tank. “They have led to tremendous fraud and waste, they reduce employer coverage, and they should be permitted to expire.”

Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, acknowledged that people earning more than 400% of the poverty level would not be happy with losing access to subsidies, but he expects most to stay enrolled because they want to avoid huge medical bills that could threaten their businesses or savings.

“They are middle-class or upper-income people who are self-employed, or early retirees with significant income, which means they have a lot of assets behind that income,” he said. “These are people who view insurance as financial protection.”

He thinks lawmakers would win political support from voters in this category by addressing two of their other major ACA concerns: that annual deductibles are too high and insurers’ networks of doctors and hospitals are too small.

“If you just give these people money by extending subsidies, it’s only addressing one of their problems, and it’s the one they are least upset about,” Haislmaier said. “That is the political dynamics of this.”

Here’s how the expiration of subsidies could play out for some hypothetical consumers.

People in households earning less than four times the poverty rate would still get subsidies — just not as generous as the current ones.

For example, those whose earnings are at the lower end of the income scale — say, just over 150% of the poverty threshold, or about $23,000 — will go from paying a national average of about $2 a month, or $24 toward coverage for the year, to $72 a month, or $864 a year, according to a KFF online calculator.

On the other end of the income spectrum, a 55-year-old Portland, Oregon, couple with a household income of $85,000 would also take a big hit on the cost of their benchmark plan. They currently pay about $600 a month in premiums — about 8.5% of their household income — with subsidies kicking in about $1,000 to cover the remainder.

Next year, if the tax credits expire, the same couple would not get any federal help because they earn over four times the poverty limit. They would pay the full monthly premium, with no subsidies, which would be about $1,800, based on initial 2026 premium rates filed with state regulators, said Jared Ortaliza, a policy analyst at KFF.

People should begin to see insurance rates late this fall, and certainly by Nov. 1, when the ACA’s open enrollment season begins, said Jenkins, the Oklahoma insurance agent. That gives them time to mull over whether they want to make changes in their plan — or in their lives, such as quitting a job that has health insurance or retiring early. This year, open enrollment extends to Jan. 15. Under new legislation, that open period will shorten by about a month, starting with the 2027 sign-up period.

Those who do enroll for 2026, especially the self-employed and people retiring early, should closely track their incomes during the year, she said.

It would be easy to bust through that income cap, she said.

If they do, they’ll have to pay back any tax credits they initially qualified for. Their income might rise unexpectedly during the year, for example, pushing them over the limit. An income bump could come from drawing down more money from retirement accounts than planned, landing a new customer account, or even from winning big at the casino.

“Maybe they win $5,000 at the casino, but that puts them $500 over the limit for the year,” Jenkins said. “They might have to pay back $12,000 in tax credits for winning a few thousand at the casino.”

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Elisabeth Rosenthal and Hannah Norman, KFF Health News

Amid the challenges of adulthood, one rite of passage is unique to the United States: the need to find your own health insurance by the time you turn 26.

That is the age at which the Affordable Care Act declares that young adults generally must get off their family’s plan and figure out their coverage themselves.

When the ACA was voted into law in 2010, what’s known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.

But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA’s online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.

The erosion of the law has now created an “insurance cliff” for Americans who are turning 26 and don’t have a job that provides medical coverage.

Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.

Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.

If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.

Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.

They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.

The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.

“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.

“The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”

(Ethan Evans)

(Maxwell Frost)

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

(Elizabeth Mathis)

(Kayla Anderson)

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, ‘What if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

(Daisy Creager)

(Madeline Nelkin)

(Valeria Chávez)

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “easy pricing” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

It was supposed to be easier than this.

When the Affordable Care Act was passed in March 2010, the goal was to help more Americans get health insurance. And, indeed, the establishment of online marketplaces and a broadening of the eligibility guidelines for Medicaid accomplished that.

Fifteen years later, however, that system is anything but user-friendly.

Young adults looking for health insurance will likely benefit from talking with so-called navigators who work for the online marketplaces. But if you want to go it alone, here are some tips about shopping for a plan, based on the advice of policy experts and people who have spent hundreds of hours helping others navigate this unwieldy set-up.

Buckle up.

Start Here

Begin your search at least two months before your 26th birthday. In some cases, you can sign up for a plan in advance so that it takes effect on your birthday.

First, find out if your family plan ends on your birthday or at the end of your birthday month. A few states allow young adults to stay on their family plan until they are 29, with certain conditions and, generally, higher costs. A navigator will know more.

You may have the option to stay, for a limited time, on your family’s plan under COBRA, a federal program that allows those with group health plans to extend their coverage past age 26. Odds that you will be approved for an extension are even higher if you can claim a disability.

Be aware, though, that this option will involve a considerable expense, since you will be required to pay the entire premium (the employer will no longer pay what is usually a substantial share). Those who claim a disability can often stay on the family plan after age 26, depending on the type of insurance the family holds.

If you’re undergoing medical treatment and can’t change hospitals or doctors, paying this premium may be your best course. You don’t have this option, however, if your family is insured through an Obamacare plan.

Before you start your search, make a list of the medicines and physicians you rely on, and highlight those you can’t do without. Rank them, even.

It’s quite likely that you will have fewer choices on the marketplace than you had on a parent’s plan. Be prepared to make some switches and trade-offs.

Find the Right Marketplace

Thirty-two states have adopted the federal marketplace as the place residents can go to compare and buy insurance policies. The rest run their own online marketplaces. You can find out here where to shop for insurance policies in your state.

Make sure you land at an official ACA website. There are many look-alikes run by private insurance brokers. The federal marketplace is found at healthcare.gov and nowhere else.

Note that official state marketplaces sometimes have unusual names. The New York State of Health, Kynect (Kentucky), Covered California, and CoverMe (Maine) are examples.

In states that use the federal marketplace, shoppers can find assistance here. On the state-based marketplaces, there is often a “find local help” button or a tab that directs you to a person who can help you find a good plan.

You will generally be asked to choose a broker, who is paid a commission if you sign up, or an “assister,” who provides the service at no cost. Assisters have received special training in the marketplace they serve, and, because they provide the service free, they have no financial incentive to steer you to a plan that pays a commission to the seller.

Assisters are often navigators who are funded by the marketplace, but in some cases they work for hospitals, health plans, or local nonprofits. You’ll have to ask.

While navigators are generally a surefire option for sound advice, they may become harder to find now that the Trump administration has cut funding for them in states that rely on the federal marketplace. (States that run their own marketplaces are unaffected.)

Many nonprofits and states run excellent programs that offer free assistance. And if, for example, you’re in the middle of cancer treatment, an assister affiliated with your hospital may offer better advice on picking a plan, since they will know which ones have contracts that may cover more of your expenses.

Ideally, these experts will walk you through the process and know which buttons to push to ensure you get the best coverage for your needs at the best rate for which you are eligible.

Sign Up

Once you’re on an official website that markets plans under the ACA, you will be asked to enter your personal information as well as an estimate of your income.

Forty states and the District of Columbia cover single young adults with no children under Medicaid if their income is low enough to qualify. If you’re eligible, you should be redirected to the Medicaid website to start the enrollment process, or you may enroll directly on the marketplace site.

But be aware that the Republicans’ recently passed domestic policy bill has increased the requirements and the paperwork required to get on, and stay on, Medicaid.

Medicaid, a joint federal and state program that provides health insurance to low-income Americans, does not charge its members a premium, and it covers medications at a nominal cost or free. The caveat is that those enrolled in the program have a smaller number of in-network doctors and hospitals to choose from.

If your income is above the threshold for Medicaid, you will need to shop on the marketplace for a policy.

On most sites, a search tool allows you to check whether your doctor or hospital is in a particular plan’s network. But beware: The directories on which this search relies are notoriously inaccurate, despite federal laws mandating otherwise.

So, before you select a plan, call the doctor or hospital to confirm they accept the insurance plan you’re considering purchasing.

Do the Math

When it comes to the math, it’s better to work on a computer than a phone. Generally, you can compare the costs of, and coverage offered by, only three plans at a time.

The following factors include premiums (taking account of any subsidy you get based on your income), as well as other expenses you’ll have to pay, called collective cost sharing:

• The deductible — the amount you generally have to pay out-of-pocket before your insurance kicks in. (You may get a few “covered” visits with a primary care doctor; these won’t count against the deductible.)
• Copayments — a fixed payment that you owe for any visit to a doctor or emergency room.
• Coinsurance (this one can break the bank) — a percentage of the total bill, generally applied to hospital bills, that you have to pay. The plan may make it sound small, say, 10% to 30%. But if you have, for example, the common 80-20 split (in which the insurer pays 80% and you pay 20%), that can add up to a substantial sum. A single day in the hospital can cost tens or even hundreds of thousands of dollars, and 20% percent of that is a large amount.
• The out-of-pocket maximum — the most you’ll have to pay out in a year, so long as you stay in network and pay the deductible.

Doing the math means looking at this holistically, balancing what you can pay in a premium against what you can afford for the above charges. If the deductible is over $3,000 and the out-of-pocket maximum allowed yearly is $9,200 — do you have that much money on hand?

Generally, the lower the monthly premium in a plan, the higher the share of costs you’ll have to pay should you need medical care. Note that an insurer may offer very different plans on the same marketplace, with different payment policies and networks.

People with incomes up to 2½ times the poverty level may gain some relief from cost-sharing charges, but only if they sign up for silver plans. Plans are typically labeled bronze, silver, gold, and platinum; each tier reflects the percentage of your medical expenses that your plan pays overall. Bronze plans offer the least amount of coverage.

Choose Wisely

Once you’ve narrowed your choices to a few plans, study each closely.

A plan with a low deductible might require a $1,000 daily copayment, or 50% coinsurance (you pay 50%) for hospital stays. A plan that lists your desired hospital system as in-network may include only some of its locations, and not necessarily the ones close to you or that offer the type of care you need.

When looking at a plan’s details, make sure to scroll down and read its “summary of benefits and coverage” for examples of the plan’s coverage of common medical needs. Pay close attention to which services require preauthorization and, for example, how many physical therapy visits they’ll cover each year. Preauthorization can be a long and cumbersome process.

Generally, the lower the premium, the more preauthorization will be required and the more limited the coverage will be. And check what drugs the plan covers (called the formulary) to see if yours are included, as well as its network of providers, to see whether your doctors are in it.

Marketplace plans tend to have limited offerings compared with job-based insurance; there aren’t as many doctors and hospitals to choose from. Click on the “provider directory” to see if an insurer’s network includes doctors and specialists you’re most likely to need, and hospitals that are acceptable and accessible to you.

Check to see if the policy offers any coverage for out-of-network providers. Some will pay, say, 60% or 70% of approved charges. It’s a useful perk if you need to see an out-of-network specialist, or if the wait for an in-network appointment is too long.

One study found that patients with marketplace plans have access to only 40% of doctors near their home, on average, and in some areas that figure was as low as 25%. It’s quite likely even lower for mental health providers.

A Backstop

If you’ve tried to choose a plan and you’re still confused, look for one of the “easy pricing” or standard plans. These conform to certain basic standards laid out by the federal Centers for Medicare & Medicaid Services, which oversees the marketplaces for the federal government. These plans offer some primary care appointments before you have to start paying the deductible.

The government says these plans must carry the label “easy pricing” on federal marketplace sites. But they may be identified differently on state-run marketplaces. In New York state, for example, they are simply marked with an ST (for standard).

Still, funding for premium subsidies is in place for this year at least, and free expert assistance is still out there, so don’t delay. There are good deals to be had, if only you put in the work.

Good luck.

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Despite recent efforts to bolster California’s behavioral health workforce, the state is operating with only about two-thirds of the psychiatrists and therapists it needs. The problem is so severe it’s making it hard to backfill retiring practitioners, particularly in the state’s rural areas. 

“It feels helpless, because there is more than you can fix. There’s more people than you can help that need it,” said Nick Zepponi, a social worker at the Hill Country Community Clinic CARE Center in Redding in Northern California. The county’s suicide rate is more than double the state average and during the covid-19 pandemic overdose deaths increased more than threefold.

For years, experts have warned of California’s severe shortages of psychologists, psychiatrists, and other professionals in the mental health and substance use fields, exacerbated by many providers’ nearing retirement. Demand has also skyrocketed, due in part to the pandemic. 

Roughly 11 million Californians live in mental health professional shortage areas, the most after Texas, according to KFF, a health information nonprofit that includes KFF Health News. Democratic Gov. Gavin Newsom’s quest to make mental health and homelessness two of his signature issues have brought additional resources into California’s behavioral health system. 

State legislators have dedicated more than $1 billion for recruitment and training and California is now tapping $1.9 billion in Medicaid funds to attract and retain behavioral health workers, enticing them with scholarships and loan repayments, and helping schools fund new residencies and fellowships. 

But the Medicaid-backed initiative took effect only in January, and proponents are unsure whether the Trump administration will maintain such investments. In a statement, U.S. Department of Health and Human Services spokesperson Emily Hilliard said the Centers for Medicare & Medicaid Services has made clear that approved waivers remain in effect. 

“That said, states should not rely on temporary demonstration funding as a substitute for sustained, direct investment in their healthcare workforce,” Hilliard added, saying the agency would continue to evaluate California’s experiment, which sunsets at the end of 2029. 

One of California’s biggest bottlenecks is its acute shortage of psychiatrists — licensed medical doctors who can prescribe antidepressants and antipsychotic drugs. While the state has opened more training slots in recent years, they can cost as much as $250,000 a year and require 12 years of postsecondary education. 

Only a tenth of the target for expanded psychiatry residencies has been met, according to the California Health Care Foundation. 

As a result, existing personnel are buckling under the workload while patients without quick access to help during a crisis are turning to costly emergency care. In 2022, patients with mental health or substance use disorders accounted for 1 in 3 inpatient hospitalizations and 1 in 6 emergency room visits, state data shows. In ERs, doctors can often do little more than temporarily stabilize these patients, since long-term treatment beds are nearly impossible to find.

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MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act’s Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.

Instead, the Republican-passed budget law that includes many of President Donald Trump’s priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.

For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.

The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.

The budget law, which Republicans called the “One Big Beautiful Bill,” will cause sweeping changes to health care across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.

Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn’t make it into the law.

“Politicians in non-expansion states should be furious about that,” said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.

The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.

For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.

Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she’d splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.

Cham choked up describing the “safety net” that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.

“Obamacare has been my lifesaver,” she said.

If the enhanced ACA subsidies aren’t extended, “everyone will be hit hard,” said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for the Centers for Medicare & Medicaid Services.

“But a state that hasn’t expanded Medicaid will have marketplace people enrolling at lower income levels,” she said. “So, a greater share of residents are reliant on the marketplace.”

Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven’t are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.

KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.

Brandon Charochak, a spokesperson for McMaster’s office, said South Carolina’s Medicaid program focuses on “low-income children and families and disabled individuals,” adding, “The state’s Medicaid program does not anticipate a large impact on the agency’s Medicaid population.”

Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.

The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump’s budget law.

“That is problematic and scary for us,” said Eric Boley, president of the Wyoming Hospital Association.

He said his state, which did not expand Medicaid, has a relatively small population and hasn’t been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would “collapse the insurance market.”

As the uninsured rate rises in non-expansion states and the budget law’s Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.

Those states got slightly favorable treatment under the law, but it’s not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.

“Kansans’ ability to access affordable healthcare will be harmed,” Hoge said in an email. “Kansas, nor our rural hospitals, will not be able to make up for these cuts.”

For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.

Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.

Richard Roberson, president of the Mississippi Hospital Association, said the state’s use of what’s called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi’s rural hospitals stay open.

“That payment program has just been a lifeline,” Roberson said.

The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.

Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.

“Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,’” she said.

Those funds are not affected by Trump’s new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. “This is paying hospitals, but it’s not giving people health care,” she said. “It’s not giving people prevention.”

States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.

Mary Mayhew, president of the Florida Hospital Association, said the state’s Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.

“Children don’t have timely access to dentists,” she said. “Expectant moms don’t have access nearby to an OB-GYN. We’ve had labor and delivery units close in Florida.”

She said the law will cost states more in the long run.

“The health care outcomes for the individuals we serve will deteriorate,” Mayhew said. “That’s going to lead to higher cost, more spending, more dependency on the emergency department.”

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Michelle Andrews

Si quieres vacunarte contra covid-19 este otoño, ¿lo cubrirá el seguro médico de tu empleador? No hay una respuesta clara.

El secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., un veterano activista antivacunas, ha modificado radicalmente la forma en que se aprueban estas vacunas, y para quiénes se recomiendan, creando incertidumbre cuando la cobertura era rutinaria.

Las agencias dentro del Departamento de Salud y Servicios Sociales (HHS)  responsables de especificar quién debe vacunarse no están necesariamente sincronizadas, emitiendo recomendaciones en apariencia contradictorias basadas en la edad o los factores de riesgo de enfermedades graves.

Pero la ambigüedad podría no afectar tu cobertura, al menos este año.

“Creo que en 2025 es muy probable que los planes de las empresas cubran las vacunas contra covid-19”, afirmó Jeff Levin-Scherz, médico de atención primaria, líder de salud poblacional de la consultora de gestión WTW y profesor adjunto de la Escuela de Salud Pública T.H. Chan de la Universidad de Harvard.

Ya lo han presupuestado, “y sería un gran esfuerzo administrativo intentar excluir la cobertura para quienes no tienen mayor riesgo”, dijo.

Con tantos cambios, es importante consultar con tu empleador o aseguradora sobre las políticas de cobertura antes de arremangarte la camisa.

Esto es lo que sabemos hasta ahora y lo que aún no está claro.

¿Cómo han cambiado las recomendaciones?

Lo que antes era sencillo ahora es mucho más confuso. El año pasado, las vacunas contra covid de Moderna y Pfizer-BioNTech se recomendaron para cualquier persona a partir de los 6 meses de edad.

Este año, la recomendación de los Centros para el Control y Prevención de Enfermedades (CDC) es más restringida. Aunque las vacunas se recomiendan ampliamente para adultos mayores de 19 años, ya no para embarazadas sanas ni para niños y adolescentes sanos de 6 meses a 17 años.

Kennedy anunció los cambios en un video en mayo, citando como justificación los riesgos de seguridad para los jóvenes y las embarazadas.

Sin embargo, sus afirmaciones han sido ampliamente cuestionadas por expertos en vacunas, pediatría y salud femenina. Un análisis de FactCheck.org reveló que el secretario “tergiversó la investigación científica para hacer afirmaciones infundadas sobre la seguridad de las vacunas para embarazadas y niños”.

Además, los cambios anunciados recientemente en el marco de aprobación de vacunas han reducido aún más la elegibilidad.

Moderna anunció el 10 de julio que la Administración de Drogas y Alimentos (FDA) había aprobado completamente su vacuna contra covid Spikevax, pero la aprobación está restringida a adultos mayores de 65 años y a personas de entre 6 meses y 64 años que tienen un mayor riesgo de desarrollar un caso grave de covid.

Otras dos vacunas contra covid que se espera estén disponibles este otoño, Nuvaxovid de Novavax y mNexspike de Moderna, también tienen restricciones. Están aprobadas para personas mayores de 65 años y para aquellas de entre 12 y 64 años que tienen afecciones subyacentes que las aumentan el riesgo de desarrollar covid grave.

Por ahora,  la vacuna contra covid Comirnaty de Pfizer sigue aprobada o autorizada a partir de los 6 meses sin ninguna restricción basada en factores de riesgo para covid.

Sin embargo, la FDA podría cambiar esto en cualquier momento, según expertos. El aumento de las restricciones “es definitivamente la dirección en la que se están moviendo”, afirmó Jen Kates, vicepresidenta sénior de KFF, autora de un análisis sobre las normas de cobertura del seguro de vacunas.

El HHS no ofreció comentarios oficiales para este artículo.

¿Cómo podrían estos cambios afectar mi cobertura para la vacuna?

Esa es la gran pregunta, y la respuesta es incierta. Sin cobertura, las personas podrían deber cientos de dólares por la vacuna.

La mayoría de los planes de salud privados están obligados por ley a cubrir las vacunas recomendadas, ya sea para covid, el sarampión o la gripe, sin cobrarles a sus miembros. Sin embargo, según el análisis de KFF, este requisito entra en vigencia después que un panel federal —el Comité Asesor sobre Prácticas de Inmunización (ACIP)— recomiende las vacunas y las adopte el director de los CDC.

El comité aún no ha votado sobre las recomendaciones de la vacuna contra covid para este otoño. Se espera que su próxima reunión sea en agosto o septiembre. Aun así, los empleadores y las aseguradoras pueden optar por cubrir las vacunas por su cuenta, como muchos lo hacían antes de que la ley los obligara. Sin embargo, podrían exigir a las personas que pagaran algo de sus bolsillos.

Además, las recomendaciones más restrictivas de las diferentes agencias del HHS podrían resultar en que algunos planes de salud se nieguen a pagar a ciertas categorías de personas para que reciban ciertas vacunas, según expertos.

“No creo que un empleador o una aseguradora nieguen la cobertura”, dijo Kates. “Pero podrían decir: debes tener este producto”.

Eso podría significar que una persona de 45 años sin afecciones subyacentes que aumenten su riesgo de covid podría tener que recibir la vacuna de Pfizer en lugar de la de Moderna si quiere que su plan de salud la cubra, dicen expertos.

Además, hasta 200 millones de personas podrían calificar para las vacunas porque tienen afecciones como asma o diabetes que aumentan su riesgo de enfermedad grave, según un comentario publicado por funcionarios de la FDA en el New England Journal of Medicine.

Profesionales de atención médica pueden ayudar a las personas a determinar si califican para la vacuna según sus afecciones de salud.

Tina Stow, vocera del America’s Health Insurance Plans (AHIP), que representa a los planes de salud, declaró que los planes seguirán cumpliendo con los requisitos federales para la cobertura de la vacuna.

¿Cuáles son las opciones para las personas embarazadas o con hijos que quieran vacunar?

Según una encuesta de KFF publicada el 1 de agosto, muchos padres tienen dudas sobre la vacunación de sus hijos. Aproximadamente la mitad afirmó desconocer si las agencias federales recomiendan que los niños sanos se vacunen este otoño. Entre la otra mitad, la mayoría dijo que no se recomienda la vacuna.

Mientras tanto, la recomendación de Kennedy de no vacunar a los niños sanos tiene una salvedad importante: si un padre quiere que su hijo se vacune contra covid y un profesional de salud lo recomienda, el niño puede recibirla bajo el modelo de “toma de decisiones clínicas compartidas” y debería estar cubierta sin costos compartidos.

Algunos expertos en políticas señalan que, de todos modos, esta es la forma en que se suele brindar atención a los niños. “Más allá de cualquier requisito, las vacunas siempre se han proporcionado con decisiones compartida”, afirmó Amanda Jezek, vicepresidenta sénior de políticas públicas y relaciones gubernamentales de la Infectious Diseases Society of America.

No existe una asignación similar para las personas embarazadas. Sin embargo, aunque Kennedy ha declarado que las vacunas contra covid ya no se recomiendan para embarazadas sanas, el embarazo es una de las afecciones médicas subyacentes que aumentan el riesgo de enfermarse gravemente por covid, según los CDC. Esto podría hacer que las embarazadas sean elegibles para la vacuna.

Dependiendo de la etapa del embarazo, podría ser difícil saber si se debe negar la vacuna a alguien debido a su condición. “Esto es un territorio desconocido”, afirmó Sabrina Corlette, codirectora del Center on Health Insurance Reforms de la Universidad de Georgetown.

¿Cómo afectarán estos cambios el acceso a la vacuna? ¿Podré seguir yendo a la farmacia para vacunarme?

“Si se espera que se vacunen muchas menos personas, menos centros ofrecerán las vacunas”, afirmó Levin-Scherz. Esto podría ser un obstáculo especialmente importante para quienes buscan dosis pediátricas de la vacuna contra covid.

Además, la autoridad de los farmacéuticos para administrar vacunas depende de varios factores. Por ejemplo, en algunos estados pueden administrar vacunas aprobadas por la FDA, mientras que en otros deben haber sido recomendadas por el ACIP, explicó Hannah Fish, directora sénior de iniciativas estratégicas de la National Community Pharmacists Association. Dado que el ACIP aún no ha recomendado las vacunas contra covid para el otoño, esto podría suponer un obstáculo en algunos estados.

“Dependiendo de las normas, es posible que aún se pueda obtener la vacuna en una farmacia, pero es posible que tengan que llamar al médico para que envíe una receta”, explicó Fish.

¿Qué significan estos cambios a largo plazo?

Es imposible saberlo. Pero dado el escepticismo sonoro de Kennedy sobre las vacunas y su aceptación de teorías refutadas desde hace tiempo sobre la conexión entre las vacunas y el autismo, entre otras cosas, a los profesionales médicos y de salud pública les preocupa que estas opiniones influyan en las políticas futuras.

“Los cambios en las recomendaciones que se hicieron con respecto a los niños y las mujeres embarazadas no se basaron necesariamente en una buena base científica”, dijo Corlette.

Convencer a la gente de que necesita la vacuna contra covid anualmente ya es un desafío, y los cambios en las directrices podrían dificultarlo aún más, advierten algunos expertos en salud pública.

“Lo preocupante es que esto podría reducir aún más la vacunación contra covid”, dijo Jezek.

Cuando el presidente Donald Trump firmó una ley que agrega requisitos laborales para algunos beneficiarios de Medicaid, es posible que haya perjudicado a legisladores de al menos 14 estados que estaban diseñando sus propios planes, según observadores del sector de salud.

Georgia es el único estado con un requisito laboral para Medicaid, pero varios estados llevan años intentando implementarlo, solo para ser bloqueados por los tribunales o, más recientemente, por la administración Biden.

Algunos buscan modificaciones específicas a las nuevas normas para cada estado. Otros pretenden implementar los requisitos laborales antes de que la ley federal entre en vigencia a finales de 2026.

Las acciones de estos estados y la enorme ley de impuestos y gastos de Trump comparten una exigencia: para mantener la cobertura de Medicaid, los adultos que puedan trabajar deben demostrar que lo están haciendo por un mínimo de horas en un trabajo o estudiando, o bien calificar para una de las pocas exenciones.

Pero ahora, los estados que se adelantaron deben asegurarse de que sus propuestas, que requieren aprobación federal, no se alejen demasiado de la ley de Trump.

“El estatuto establece el mínimo y el máximo” para los requisitos laborales, afirmó Sara Rosenbaum, profesora de derecho y políticas sanitarias de la Universidad George Washington.

Por ejemplo, Dakota del Sur anunció en julio que no presentaría una solicitud para los requisitos laborales como se había planeado previamente, ante la preocupación de que las normas estatales, menos estrictas, no se permitieran bajo la nueva ley federal. El secretario del Departamento de Servicios Sociales del estado advirtió que trabajar en una propuesta estatal mientras se debatían las normas federales podría ser “un ejercicio inútil”.

El plan de Arkansas, por otro lado, es más estricto que la ley federal. No hay exenciones a sus requisitos laborales en la solicitud, que está pendiente en los Centros de Servicios de Medicare y Medicaid (CMS).

La propuesta de Arizona también incluye algo que no está en la ley federal: la prohibición de que los “adultos sin discapacidad” reciban beneficios de Medicaid por más de cinco años en total a lo largo de su vida.

Funcionarios gubernamentales de Arkansas y Arizona afirmaron estar trabajando con funcionarios federales para adecuar sus planes a las nuevas normas.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), afirmó que el departamento está analizando cómo interactúan las nuevas normas federales con las exenciones estatales.

El HHS debe publicar, antes de junio del próximo año, las normas que describan cómo los estados implementarán los requisitos laborales, según Elizabeth Hinton, quien ha monitoreando estas exenciones como parte del Programa de Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro dedicada a la información de salud que incluye a KFF Health News.

“No sabemos exactamente qué cubrirá”, declaró Hinton.

Hinton agregó que no está claro cómo responderán los funcionarios federales a las solicitudes de los estados, pero dijo que “somos conscientes de que algunos piensan que no hay margen de maniobra”.

Los estados pueden ajustar sus programas de Medicaid mediante las llamadas “exenciones de demostración”, sujetas a la aprobación federal. Estas exenciones están diseñadas para probar nuevas ideas en áreas política “grises”.

Los estados que han presentado o planean presentar solicitudes con requisitos laborales incluyen: Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, Carolina del Norte, Ohio, Carolina del Sur, Dakota del Sur y Utah.

Los republicanos del Congreso que aprobaron el proyecto de ley de reconciliación presupuestaria permitieron a los estados utilizar exenciones para acelerar la aplicación de las normas nacionales. Tara Sklar, profesora a cargo del Programa de Derecho y Políticas de Salud de la Universidad de Arizona, afirmó que espera que los estados que soliciten requisitos más estrictos tengan posibilidades de ser aprobados, mientras que los más flexibles podrían ser rechazados.

Sklar dijo que oficiales federales podrían ver con buenos ojos el plan de Arizona, ya que un límite vitalicio de cinco años para Medicaid es diferente a los requisitos laborales. Incluso si el gobierno federal aprueba estos requisitos más estrictos que los que exige la ley federal, es probable que esos programas enfrenten impugnaciones legales, afirmó.

La ley federal incluye un mínimo de 80 horas mensuales para trabajar o estudiar, con exenciones para ciertos adultos, como personas con problemas médicos delicados y padres con hijos pequeños dependientes.

Montana es el primer estado en redactar una solicitud de exención desde que el Congreso finalizó los requisitos laborales nacionales. Legisladores estatales aprobaron inicialmente los requisitos laborales —denominados estándares de “participación comunitaria” según el plan estatal— en 2019, pero la solicitud del estado se estancó hasta el final del primer mandato de Trump y durante la administración Biden.

Luego de la reelección de Trump, los legisladores de Montana levantaron la fecha de vencimiento de 2025 de su programa de expansión de Medicaid, declarando permanente el programa que cubría a más de 76.000 adultos en abril, con la expectativa de que la administración Trump aprobara los requisitos laborales.

A mediados de julio, las autoridades estatales publicaron su plan preliminar para hacerlo realidad “tan pronto como sea posible”.

El plan de Montana se alinea en gran medida con la ley federal, pero crearía exenciones adicionales, incluso para personas sin hogar o que huyen de la violencia doméstica.

La senadora estatal republicana Gayle Lammers afirmó que los requisitos laborales que también protegen a las personas que necesitan Medicaid fueron un factor clave para persuadir a los legisladores a mantener el programa de expansión. En ese momento, las autoridades desconocían la postura del gobierno federal sobre los requisitos laborales. Y ahora, según Lammers, tiene sentido que Montana se apegue a su plan.

“El estado debería tener voz y voto”, afirmó Lammers. “Somos muy independientes y cada persona es diferente”.

En Carolina del Sur, las autoridades estatales buscan implementar requisitos laborales para un número limitado de nuevos beneficiarios de Medicaid elegibles. Carolina del Sur es uno de los 10 estados que no ha ampliado la elegibilidad para Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA). Sin embargo, en junio presentó una solicitud al gobierno federal para una expansión parcial de Medicaid que incluye un componente de requisito de trabajo que refleja en gran medida las nuevas normas federales.

En una carta al Secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., el gobernador de Carolina del Sur, el republicano Henry McMaster, calificó la propuesta estatal como “una solución específica para el estado”.

El único estado con un programa de requisito de trabajo activo ahora quiere reducirlo y espera la aprobación federal para hacerlo. “Georgia Pathways to Coverage” vence a finales de septiembre a menos que los CMS autoricen una extensión del programa con un cambio clave: exigir a los afiliados que documenten su trabajo una vez al año, no mensualmente. Esto representa un cambio con respecto al diseño inicial del programa, pero también difiere de las nuevas normas federales, que exigen verificaciones cada seis meses.

Fiona Roberts, vocera de la agencia de Medicaid de Georgia, afirmó que el estado aún espera saber si necesita modificar su plan.

Por lo tanto, Georgia se encuentra entre los estados en estado de incertidumbre, a la espera de la orientación del gobierno federal.

Los corresponsales de KFF Health News, Sam Whitehead y Lauren Sausser, contribuyeron con este informe.

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When President Donald Trump signed a law adding work requirements for some Medicaid recipients, he may have undercut lawmakers in at least 14 states who were designing their own plans, according to health industry observers.

Georgia is the only state with a work requirement in place for Medicaid, but several states have been pursuing such a policy for years, only to be blocked by courts or, most recently, the Biden administration. Some seek state-specific touches to the new rules. Others aim to implement work requirements before the federal law takes effect at the end of 2026.

These states’ moves and Trump’s massive tax-and-spending law share one demand: To keep their Medicaid health coverage, adults who can work must prove they’re logging a minimum number of hours at a job or school, or else qualify for one of the few exemptions.

But now, states that jumped ahead need to ensure their proposals, which require federal approval, don’t stray too far from Trump’s law.

“The statute sets both the floor and ceiling” for work requirements, said Sara Rosenbaum, a health law and policy professor with George Washington University.

South Dakota, for example, announced in July that it would not submit an application for work requirements as previously planned amid concerns that the state’s laxer rules would not be allowed under the new federal law. The state’s Department of Social Services secretary had warned that working on a state proposal while the federal rules are being hashed out could be “an exercise in futility.”

Arkansas’ plan, on the other hand, is more stringent than the federal law. There are no exemptions to its work requirements in the application, which is pending with the Centers for Medicare & Medicaid Services.

Arizona’s proposal also includes something that’s not in the federal law: a ban on “able-bodied adults” receiving Medicaid benefits for longer than five years total in their lives.

Arkansas and Arizona government officials said they were working with federal officials to square their plans with the new standards.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, said the department is analyzing how the new federal standards interact with state waivers.

The federal health department must release rules by next June that outline how states are to implement work requirements, according to Elizabeth Hinton, who has been tracking such waivers as part of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News.

“We don’t exactly know what that will cover,” Hinton said.

It’s unclear how federal officials will respond to the states’ requests, she added, but “we are aware that some folks think there is no wiggle room here.”

States can tweak their Medicaid programs through what are known as demonstration waivers, which are subject to federal approval. The waivers are designed to test new ideas in policy gray areas.

The states that have filed or plan to file such applications with work requirements include Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Montana, New Hampshire, North Carolina, Ohio, South Carolina, South Dakota, and Utah.

Congressional Republicans who passed the budget reconciliation bill left room for states to use waivers to fast-track the national standards. Tara Sklar, a professor leading the University of Arizona’s Health Law & Policy Program, said she expects states seeking certain stricter requirements to have a chance of approval, while more lenient ones may face denials.

Federal officials may look favorably on Arizona’s plan, Sklar said, as a five-year lifetime Medicaid limit is different from work requirements. Even if the federal government greenlights stricter work requirements than the federal law calls for, those programs are likely to face legal challenges, she added.

The federal law includes an 80-hour-per-month minimum for work or education, with exemptions for certain adults, including people who are medically frail and parents with young, dependent children.

Montana is the first state to draft a waiver application since Congress finalized national work requirements. State lawmakers first approved work requirements — called “community engagement” standards under the state plan — in 2019, but the state’s application stalled through the end of the first Trump term and the Biden administration.

After Trump was elected again, Montana lawmakers lifted the 2025 expiration date of its Medicaid expansion program, making permanent the program that covered more than 76,000 adults in April, with the expectation that the Trump administration would approve work requirements. In mid-July, state officials released their draft plan to make that a reality “as soon as is practicable.”

The Montana plan largely aligns with the federal law, but it would create additional exemptions, including for people who are homeless or fleeing domestic violence.

Republican state Sen. Gayle Lammers said work requirements that also protect such people who need Medicaid were a big part of persuading legislators to keep the expansion program. At the time, officials didn’t know where the federal government would land on work requirements. And now, Lammers said, it makes sense for Montana to stick to its plan.

“The state should have a say,” Lammers said. “We’re very independent, and everyone is different.”

In South Carolina, state officials are seeking to roll out work requirements for a limited number of newly eligible Medicaid beneficiaries. South Carolina is one of 10 states that has not expanded Medicaid eligibility under the Affordable Care Act, and yet the state submitted a request with the federal government in June for a partial Medicaid expansion that includes a work requirement component that largely reflects the new federal standards.

In a letter to Health and Human Services Secretary Robert F. Kennedy Jr., South Carolina Gov. Henry McMaster, a Republican, called South Carolina’s proposal “a state-specific solution.”

The only state with an active work requirement program now wants to scale it back and awaits federal approval to do so. “Georgia Pathways to Coverage” expires at the end of September unless CMS greenlights an extension of the program with a key change: requiring enrollees to document once a year that they’re working, not monthly. That’s a pivot away from the program’s initial design but also differs from the new federal rules, which call for checks every six months.

Fiona Roberts, a spokesperson for Georgia’s Medicaid agency, said the state is still waiting to hear whether it needs to alter its plan.

So Georgia is among the states in limbo, awaiting guidance from the federal government.

KFF Health News correspondents Sam Whitehead and Lauren Sausser contributed to this report.

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If you want a covid-19 shot this fall, will your employer’s health insurance plan pay for it? There’s no clear answer.

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, has upended the way covid vaccines are approved and for whom they’re recommended, creating uncertainty where coverage was routine.

Agencies within HHS responsible for spelling out who should get vaccinated aren’t necessarily in sync, issuing seemingly contradictory recommendations based on age or risk factors for serious disease.

But the ambiguity may not affect your coverage, at least this year.

“I think in 2025 it’s highly likely that the employer plans will cover” the covid vaccines, said Jeff Levin-Scherz, a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard’s T.H. Chan School of Public Health. They’ve already budgeted for it, “and it would be a large administrative effort to try to exclude coverage for those not at increased risk,” he said.

With so much in flux, it’s important to check with your employer or insurer about coverage policies before you roll up your sleeve.

Here’s what we know so far, and what remains unclear.

Q: How have the recommendations changed?

What used to be straightforward is now much murkier. Last year, the Moderna and Pfizer-BioNTech covid vaccines were recommended for anyone at least 6 months old.

This year, the recommendation by the Centers for Disease Control and Prevention is narrower. Although the vaccines are broadly recommended for adults 19 and older, they are no longer recommended for healthy pregnant people or for healthy children 6 months through 17 years old.

Kennedy announced the changes in a video in May, citing safety risks for young people and pregnant people as justification.

But his claims have been widely disputed by experts in vaccines, pediatrics, and women’s health. An analysis by FactCheck.org found that the secretary “misrepresented scientific research to make unfounded claims about vaccine safety for pregnant people and children.”

In addition, recently announced changes to the vaccine approval framework have further chipped away at eligibility.

Moderna announced July 10 that the FDA had fully approved its Spikevax covid vaccine — but approval is restricted to adults 65 and older, and for people from 6 months through 64 years old who are at increased risk of developing a serious case of covid.

Two other covid vaccines expected to be available this fall, Novavax’s Nuvaxovid and Moderna’s mNexspike, are also restricted. They are approved for people 65 or older and those 12 to 64 who have underlying health conditions that put them at higher risk of developing severe covid.

Notably, Pfizer’s Comirnaty covid vaccine is still approved or authorized for people 6 months of age and older without any restrictions based on risk factors for covid — at least for now. But the FDA could change that at any time, experts said.

Increasing restrictions “is definitely the direction they are moving,” said Jen Kates, a senior vice president at KFF who authored a KFF analysis of vaccine insurance coverage rules. KFF is a health information nonprofit that includes KFF Health News.

HHS did not provide an on-the-record comment for this article.

Q: How might these changes alter my insurance coverage for the vaccine?

That’s the big question, and the answer is uncertain. Without insurance coverage, people could owe hundreds of dollars for the shot.

Most private health plans are required by law to cover recommended vaccines, whether for covid, measles, or the flu, without charging their members. But that requirement kicks in after the shots are recommended by a federal panel — the Advisory Committee on Immunization Practices — and adopted by the CDC director, according to the KFF analysis. The committee hasn’t yet voted on covid vaccine recommendations for this fall. Its next meeting is expected to occur in August or September.

Still, employers and insurers can opt to cover the vaccines on their own, as many did before the law required them to do so. But they may require people to pay something for it.

In addition, the narrower recommendations from different HHS agencies might result in some health plans declining to pay for certain categories of people to get certain vaccines, experts said.

“I don’t think an employer or insurer would deny coverage,” Kates said. “But they could say: You have to get this product.”

That could mean a 45-year-old with no underlying health conditions raising their covid risk might have to get the Pfizer shot rather than the Moderna version if they want their health plan to pay for it, experts said.

In addition, up to 200 million people may qualify for the vaccines because they have health conditions such as asthma or diabetes that increase their risk of severe disease, according to a commentary published by FDA officials in the New England Journal of Medicine.

Health care professionals can help people determine whether they qualify for the shot based on health conditions.

Tina Stow, a spokesperson for AHIP, which represents health plans, said in a statement that plans will continue to follow federal requirements for vaccine coverage.

Q: What are the options for people who are pregnant or have children they want to have vaccinated?

Many parents are confused about getting their kids vaccinated, according to a KFF poll released on Aug. 1. About half said they don’t know whether federal agencies recommend healthy children get the vaccine this fall. Among the other half, more said the vaccine is not recommended than recommended.

Meanwhile, Kennedy’s recommendation that healthy children not get vaccinated has a notable caveat: If a parent wishes a child to get a covid vaccine and a health care provider recommends it, the child can receive it under the “shared clinical decision-making” model, and it should be covered without cost sharing.

Some policy experts point out that this is the way care for kids is typically provided anyway.

“Outside of any requirements, vaccines have always been provided through shared decision-making,” said Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America.

There’s no similar allowance for pregnant people. However, even though Kennedy has stated that covid vaccines are no longer recommended for healthy pregnant people, pregnancy is one of the underlying medical conditions that put people at high risk for getting very sick from covid, according to the CDC. That could make pregnant people eligible for the shot.

Depending on the stage of someone’s pregnancy, it could be difficult to know whether someone should be denied the shot based on their condition. “This is uncharted territory,” said Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms.

Q: How will these changes affect access to the vaccine? Will I still be able to go to the pharmacy for the shot?

“If far fewer are expected to be vaccinated, fewer sites will offer the vaccinations,” Levin-Scherz said. This could be an especially notable hurdle for people looking for pediatric doses of a covid vaccine, he said.

In addition, pharmacists’ authority to administer vaccines depends on several factors. For example, in some states they can administer shots that have been approved by the FDA, while in others the shots must have been recommended by the ACIP, said Hannah Fish, senior director of strategic initiatives at the National Community Pharmacists Association. Since ACIP hasn’t yet recommended covid shots for the fall, that could create a speed bump in some states.

“Depending on the rules, you still may be able to get the shot at the pharmacy, but they might have to call the physician to send over a prescription,” Fish said.

Q: What do these changes mean long-term?

It’s impossible to know. But given Kennedy’s vocal skepticism of vaccines and his embrace of long-disproven theories about connections between vaccines and autism, among other things, medical and public health professionals are concerned those views will shape future policies.

“The recommendation changes that were made with respect to children and pregnant women were not necessarily made in good science,” Corlette said.

It’s already a challenge to convince people they need annual covid shots, and shifting guidelines may make it tougher, some public health experts warn.

“What’s concerning is that this could even further depress the uptake of the covid vaccines,” Jezek said.

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In his ongoing effort to reshape health policy, Secretary of Health and Human Services Robert F. Kennedy Jr. reportedly plans to overhaul two more government entities: the U.S. Preventive Services Task Force and the National Vaccine Injury Compensation Program. Ousting the existing members of the task force would give Kennedy a measure of control in determining the kinds of preventive care that are covered at no cost to patients in the United States. And while it’s unclear what the secretary would do to the vaccine injury program, Kennedy has made no secret of his belief that vaccines can do more harm than good.

Meanwhile, last week marked the 35th anniversary of the Americans with Disabilities Act, and President Donald Trump signed an executive order that would enable local and state governments to forcibly hospitalize some people who are homeless and struggling with mental health problems.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.

Among the takeaways from this week’s episode:

• Less than two months after Kennedy removed all members of the Advisory Committee on Immunization Practices, he is reportedly considering a similar purge of members of the task force that recommends the preventive services insurers must cover — a list whose services, some of them controversial among Trump officials, include drugs that prevent HIV and certain cancer screenings. He is also considering changes to the federal program that compensates people who experience adverse effects from immunizations.
• This week Vinay Prasad, the Food and Drug Administration’s top vaccine official, resigned just months into his tenure. Prasad had come under attack, notably by right-wing personality Laura Loomer, and had been blasted for some agency decisions about new drugs for rare diseases — despite his work limiting the use of covid shots.
• Trump’s newly announced trade deal with the European Union includes a 15% tariff on brand-name pharmaceuticals, which would include, for example, the diabetes drug Ozempic, often used for weight loss. But it would be difficult to lower prices on brand-name drugs through tariffs; it is unlikely that drugmakers, facing higher import costs, would relocate production to the United States.
• Also, Trump’s big tax and spending law, hastened through Congress weeks ago, renders some lawfully present immigrants ineligible for Affordable Care Act subsidies. But a new KFF Health News column points out that the change would actually raise premiums for everyone else, taking more healthy people out of the insurance pool.

Also this week, Rovner interviews George Washington University health policy professor Sara Rosenbaum, one of the nation’s leading Medicaid experts, to mark Medicaid’s 60th anniversary this week.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KFF Health News’ “Cosmetic Surgeries Led to Disfiguring Injuries, Patients Allege,” by Fred Schulte.

Anna Edney: The Washington Post’s “Morton Mintz, Post Reporter With a Muckraker Spirit, Dies at 103,” by Stefanie Dazio.

Joanne Kenen: ScienceAlert’s “New Kind of Dental Floss Could Replace Vaccine Needles, Study Finds,” by David Nield.

Shefali Luthra: The New Yorker’s “Mexico’s Molar City Could Transform My Smile. Did I Want It To?” by Burkhard Bilger.

Also mentioned in this week’s podcast:

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Durante dos décadas, la pediatra Lanre Falusi, de Washington D.C., ha asesorado a los padres sobre el calendario de vacunas que deben recibir sus hijos, la seguridad de la vacunación y sus efectos secundarios.

Pero dijo que este año las charlas han cambiado.

“Por primera vez, los padres de recién nacidos me preguntan si en el futuro sus bebés podrán seguir recibiendo las vacunas”, contó Falusi.

A lo largo del país, pediatras dicen que padres ansiosos están preocupados por si continuará habiendo acceso a las vacunas infantiles de rutina. Los más intranquilos son aquellos con hijos en Medicaid, el programa del gobierno que ofrece seguro médico para familias de bajos ingresos y personas con discapacidades.

Medicaid cubre a 4 de cada 10 niños en el país.

“El problema realmente surgió cuando RFK Jr. asumió el cargo de secretario de Salud y Servicios Humanos (HHS)”, afirmó Deborah Greenhouse, pediatra de Carolina del Sur.

La preocupación aumentó tras la reestructuración, en el mes de junio, de un órgano asesor clave sobre vacunas de los Centros para el Control y Prevención de Enfermedades (CDC). Millones de familias temen que en un futuro cercano tengan que pagar de su bolsillo las vacunas que actualmente están cubiertas por su seguro médico.

El secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., conocido activista antivacunas, destituyó a los 17 miembros del Comité Asesor sobre Prácticas de Inmunización (ACIP), el grupo responsable de recomendar las vacunas que deberían ser incluidas en los calendarios nacionales de inmunización para niños y adultos.

Kennedy sustituyó a los miembros del panel por otros nuevos, afines a sus puntos de vista, lo que generó alarma entre profesionales médicos y los expertos en salud pública.

“La gente debería preocuparse por lo que va a pasar con la disponibilidad de vacunas para los niños”, afirmó Jennifer Tolbert, directora adjunta del Programa sobre Medicaid y Personas sin Seguro Médico de KFF.

En virtud de la Ley de Cuidado de Salud a Bajo Precio (ACA), las aseguradoras médicas actualmente están obligadas a cubrir todas las vacunas recomendadas por el ACIP. Además, los estados y otras jurisdicciones utilizan el calendario de vacunación infantil para establecer los requisitos de inmunización de los escolares.

Las recomendaciones del ACIP también determinan qué vacunas están cubiertas por el programa Vaccines for Children (VFC), una iniciativa financiada por los CDC que proporciona dosis gratuitas a niños de familias de bajos ingresos y sin seguro médico.

La mitad de los niños del país son elegibles para este programa.

Si los nuevos miembros del ACIP retiraran su apoyo a una vacuna concreta y el director de los CDC estuviera de acuerdo, las consecuencias serían inmediatas, aseguró Tolbert. “Eso afectaría automáticamente qué vacunas están cubiertas y, por lo tanto, cuáles se encuentran disponibles para los niños beneficiarios de Medicaid”, explicó.

Las aseguradoras aún no han dicho cómo modificarían la cobertura, pero Tolbert afirmó que una medida de ese tipo abriría la puerta a que los planes de salud privados se negaran a cubrir la vacuna.

Los pediatras temen que en el futuro los padres se vean obligados a elegir entre pagar cientos de dólares de su bolsillo por las vacunas o dejar a sus hijos desprotegidos.

Por su parte el AHIP, la asociación nacional que agrupa a la industria de seguros médicos, dijo que los planes “siguen cumpliendo los requisitos federales relacionados con la cobertura de las vacunas recomendadas por el ACIP y seguirán apoyando el amplio acceso a servicios preventivos críticos, incluidas las vacunas”.

Los pediatras también dicen que las noticias sobre la nueva ley presupuestaria del presidente Donald Trump, que se espera que reduzca el gasto en Medicaid en aproximadamente $1.000 millones durante la próxima década, también han generado mucha inquietud entre los padres.

En realidad, aunque pueden estar preocupados por perder su Medicaid, Tolbert advirtió que la ley no menciona las vacunas ni cambia los requisitos de elegibilidad o las prestaciones de Medicaid para los niños. Sin embargo, menos financiación federal significa que los estados tendrán que tomar decisiones sobre a quiénes seguirán cubriendo y qué servicios se les ofrecerá.

Para tener los fondos necesarios para pagar Medicaid, los estados podrían aumentar los impuestos y destinar a este programa fondos destinados a otras áreas, como la educación o el sistema penitenciario. Pero lo más probable es que opten por reducir el gasto en Medicaid.

“También podrían hacerlo recortando la elegibilidad de poblaciones opcionales, recortando servicios que son opcionales o reduciendo los pagos a los proveedores”, argumentó Tolbert. “No está claro cómo se desarrollará esto, y es probable que sea diferente en cada uno de los estados”.

En junio, Kennedy anunció en una publicación en X que los CDC ya no recomiendan la vacuna contra covid-19 para niños sanos y embarazadas. La medida provocó una demanda judicial por parte de la Academia Americana de Pediatría y otras asociaciones de médicos que buscan frenar la directiva de Kennedy.

También ese mes, los nuevos miembros del ACIP nombrados por Kennedy votaron a favor de recomendar que los adultos y los niños ya no reciban vacunas contra la gripe con timerosal, un conservante que rara vez se utiliza en vacunas contra la gripe.

Los activistas antivacunas, entre ellos Kennedy, llevan décadas manifestándose contra el timerosal, alegando que está relacionado con el autismo, a pesar de que no existe evidencia científica que respalde esa relación.

“No hay motivo de preocupación”, afirmó en un comunicado Emily Hilliard, vocera del Departamento de Salud y Servicios Humanos. “Como ha declarado el secretario Kennedy, no se negará a nadie el acceso a una vacuna autorizada si decide recibirla”.

“Cuando el comité del ACIP se reunió en junio, reafirmó que las vacunas contra la gripe seguirán siendo accesibles y estarán dentro de la cobertura. Por otra parte, hizo hincapié en la seguridad garantizando que estas vacunas no contienen mercurio”, escribió Hilliard.

“El programa Vaccines for Children sigue proporcionando vacunas contra covid-19 sin costo alguno para los niños que cumplen los requisitos cuando los padres, el proveedor y el paciente consideren que la vacunación es adecuada. Medicaid seguirá reembolsando los gastos de administración”.

Sin embargo, la posibilidad de que una vacuna sea restringida o deje de estar cubierta ya está cambiando la forma en que los padres abordan la inmunización. En el consultorio de Falusi, están programando citas para que la vacunación coincida exactamente con los requisitos de elegibilidad de sus hijos, a veces incluso en la misma semana de su cumpleaños.

En Albuquerque, Nuevo México, la pediatra Melissa Mason, ha atendido algunos pacientes que contrajeron sarampión durante el brote en varios estados que comenzó en Texas.

Teme que nuevas limitaciones a la vacunación derive en más enfermedad y muertes.

Desde enero, se han registrado a nivel nacional más de 1.300 casos de sarampión, según los CDC. “Estamos viendo este brote porque las tasas de vacunación son demasiado bajas y eso permite que el sarampión se propague en la comunidad”, dijo Mason.

Los niños y adolescentes representan el 66% de los casos de sarampión, indican los CDC. En respuesta, Mason ha comenzado a ofrecer la vacuna contra el sarampión a bebés de tan solo 6 meses, medio año antes de lo habitual, aunque dentro de las directrices federales.

El año pasado, las tasas generales de vacunación en los jardines de infantes descendieron en el país, y el número de niños con exención de vacunación escolar siguió aumentando.

Mason teme que, si se restringe el acceso a las vacunas, las comunidades vean el regreso de otras enfermedades prevenibles que se han mantenido bajo control durante mucho tiempo, especialmente en estados como Nuevo México, donde el 61% de los niños están bajo Medicaid.

La tos ferina, otra enfermedad que puede ser mortal para los niños más pequeños, también se está propagando. Según informaron los CDC, hasta el 5 de julio se habían identificado más de 15.100 casos. Mason explicó que la tos ferina es especialmente peligrosa para los bebés demasiado pequeños para recibir la vacuna.

Por ahora, los pediatras están tratando de subrayar la urgencia sin provocar pánico en la población.

En Columbia, Carolina del Sur, Greenhouse solía ofrecer a las familias un rango de edad flexible para las vacunas de rutina.

“Ya no digo eso”, expresó la pediatra.

Ahora, la médica recomienda a los padres a vacunar a sus hijos tan pronto como puedan hacerlo.

Muchos de ellos le han preguntado si la vacuna contra el VPH, que ayuda a prevenir el cáncer de cuello uterino, se puede administrar a niños menores de la edad recomendada, que es de 9 años.

“De hecho, hoy mismo dos padres me han preguntado si sus hijos de 7 u 8 años podían recibir la vacuna contra el VPH”, contó Greenhouse. “Tuve que responderles que no está permitido”.

Dado que la vacuna requiere varias dosis aplicadas con meses de diferencia, Greenhouse teme que se acabe el tiempo para que las familias puedan cubrir la serie con el seguro de salud. Algunas familias pueden decidir no comprar la segunda dosis si tienen que pagarla de su bolsillo. Si ya no está cubierta por el seguro, esa segunda dosis podría costar alrededor de $300.

“No puedo estar 100% segura de cómo será el futuro de algunas de estas vacunas”, reflexionó Greenhouse. “Lo que sí puedo decir es que es una situación muy aterradora”.

Se espera que el comité asesor sobre vacunas que nombró recientemente el secretario Kennedy realice su próxima reunión pública en agosto.

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If you want to create a perfect storm at Covered California and other Affordable Care Act marketplaces, all you have to do is make enrollment more time-consuming, ratchet up the toll on consumers’ pocketbooks, and terminate financial aid for some of the youngest and healthiest enrollees.

And presto: You’ve got people dropping coverage; rising costs; and a smaller, sicker group of enrollees, which translates to higher premiums.

The Trump administration and congressional Republicans have just checked that achievement off their list.

They have done it with the sprawling tax and spending law President Donald Trump signed on July 4 and a related set of new regulations released by the Centers for Medicare & Medicaid Services that will govern how the ACA marketplaces are run.

Among the many provisions, there’s this: Large numbers of lawfully present immigrants currently enrolled in Obamacare health plans will lose their subsidies and be forced to pay full fare or drop their coverage.

Wait. What?

I understand that proponents of the new policies think the government spends too much on taxpayer subsidies, especially those who believe the ACA marketplaces are rife with fraud. It makes sense that they would support toughening enrollment and eligibility procedures and even slashing subsidies. But taking coverage away from people who live here legally is not health care policy. It’s an echo of the federal immigration raids in Los Angeles and elsewhere.

“It’s creating a very hostile environment for them, especially after having to leave their countries because of some very traumatic experiences,” says Arturo Vargas Bustamante, a professor of health policy and management at UCLA’s Fielding School of Public Health. “For those who believe health care is a human right, this is like excluding that population from something that should be a given.”

In Covered California, 112,600 immigrants, or nearly 6% of total enrollees, stand to lose their federal tax subsidies when the policy takes effect in 2027, according to data provided by the exchange. In the Massachusetts and Maryland marketplaces, the figure is closer to 14%, according to their directors, Audrey Morse Gasteier and Michele Eberle, respectively.

It’s not clear exactly how much financial aid those immigrants currently receive in ACA marketplaces. But in Covered California, for example, the average for all subsidized enrollees is $561 per month, which covers 80% of the $698 average monthly premium per person. And immigrants, who tend to have lower-than-average incomes, are likely to get more of a subsidy.

The immigrants who will lose their subsidies include victims of human trafficking and domestic violence, as well as refugees with asylum or with some temporary protected status. And “Dreamers” will no longer be eligible for ACA marketplace health plans because they will not be considered lawfully present. Immigrants who are not in the country legally cannot get coverage through Covered California or most other ACA marketplaces.

The nearly 540,000 Dreamers in the United States arrived in the U.S. as kids without immigration papers and were granted temporary legal status by President Barack Obama in 2012. Of those, an estimated 11,000 have ACA health plans and would lose them, including 2,300 in Covered California.

Supporters of the policy changes enshrined in the CMS rule and budget law think it’s high time to rein in what they say are abuses in the system that started under the Biden administration with expanded tax credits and overly flexible enrollment policies.

“It’s about making Obamacare lawful and implementing it as drafted rather than what Biden turned it into, which was a fraud and a waste-infused program,” says Brian Blase, president of Arlington, Virginia-based Paragon Health Institute, which produces policy papers with a free-market bent and influenced the Republican-driven policies.

But Blase doesn’t have much to say about the termination of Obamacare subsidies for lawfully present immigrants. He says Paragon has not focused much on that subject.

Jessica Altman, executive director of Covered California, expects most immigrants who lose subsidies will discontinue their enrollment. “If you look at where those populations fall on the income scale, the vast majority are not going to be able to afford the full cost of the premium to stay covered,” she says.

Apart from the human hardship cited by Bustamante, the exodus of immigrants could compromise the financial stability of coverage for the rest of Covered California’s 1.9 million enrollees. That’s because immigrants tend to be younger than the average enrollee and use fewer medical resources, thus helping offset the costs of older and sicker people who are more expensive to cover.

Covered California data shows that immigrant enrollees targeted by the new federal policies pose significantly lower medical risk than U.S. citizens. And a significantly higher percentage of immigrants in the exchange are ages 26 to 44, while 55- to 64-year-olds make up a smaller percentage.

Still, it would be manageable if immigrants were the only younger people to leave the exchange. But that is unlikely to be the case. More red tape and higher out-of-pocket costs — especially if enhanced tax credits disappear — could lead a lot of young people to think twice about health insurance.

The covid-era enhanced tax credits, which have more than doubled ACA marketplace enrollment since their advent in 2021, are set to expire at the end of December without congressional action. And, so far, Republicans in Congress do not seem inclined to renew them. Ending them would reverse much of that enrollment gain by jacking up the amount consumers would have to spend on premiums out of their own pockets by an average of 66% at Covered California and more than 75% nationally.

And an analysis by the Congressional Budget Office shows that a consequent exodus of younger, healthier people from the marketplaces would lead to even greater costs over time.

Enhanced tax credits aside, consumers face additional hurdles: The annual enrollment period for Covered California and other marketplaces will be shorter than it is now. Special enrollment periods for people with the lowest incomes will be effectively eliminated. So will automatic renewals, which have greatly simplified the process for a majority of enrollees at Covered California and some other marketplaces. Enrollees will no longer be able to start subsidized coverage, as they can now, before all their information is fully verified.

“Who are the people who are going to decide to go through hours and hours of onerous paperwork?” says Morse Gasteier. “They’re people who have chronic conditions. They have health care issues they need to manage. The folks we would expect not to wade through all that red tape would be the younger, healthier folks.”

California and 20 other states this month challenged some of that red tape in a federal lawsuit to stop provisions of the CMS rule that erect “unreasonable barriers to coverage.” California Attorney General Rob Bonta said he and his fellow attorneys general hoped for a court ruling before the rule takes effect on Aug. 25.

“The Trump administration claims that their final rule will prevent fraud,” Bonta said. “It’s obvious what this is really about. It’s yet another political move to punish vulnerable communities by removing access to vital care and gutting the Affordable Care Act.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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For two decades, Washington, D.C., pediatrician Lanre Falusi has counseled parents about vaccine safety, side effects, and timing. But this year, she said, the conversations have changed.

“For the first time, I’m having parents of newborns ask me if their baby will still be able to get vaccines,” Falusi said.

Throughout the country, pediatricians say anxious parents are concerned about access to routine childhood immunizations, especially those with children on Medicaid, the government insurance program for low-income families and people with disabilities. Medicaid covers 4 in 10 children in the U.S.

“It really became an issue when RFK Jr. stepped into the role of HHS secretary,” said Deborah Greenhouse, a pediatrician in South Carolina.

The concern accelerated after the shake-up of a key Centers for Disease Control and Prevention vaccine advisory body in June, raising fears that millions of American families could soon have to pay out-of-pocket for shots now covered by their health insurance.

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, removed all 17 members of the CDC’s Advisory Committee on Immunization Practices, the panel responsible for recommending which shots are included in the nation’s adult and childhood immunization schedules.

Kennedy replaced the panelists with new members aligned with his views, prompting alarm among medical professionals and public health experts.

“People should be worried about what’s going to happen to the availability of vaccines for children,” said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a national health information nonprofit that includes KFF Health News.

Under the Affordable Care Act, health insurers are required to cover all ACIP-recommended vaccines. States and other jurisdictions use the childhood vaccine schedule to set immunization requirements for schoolchildren. ACIP’s recommendations also determine which vaccines get covered by the Vaccines for Children Program, a CDC-funded initiative that provides free immunizations to low-income and uninsured children. Half of children in the U.S. are eligible for the VFC program.

If the new ACIP members withdraw support for a particular vaccine and the CDC director agrees, Tolbert said, the consequences would be immediate. “It would automatically affect what is covered and therefore which vaccines are available to children on Medicaid,” she said.

Health insurance companies have not yet said how they would alter coverage, but Tolbert said such a move would open the door for private insurers to refuse to cover the vaccine.

Pediatricians worry about a future where parents might have to choose — pay hundreds of dollars out-of-pocket for shots or leave their kids unprotected.

The health insurance industry group AHIP said that health plans “continue to follow federal requirements related to coverage of ACIP-recommended vaccines and will continue to support broad access to critical preventive services, including immunizations.”

Pediatricians say news about President Donald Trump’s new budget law, which is expected to reduce Medicaid spending by about $1 trillion over the next decade, also prompted questions from parents.

While parents may be worried about losing their Medicaid, the law doesn’t mention vaccines or change eligibility or benefits for children’s Medicaid, Tolbert said. But less federal funding means states will have to make decisions about who is covered and which services are offered.

To raise the revenue needed to pay for Medicaid, states could raise taxes; move money earmarked for other spending, such as education or corrections; or, more likely, reduce Medicaid spending.

“And they may do that by cutting eligibility for optional populations or by cutting services that are optional, or by reducing payments to providers in the form of provider rates,” Tolbert said. “It’s unclear how this will play out, and it will likely look different across all states.”

In May, Kennedy announced in a post on X that the CDC is no longer recommending the covid-19 vaccine for healthy children and pregnant women. The move prompted a lawsuit by the American Academy of Pediatrics and other physician groups that seeks to freeze Kennedy’s directive.

In June, the new ACIP members appointed by Kennedy voted to recommend that adults and children no longer receive flu vaccines with thimerosal, a preservative rarely used in some flu vaccines. Anti-vaccine activists, including Kennedy, have rallied against thimerosal for decades, alleging links to autism despite no evidence of any association.

“There is no cause for concern,” Department of Health and Human Services spokesperson Emily Hilliard said in a statement. “As Secretary Kennedy has stated, no one will be denied access to a licensed vaccine if they choose to receive one.”

“When the ACIP committee met last month, they reaffirmed that flu vaccines will remain accessible and covered, and they emphasized safety by ensuring these vaccines are mercury-free,” Hilliard wrote. “The Vaccines for Children (VFC) program continues to provide COVID-19 vaccines at no cost for eligible children when the parent, provider, and patient decide vaccination is appropriate. Medicaid will continue to reimburse the administration fee.”

But the possibility that a vaccine could be restricted or no longer covered by insurance is already changing how parents approach immunization. In Falusi’s practice, parents are scheduling appointments to coincide precisely with their child’s eligibility, sometimes making appointments the same week as their birthdays.

Melissa Mason, a pediatrician in Albuquerque, New Mexico, has evaluated some patients who contracted measles during the multistate outbreak that started in neighboring Texas.

She’s concerned that any new limitations on access or reimbursement for childhood vaccines could lead to even more preventable illnesses and deaths.

Nationally, there have been more than 1,300 measles cases since January, including three deaths, according to the CDC. “We’re seeing this outbreak because vaccination rates are too low and it allows measles to spread in the community,” Mason said.

Children and teens account for 66% of national measles cases. Mason has begun offering the measles vaccine to infants as young as 6 months old, a full six months earlier than standard practice, though still within federal guidelines.

Last year, overall kindergarten vaccination rates fell in the U.S. At the same time, the number of children with a school vaccination exemption continued to rise.

Pertussis, or whooping cough — another disease that can be deadly to young children — is spreading. As of July 5, more than 15,100 cases had been identified in U.S. residents this year, according to the CDC.

Mason said pertussis is especially dangerous to babies too young to receive the vaccine.

For now, pediatricians are trying to maintain a sense of urgency without inciting panic.

In Columbia, South Carolina, Greenhouse used to offer families a flexible age range for routine vaccinations.

“I’m not saying that anymore,” the pediatrician said.

She now urges parents to get their children vaccinated as soon as they are eligible.

She described anxious parents asking whether the HPV vaccine, which helps prevent cervical cancer, can be administered to children younger than the recommended age of 9.

“I actually had two parents today ask if their 7- or 8-year-olds could get the HPV shot,” Greenhouse said. “I had to tell them it’s not allowed.”

With the vaccine requiring multiple doses months apart, Greenhouse fears time may run out for families to get the series covered by insurance. If they have to pay out-of-pocket, she’s afraid some families may choose not to get the second dose. A second dose could cost about $300 if no longer covered by insurance.

“I cannot be 100% sure what the future looks like for some of these vaccines,” Greenhouse said. “I can tell you it’s a very scary place to be.”

Kennedy’s newly appointed vaccine advisory committee is expected to hold its next public meeting as soon as August.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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President Donald Trump rode to reelection last fall on voter concerns about prices. But as his administration pares back federal rules and programs designed to protect patients from the high cost of health care, Trump risks pushing more Americans into debt, further straining family budgets already stressed by medical bills.

Millions of people are expected to lose health insurance in the coming years as a result of the tax cut legislation Trump signed this month, leaving them with fewer protections from large bills if they get sick or suffer an accident.

At the same time, significant increases in health plan premiums on state insurance marketplaces next year will likely push more Americans to either drop coverage or switch to higher-deductible plans that will require them to pay more out-of-pocket before their insurance kicks in.

Smaller changes to federal rules are poised to bump up patients’ bills, as well. New federal guidelines for covid-19 vaccines, for example, will allow health insurers to stop covering the shots for millions, so if patients want the protection, some may have to pay out-of-pocket.

The new tax cut legislation will also raise the cost of certain doctor visits, requiring copays of up to $35 for some Medicaid enrollees.

And for those who do end up in debt, there will be fewer protections. This month, the Trump administration secured permission from a federal court to roll back regulations that would have removed medical debt from consumer credit reports.

That puts Americans who cannot pay their medical bills at risk of lower credit scores, hindering their ability to get a loan or forcing them to pay higher interest rates.

“For tens of millions of Americans, balancing the budget is like walking a tightrope,” said Chi Chi Wu, a staff attorney at the National Consumer Law Center. “The Trump administration is just throwing them off.”

White House spokesperson Kush Desai did not respond to questions about how the administration’s health care policies will affect Americans’ medical bills.

The president and his Republican congressional allies have brushed off the health care cuts, including hundreds of billions of dollars in Medicaid retrenchment in the mammoth tax law. “You won’t even notice it,” Trump said at the White House after the bill signing July 4. “Just waste, fraud, and abuse.”

But consumer and patient advocates around the country warn that the erosion of federal health care protections since Trump took office in January threatens to significantly undermine Americans’ financial security.

“These changes will hit our communities hard,” said Arika Sánchez, who oversees health care policy at the nonprofit New Mexico Center on Law and Poverty.

Sánchez predicted many more people the center works with will end up with medical debt. “When families get stuck with medical debt, it hurts their credit scores, makes it harder to get a car, a home, or even a job,” she said. “Medical debt wrecks people’s lives.”

For Americans with serious illnesses such as cancer, weakened federal protections from medical debt pose yet one more risk, said Elizabeth Darnall, senior director of federal advocacy at the American Cancer Society’s Cancer Action Network. “People will not seek out the treatment they need,” she said.

Trump promised a rosier future while campaigning last year, pledging to “make America affordable again” and “expand access to new Affordable Healthcare.”

Polls suggest voters were looking for relief.

About 6 in 10 adults — Democrats and Republicans — say they are worried about being able to afford health care, according to one recent survey, outpacing concerns about the cost of food or housing. And medical debt remains a widespread problem: As many as 100 million adults in the U.S. are burdened by some kind of health care debt.

Despite this, key tools that have helped prevent even more Americans from sinking into debt are now on the chopping block.

Medicaid and other government health insurance programs, in particular, have proved to be a powerful economic backstop for low-income patients and their families, said Kyle Caswell, an economist at the Urban Institute, a think tank in Washington, D.C.

Caswell and other researchers found, for example, that Medicaid expansion made possible by the 2010 Affordable Care Act led to measurable declines in medical debt and improvements in consumers’ credit scores in states that implemented the expansion.

“We’ve seen that these programs have a meaningful impact on people’s financial well-being,” Caswell said.

Trump’s tax law — which will slash more than $1 trillion in federal health spending over the next decade, mostly through Medicaid cuts — is expected to leave 10 million more people without health coverage by 2034, according to the latest estimates from the nonpartisan Congressional Budget Office. The tax cuts, which primarily benefit wealthy Americans, will add $3.4 trillion to U.S. deficits over a decade, the office calculated.

The number of uninsured could spike further if Trump and his congressional allies don’t renew additional federal subsidies for low- and moderate-income Americans who buy health coverage on state insurance marketplaces.

This aid — enacted under former President Joe Biden — lowers insurance premiums and reduces medical bills enrollees face when they go to the doctor or the hospital. But unless congressional Republicans act, those subsidies will expire later this year, leaving many with bigger bills.

Federal debt regulations developed by the Consumer Financial Protection Bureau under the Biden administration would have protected these people and others if they couldn’t pay their medical bills.

The agency issued rules in January that would have removed medical debts from consumer credit reports. That would have helped an estimated 15 million people.

But the Trump administration chose not to defend the new regulations when they were challenged in court by debt collectors and the credit bureaus, who argued the federal agency had exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

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Julie Rovner
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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Much of the hubbub in health care this year has been focused on Medicaid, which faces dramatically reduced federal funding as the result of the huge budget bill signed by President Donald Trump earlier this month. But now the attention is turning to the Affordable Care Act, which is facing some big changes that could cost many consumers their health coverage as soon as 2026.

Meanwhile, changes to immigration policy under Trump could have an outsize impact on the nation’s health care system, both by exacerbating shortages of health workers and by eliminating insurance coverage that helps keep some hospitals and clinics afloat.

This week’s panelists are Julie Rovner of KFF Health News, Julie Appleby of KFF Health News, Jessie Hellmann of CQ Roll Call, and Alice Miranda Ollstein of Politico.

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Julie Appleby
KFF Health News

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Jessie Hellmann
CQ Roll Call

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Alice Miranda Ollstein
Politico

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Among the takeaways from this week’s episode:

• Many Americans can expect their health insurance premiums to rise next year, but those rate hikes could be even bigger for the millions who rely on ACA health plans. To afford such plans, most consumers rely on enhanced federal government subsidies, which are set to expire — and GOP lawmakers seem loath to extend them, even though many of their constituents could lose their insurance as a result.
• Congress included a $50 billion fund for rural health care in Trump’s new law, aiming to cushion the blow of Medicaid cuts. But the fund is expected to fall short, especially as many people lose their health insurance and clinics, hospitals, and health systems are left to cover their bills.
• Abortion opponents continue to claim the abortion pill mifepristone is unsafe, more recently by citing a problematic analysis — and some lawmakers are using it to pressure federal officials to take another look at the drug’s approval. Meanwhile, many Planned Parenthood clinics are bracing for an end to federal funding, stripping money not only from busy clinics where abortion is legal but also from clinics that provide only contraception, testing for sexually transmitted infections, and other non-abortion care in states where the procedure is banned.
• And as more states implement laws enabling doctors to opt out of treatments that violate their morals, a pregnant woman in Tennessee says her doctor refused to provide prenatal care, because she is unmarried.

Also this week, Rovner interviews Jonathan Oberlander, a Medicare historian and University of North Carolina health policy professor, to mark Medicare’s 60th anniversary later this month.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “Republicans Call Medicaid Rife with Fraudsters. This Man Sees No Choice but To Break the Rules,” by Katheryn Houghton.  

Julie Appleby: NPR’s “Many Beauty Products Have Toxic Ingredients. Newly Proposed Bills Could Change That,” by Rachel Treisman.  

Jessie Hellmann: Roll Call’s “Kennedy’s Mental Health Drug Skepticism Lands at FDA Panel,” by Ariel Cohen.  

Alice Miranda Ollstein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and Jonel Aleccia.  

Also mentioned in this week’s podcast:

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MISSOULA, Mont. — As congressional Republicans finalized Medicaid work requirements in President Donald Trump’s budget bill, one man who relies on that government-subsidized health coverage was trying to coax his old car to start after an eight-hour shift making sandwiches.

James asked that only his middle name be used to tell his story so that he wouldn’t lose health coverage or be accused of Medicaid fraud. He found his food service gig a few weeks into an addiction treatment program. The man in his late 30s said his boss “hasn’t been disappointed.”

“I’m a good worker,” he said with a grin.

James can get the prescription drugs that help him stabilize his life and hold down that job through Medicaid, the state-federal insurance program that covers people with low incomes or disabilities. Those drugs curb his desire for alcohol and treat long-standing conditions that exacerbate his addiction, including bipolar and insomnia disorders.

But he hasn’t qualified for the program in months, ever since his work hours increased and he received a raise of about $1 an hour. He exceeds his income eligibility limit of about $21,000 per year by roughly $50 a week.

James said that despite his raise, he’s struggling to cover routine expenses, such as keeping his car running and paying his phone bill. He said he can’t afford the care he needs even on the cheapest insurance plan available to him through the Affordable Care Act’s marketplace or through his job’s health insurance plan. Even paying $60 a month for his sleep medications — one of six prescriptions he takes daily — is too expensive.

“I only saw one option,” James said. “Fudge the numbers.”

James hasn’t reported his new income to the state. That puts him at odds with congressional Republicans who justified adding hurdles to Medicaid by claiming the system is rife with waste, fraud, and abuse. But James isn’t someone sitting on his couch playing video games, the type of person House Speaker Mike Johnson and other people said they would target as they sought work requirements.

Medicaid provides health coverage and long-term care to more than 70 million people in the United States. Those who study safety-net systems say it’s extremely rare for enrollees to commit fraud to tap into that coverage. In fact, research shows swaths of eligible people aren’t enrolled in Medicaid, likely because the system is so confusing. And nearly two-thirds of people on Medicaid in 2023 had jobs, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

Those transitioning off Medicaid may qualify for other subsidized or low-priced health plans through the Affordable Care Act’s marketplace. But, as in James’ case, such plans can have gaps in what care is covered, and more comprehensive private plans may be too expensive. So James and an unknown number of other people find themselves caught between working too much to qualify for Medicaid but earning too little to pay for their own health care.

James considers himself to be a patriot and said that people shouldn’t “use government funding to just be lazy.” He agrees with the Republican argument that, if able, people should work if they receive Medicaid. Hiding his hours on the job from the government bothers him, especially since he feels he must lie to access the medical care that enables him to work.

“I don’t want to be a fraud. I don’t want to die,” James said. “Those shouldn’t be the only two options.”

On July 4, Trump signed into law the major tax and spending bill that makes it harder for low-income workers to get Medicaid. That includes requiring beneficiaries to work or go to school and adding paperwork to prove every six months they meet a minimum number of hours on the job.

“It’s going to hurt people, whether they’re playing by the rules or not,” said Ben Sommers, a health economist at Harvard University. “We see this vilification of mostly very hard-working people who are really struggling and are benefiting from a program that helps them stay alive.”

James said he initially declined his raise because he worried about losing Medicaid. He had previously been kicked off the coverage about a month into his rehab program after finding work. To stay in the sober-living program he otherwise couldn’t afford, James said, he dropped just enough hours at work to requalify for Medicaid and then soon picked up hours again. If he didn’t earn more, he said, he had no chance of saving enough money to find housing after graduating from the treatment program.

“They’ll give you a bone if you stay in the mud,” James said. “But you have to stay there.”

That problem — becoming just successful enough to suddenly lose Medicaid — is common. It’s called a benefit cliff, said Pamela Herd, who researches government aid at the University of Michigan.

“It just doesn’t make any sense that someone gets a dollar pay raise and all of a sudden they lose all access to their health insurance,” Herd said.

She said a partial fix exists called continuous eligibility, which guarantees an individual’s Medicaid coverage for a specific period, such as a year or longer. The goal is to give people time to adjust when they do earn more money. Continuous eligibility also helps maintain coverage for low-income workers with unpredictable hours and whose pay changes month to month.

But Congress has moved in the other direction. Under the new law, policymakers limited windows of eligibility for able-bodied adults to every six months. That will put more people on the program’s eligibility cliff, Herd said, in which they must decide between losing access to coverage or dropping hours at work.

“It is going to be a nightmare,” Herd said.

Those federal changes will be especially difficult for people with chronic conditions, such as James in Montana.

Not that long ago, James wouldn’t have been breaking the rules to access Medicaid because his state had 12-month continuous eligibility. But in 2023, Montana began requiring enrollees to report any change in their income within 10 days.

James is proud of how far he’s come. About a year ago, his body was breaking down. He couldn’t hold a spoon to eat breakfast without whiskey — his hands shook too hard. He had alcohol-induced seizures. He said his memories from his unhealthiest times come in flashes: being put on a stretcher, the face of a worried landlord, ambulance lights in the background.

James recently graduated from his treatment program. He’s staying with a relative to save money as he and his girlfriend try to find an affordable place to rent — though even with Medicaid, finding housing feels like a stretch to him. He’s taking classes part-time to become a licensed addiction counselor. His dream is to help others survive addiction, and he also sees that career as a way out of poverty.

To James, all his progress rides on keeping Medicaid a bit longer.

“Every time I get a piece of mail, I am terrified that I’m gonna open it up and it’s gonna say I don’t have Medicaid anymore,” he said. “I’m constantly in fear that it’s gonna go away.”

As of mid-July, officials hadn’t noticed the extra $50 he makes each week.

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When Lawrence and Penny Higgins of Fairfield, Maine, first learned in 2020 that high levels of toxic chemicals called PFAS taint their home’s well water, they wondered how their health might suffer. They had consumed the water for decades, given it to their pets and farm animals, and used it to irrigate their vegetable garden and fruit trees.

“We wanted to find out just what it’s going to do to us,” Penny Higgins said. They contacted a couple of doctors, but “we were met with a brick wall. Nobody knew anything.”

Worse still, she added, they “really didn’t want to hear about it.”

Many clinicians remain unaware of the health risks linked to PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, despite rising medical and public awareness of the chemicals and their toxicity. PFAS can affect nearly every organ system and linger in bodies for decades, raising risks of cancer, immune deficiencies, and pregnancy complications.

These “forever chemicals” have been widely used since the 1950s in products including cosmetics, cookware, clothing, carpeting, food packaging, and firefighting foam. Researchers say they permeate water systems and soils nationwide, with a federal study estimating that at least 45% of U.S. tap water is contaminated. PFAS can be detected in the blood of nearly all Americans, according to the Centers for Disease Control and Prevention.

Maine was among the first states to begin extensive water and soil testing and to try to limit further public exposure to PFAS through policy action, after discovering that farms and residences — like the Higgins’ property — had been contaminated by land-spreading of wastewater sludge containing PFAS. Exposure can also be high for people living near military bases, fire training areas, landfills, or manufacturing facilities.

In regions where testing reveals PFAS hot spots, medical providers can be caught flat-footed and patients left adrift.

Rachel Criswell, a family practice doctor and environmental health researcher, is working to change that. She was completing her residency in Central Maine around the time that the Higginses and others there began discovering the extent of the contamination. Her medical training at Columbia University included more than a year in Norway researching the effects of PFAS and other chemicals on maternal and infant health.

When patients began asking about PFAS, Criswell and the state toxicologist offered primary care providers lunchtime presentations on how to respond. Since then, she has fielded frequent PFAS questions from doctors and patients throughout the state.

Even knowledgeable providers can find it challenging to stay current given rapidly evolving scientific information and few established protocols. “The work I do is exhausting and time-consuming and sometimes frustrating,” Criswell said, “but it’s exactly what I should be doing.”

Phil Brown, a Northeastern University sociology professor and a co-director of the PFAS Project Lab, said the medical community “doesn’t know a lot about occupational and environmental health,” adding that “it’s a very minimal part of the medical school curriculum” and continuing education.

Courtney Carignan, an environmental epidemiologist at Michigan State University, said learning of PFAS exposure, whether from their drinking water or occupational sources, “is a sensitive and upsetting situation for people” and “it’s helpful if their doctors can take it seriously.”

Clinical guidance concerning PFAS improved after the National Academies of Sciences, Engineering, and Medicine released a report on PFAS in 2022. It found strong evidence associating PFAS with kidney cancer, high cholesterol, reduced birth weights, and lower antibody responses to vaccines, and some evidence linking PFAS to breast and testicular cancer, ulcerative colitis, thyroid and liver dysfunction, and pregnancy-induced hypertension.

That guidance “revolutionized my practice,” Criswell said. “Instead of being this hand-wavey thing where we don’t know how to apply the research, it brought a degree of concreteness to PFAS exposure that was kind of missing before.”

The national academies affirmed what Criswell had already been recommending: Doctors should order blood tests for patients with known PFAS exposures.

Testing for PFAS in blood — and for related medical conditions if needed — can help ease patients’ anxiety.

“There isn’t a day that goes by,” Lawrence Higgins said, “that we don’t think and wonder when our bodies are going to shut down on us.”

‘Devastating but Incredibly Helpful’

After finding out in 2021 that his family was exposed to PFAS through sludge spread on their Unity, Maine, farm decades earlier, Adam Nordell discovered that “it was exceedingly difficult” to get tested. “Our family doctor had not heard of PFAS and didn’t know what the test was,” he said. A lab technician needed coaching from an outside expert to source the test. The lab analyzing the samples had a backlog that left the family waiting three months.

“The results were devastating but incredibly helpful,” Nordell said. Their blood serum levels for PFAS were at roughly the 99th percentile nationally, far higher than their well-water levels would have predicted — indicating that additional exposure was probably coming from other sources such as soil contact, dust, and food.

Blood levels of PFAS between 2 and 20 nanograms per milliliter may be problematic, the national academies reported. In highly contaminated settings, blood levels can run upward of 150 times the 20-ng/mL risk threshold.

Nordell and his family had been planning to remain on the farm and grow crops less affected by PFAS, but the test results persuaded them to leave. “Knowledge is power,” Nordell said, and having the blood data “gave us agency.”

The national academies’ guidance paved the way for more clinicians to order PFAS blood tests. The cost, typically $400 to $600, can be prohibitive if not picked up by insurance, and not all insurers cover the testing. Deductibles and copays can also limit patients’ capacity to get tested. Less costly finger-prick tests, administered at home, appear to capture some of the more commonly found PFAS as accurately as blood serum tests, Carignan and colleagues found.

Maine legislators recently passed, with overwhelming support, a bill — modeled after one in New Hampshire — that would require insurers to consider PFAS blood testing part of preventive care, but it was carried over to the next legislative session.

“In my mind, it’s a no-brainer that the PFAS blood serum test should be universally offered — at no cost to the patient,” said Nordell, who now works as a campaign manager for the nonprofit Defend Our Health. Early screening for the diseases associated with PFAS, he said, is “a humane policy that’s in the best interests of everyone involved” — patients, providers, and insurance companies.

Criswell tells colleagues in family practice that they can view elevated PFAS blood levels as a risk factor, akin to smoking. “What’s challenging as a primary care doctor is the nitty-gritty” of the testing and screening logistics, she said.

In trainings, she shares a handout summarizing the national academies’ guidance — including associated heath conditions, blood testing, clinical follow-up, and exposure reduction — to which she has added details about lab test order codes, insurance costs and coverage, and water filtration.

Criswell served on an advisory committee tasked with allocating $60 million in state funds to address PFAS contamination from past sludge-spreading in Maine. The group recommended that labs analyzing PFAS blood tests should report the results to state public health authorities.

That change, slated to take effect this summer, will allow Maine health officials to follow up with people who have high PFAS blood levels to better determine potential sources and to share information on health risks and medical screening. As with many earlier PFAS policies, Maine is among the first states to adopt this measure.

Screening for PFAS is falling short in many places nationwide, said Kyle Horton, an internist in Wilmington, North Carolina, and founder of the nonprofit On Your Side Health. She estimates that only about 1 in 100 people facing high PFAS exposure are getting adequate medical guidance.

Even in her highly contaminated community, “I’m not aware of anyone who is routinely screening or discussing PFAS mitigation with their patients,” Horton said. Knowledge of local PFAS threats, she added, “hasn’t translated over to folks managing patients differently or trying to get through to that next phase of medical monitoring.”

Patients as Advocates

In heavily affected communities — including in Michigan, Maine, and Massachusetts — patients are pushing the medical field to better understand PFAS.

More doctors are speaking out as well. Testifying before a Maine legislative committee this year in support of a bill that would limit occupational PFAS exposure, Criswell said, “We, as physicians, who are sworn to protect the health of our patients, must pay attention to the underlying causes of the illnesses we treat and stand up for policy solutions that reduce these causes.”

Even where policy changes are instituted, the physical and psychological toll of “forever chemicals” will extend far into the future. Criswell and other Maine doctors have observed chronic stress among patients.

Nordell, the former farmer, described his family’s contamination as “deeply, deeply jarring,” an ordeal that has at times left him “unmoored from a sense of security.”

To assess the mental health consequences of PFAS exposure in rural residents, Criswell and Abby Fleisch, a pediatric endocrinologist at the MaineHealth Institute for Research, teamed up on a study. In its first phase, winding up this summer, they collected blood samples and detailed lifestyle information from 147 people.

Nordell, the Higginses, and other Central Maine residents sit on an advisory board for the study, a step Criswell said was critical to ensuring that their research helps those most affected by PFAS.

“The urgency from the community is really needed,” she said. “I don’t think I would be as fired up if my patients weren’t such good advocates.”

Criswell has faced what she calls “cognitive dissonance,” caught between the deliberate pace of peer-reviewed medical research and the immediate needs of patients eager to lower their PFAS body burden. Initially she considered inviting residents to participate in a clinical trial to test therapies that are considered safe and may help reduce PFAS levels in the body, such as high-fiber diets and a drug designed to reduce cholesterol called cholestyramine. But the clinical trial process could take years.

Criswell and Fleisch are instead planning to produce a case series on PFAS blood-level changes in patients taking cholestyramine. “We can validate the research results and share those,” Criswell said, potentially helping other patients.

Alan Ducatman, an internist and occupational physician who helped design the largest PFAS cohort study to date, said providers should convey that “there is no risk-benefit analysis” for any of the current treatments, although they’re generally well known and low-risk.

“Some people want to be treated, and they should be allowed to be treated,” he said, because knowing they have high PFAS levels in their bodies “preys on them.”

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Loreben Tuquero, PolitiFact

“Almost 5 million able-bodied Medicaid recipients ‘simply choose not to work’ and ‘spend six hours a day socializing and watching television.’”

Scott Jennings on “CNN NewsNight with Abby Phillip” on July 1

Republicans defended the GOP megabill’s Medicaid changes as targeting a group of people they believe shouldn’t qualify: people who can work but instead choose to stay home and chill.

Several Republican politicians and pundits, including CNN senior political commentator Scott Jennings, pegged that group’s size at about 5 million people.

“There are like almost 5 million able-bodied people on Medicaid who simply choose not to work,” Jennings said July 1 on “CNN NewsNight with Abby Phillip.” “They spend six hours a day socializing and watching television. And if you can’t get off grandma’s couch and work, I don’t want to pay for your welfare.”

Centers for Medicare & Medicaid Services Administrator Mehmet Oz picked up on some of these points during a July 14 appearance on Fox News. “When the program was created 60 years ago, it never dawned on anyone that you would take able-bodied individuals who could work and put them on Medicaid. Today the average able-bodied person on Medicaid who doesn’t work, they watch 6.1 hours of television or just hang out,” Oz said.

Medicaid is a federal-state health insurance program that covers medical care for lower-income people.

Jennings cited two pieces of data: an estimate of how many fewer people would have coverage because of the work requirement and an analysis of how nonworking Medicaid recipients spend their time. But he made assumptions that the data doesn’t support.

Jennings Misrepresents CBO Estimate

The 4.8 million figure stems from a June 24 Congressional Budget Office analysis of a preliminary House version of the massive tax and spending package. The office, Congress’ nonpartisan research arm, projected that provisions of the bill would cause 7.8 million fewer people to have health coverage by 2034. They would include 4.8 million people previously eligible for Medicaid described as “able-bodied” adults 19 to 64 years old who have no dependents and who “do not meet the community engagement requirement” of doing “work-related activities” at least 80 hours a month.

Apart from working, doing community service and attending school also fulfill the community engagement requirement.

Jennings paired that statistic with a separate analysis of how nondisabled adult Medicaid recipients without dependent children spend their time.

But the CBO estimate was a projection — it doesn’t represent the current number of nondisabled Medicaid recipients, nor does it say 4.8 million people in this group “choose not to work.” The figure represented how many fewer people would have coverage because of the bill’s community engagement requirement.

“The challenge with Jennings’ comments — and they’ve been echoed elsewhere by elected Republicans — is that CBO never said that 4.8 million people were out of compliance with the proposed work requirements; they said that 4.8 million people would lose coverage because of the work requirements,” said Adrianna McIntyre, an assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health.

Among the Medicaid expansion population, the law requires most adults without dependent children and parents of children older than 13 to work or participate in other qualifying activities 80 hours every month. States will need to verify that applicants met the work requirement for one to three months before they applied. States will also be required to verify that existing enrollees met the work requirement for at least a month between eligibility determinations, which will be required at least twice a year.

Research into Medicaid work requirements imposed at the state level has shown that people found it difficult to fulfill them and submit documentation, contributing to coverage losses.

In Arkansas, which added a work requirement to Medicaid in 2018, a study based on nearly 6,000 respondents found that about 95% of the target population were already working or qualified for an exemption, but a third of them did not hear about the work requirements. As a result, nearly 17,000 Medicaid recipients subject to work requirements lost coverage.

KFF found that adults ages 50 to 64 are more at risk of losing Medicaid coverage because of the new work requirements. More than 1 in 10 in that age group said they had retired, and among them, 28% reported being disabled, said KFF, a health information nonprofit that includes KFF Health News.

Benjamin Sommers, a health care economics professor at the Harvard Chan school, said many of the 4.8 million “able-bodied” people in the CBO estimate “will actually be engaged in the activities they are supposed to be doing, and lose coverage because they are not able to navigate the reporting requirements with the state and lose coverage from red tape.”

When Recipients Don’t Work, It’s Rarely From Lack of Interest

There is no universal definition for “able-bodied”; disability can be assessed in different ways. But other studies offer much smaller estimates than 4.8 million Medicaid recipients without dependents who can work but choose not to.

Millions of working-age, nondisabled adults joined the Medicaid ranks in states that expanded eligibility under the Affordable Care Act. There were about 34 million working-age nondisabled Medicaid enrollees in 2024, according to the CBO, 15 million of whom enrolled through the ACA.

A KFF analysis found a smaller figure of 26 million Medicaid-covered adults, ages 19 to 64, who don’t receive Supplemental Security Income, Social Security Disability Insurance, or Medicare benefits.

Among this group, KFF estimated, 64% were working either full time or part time. The reasons the rest were not working included caregiving (12%); illness or disability (10%); retirement, inability to find work, or other reason (8%); and school attendance (7%).

Few people cited lack of interest in working as the reason for their unemployment. An Urban Institute study found 2% of Medicaid expansion enrollees without dependents who neither worked nor attended school — or 300,000 people out of a projected 15 million subject to work requirements — cited a lack of interest in working as the reason they were unemployed.

This was consistent with the Brookings Institution’s June 5 analysis that found that, of 4.3 million adult enrollees who worked fewer than 80 hours a month and did not have any activity limitations or illnesses, about 300,000 reported that they “did not work because they did not want to.”

Mostly Women, Mostly With a High School Degree or Less

When Republicans have described nondisabled adult Medicaid recipients, they have often portrayed them as men in their 30s “playing video games” in their parents’ basement or who “smoke weed all day.” Research paints a different picture.

Jane Tavares and Marc Cohen, of the University of Massachusetts-Boston Gerontology Department, researched Medicaid recipients who are not disabled or working, have no dependent children under 18, and are not in school. They cited 2023 census data from the American Community Survey.

They found:

• The average age of this population is 41, and 26% are older than 50.
• Almost 80% are female.
• Most, 80%, have a high school education or less.
• Their median individual income is $0, and their median household income is $44,800.
• About 56% worked in the past five years, and 23% worked in the prior year. About 30% are looking or available for work.

“They are not healthy young adults just hanging out,” the authors, along with health law experts Sara Rosenbaum and Alison Barkoff, wrote April 30.

“It’s clear based on their prior work history and family size/income that they are exceptionally poor and have likely left the workforce to care for adult children or older adults,” Tavares told PolitiFact. “Even if these individuals could work, they would have very few job opportunities and it would come at the cost of the people they are providing care for.”

AEI Study Not Definitively Linked to CBO Estimate

On the social platform X, Jennings posted the CBO letter and a May 29 analysis by the American Enterprise Institute, a conservative think tank, about “how nondisabled Medicaid recipients without children spend their time.” PolitiFact contacted CNN to reach Jennings but did not receive a reply.

The author of that study, American Enterprise Institute senior fellow Kevin Corinth, analyzed survey data and found that Medicaid recipients who do not report working spend on average 6.1 hours a day “on all socializing, relaxing and leisure activities (including television and video games).”

But it’s uncertain whether the people in the survey population he analyzed overlap with the people included in the CBO analysis, said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

Corinth told PolitiFact “it is difficult to say” how the population he analyzed differs from the CBO’s. Tavares, Cohen, Rosenbaum, and Barkoff said Corinth’s dataset defined disability narrowly, leading to a “serious underestimation of disability” among the population of Medicaid recipients he looked into. It focused on Medicaid recipients who receive Supplemental Security Income or have a health condition that prevents them from working. The researchers said this approach is too narrow because the SSI program accounts for only those “most deeply impoverished adults with severe disabilities.”

The group gave a hypothetical example of a 54-year-old woman with a serious heart condition who can work only a few hours a week. She may not be considered disabled under the SSI program, but she may be limited in the work she can do and may need time to rest.

“Using her ‘leisure time’ to justify a work requirement grossly misrepresents her reality,” the group wrote.

Corinth’s analysis also shows that nonworking Medicaid recipients spend less time socializing, relaxing, or engaged in leisure activities than nonworking people who aren’t covered by Medicaid. Nonworking Medicaid recipients also spend more time looking for work and doing housework and errands, it found.

Our Ruling

Jennings said almost 5 million nondisabled Medicaid recipients “simply choose not to work” and “spend six hours a day socializing and watching television.”

The 5 million figure stems from a CBO projection that 4.8 million people would go without coverage by 2034 as a result of not fulfilling the community engagement requirements. It is not descriptive of current enrollees and does not specify that these people choose not to work.

Jennings cited an American Enterprise Institute analysis on how nondisabled Medicaid recipients with no dependents spend their time, but it is uncertain if the population in that analysis overlaps with that in the CBO estimate.

Current snapshots of the population Jennings described produce a smaller number. A survey by the Urban Institute found that 2% of Medicaid expansion enrollees without dependents who were neither working nor attending school — about 300,000 people — cited a lack of interest in working. Other research has found reasons this group doesn’t work include caregiving, illness or disability, retirement, and inability to find work.

Studies of nonworking Medicaid recipients have found the majority are women and have a high school education or less. Their average age is 41, and more than half have a work history in the past five years.

We rate Jennings’ statement False.

Our Sources

Email interview, Jane Tavares, University of Massachusetts-Boston adjunct instructor in gerontology, July 2, 2025

Email interview, Marc Cohen, University of Massachusetts-Boston professor of gerontology, July 2, 2025

Email interview, Sara Rosenbaum, George Washington University Milken Institute School of Public Health professor emerita of health law and policy, July 2, 2025

Email interview, Alison Barkoff, George Washington University Milken Institute School of Public Health associate professor of health law and policy, July 2, 2025

Email interview, Edwin Park, Georgetown University McCourt School of Public Policy Center for Children and Families research professor, July 2, 2025

Email interview, Benjamin Sommers, Harvard T.H. Chan School of Public Health professor of health care economics, July 2, 2025

Phone interview, Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, July 2, 2025

Email interview, Adrianna McIntyre, Harvard T.H. Chan School of Public Health assistant professor of health policy and politics, July 2, 2025

Phone interview, Michael Karpman, Urban Institute Health Policy Division principal research associate, July 3, 2025

Email exchange, Congressional Budget Office spokesperson, July 2, 2025

Email interview, Kevin Corinth, American Enterprise Institute senior fellow, July 3, 2025

X post by Rapid Response 47, June 30, 2025

Transcript of “CNN NewsNight with Abby Phillip,” July 1, 2025

Congressional Budget Office, “Re: Information Concerning Medicaid-Related Provisions in Title IV of H.R. 1,” June 24, 2025

Benjamin D. Sommers, M.D., Ph.D., Anna L. Goldman, M.D., M.P.A., M.P.H., Robert J. Blendon, Sc.D., E. John Orav, Ph.D., and Arnold M. Epstein, M.D., “Medicaid Work Requirements — Results From the First Year in Arkansas,” June 19, 2019

Congressional Budget Office, Baseline Projections, Medicaid, June 2024

KFF, “Understanding the Intersection of Medicaid and Work: An Update,” May 30, 2025

Urban Institute, “Many Working People Would Be Shut Out of Medicaid Under Proposed Work Requirements,” June 11, 2025

Wisconsin Watch, “Have Millions of Nondisabled, Working-Age Adults Been Added to Medicaid?” July 2, 2025

CBS News, “Too Sick To Work, Some Americans Worry Trump’s Bill Will Strip Their Health Insurance,” June 26, 2025

Brookings Institution, “Any Way You Look at It You Lose: Medicaid Work Requirements Will Either Fall Short of Anticipating Savings or Harm Vulnerable Beneficiaries,” June 5, 2025

X post by Scott Jennings, July 2, 2025

American Enterprise Institute, “How Nondisabled Medicaid Recipients Without Children Spend Their Time,” May 29, 2025

Congressional Budget Office, “Estimated Budgetary Effects of an Amendment in the Nature of a Substitute to H.R. 1, the One Big Beautiful Bill Act, Relative to CBO’s January 2025 Baseline,” June 29, 2025

Geiger Gibson Program in Community Health, George Washington University Milken Institute School of Public Health, “The Fundamental Flaw in ‘How Workers Spend Their Time’,” June 4, 2025

X post by Aaron Rupar, July 1, 2025

X post by Congressman Brandon Gill, July 2, 2025

LeadingAge LTSS Center @UMass Boston, “Profile of Medicaid Population Age 18-64, Working and Non-Working Medicaid Beneficiaries, and ‘Able-Bodied’ Non-Working Medicaid Beneficiaries,” May 2025

The Milbank Quarterly, “Who’s Affected by Medicaid Work Requirements? It’s Not Who You Think,” April 30, 2025

KFF, “Different Data Source, but Same Results: Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work,” June 25, 2025

La terapia de rehabilitación puede ser una bendición después de una hospitalización por un derrame cerebral, una caída, un accidente, un reemplazo de articulación, una quemadura grave o una lesión de la médula espinal, entre otras afecciones.

La fisioterapia, la terapia ocupacional y la terapia del habla se ofrecen en diversos entornos: hospitales, residencias de adultos mayores, clínicas y a domicilio.

Es fundamental encontrar una opción segura y de alta calidad con profesionales con experiencia en el tratamiento de tu afección.

¿Qué tipos de terapia de rehabilitación podría necesitar?

La fisioterapia ayuda a los pacientes a mejorar su fuerza, estabilidad y movimiento, y a reducir el dolor, generalmente a través de ejercicios específicos.

Algunos fisioterapeutas se especializan en problemas neurológicos, cardiovasculares u ortopédicos. También hay especialistas en geriatría y pediatría. La terapia ocupacional se centra en actividades específicas (llamadas “ocupaciones”), que suelen requerir habilidades motoras finas, como cepillarse los dientes, cortar alimentos con un cuchillo o vestirse.

La terapia del habla y del lenguaje ayuda a las personas a comunicarse. Algunos pacientes pueden necesitar terapia respiratoria si tienen dificultad para respirar o necesitan que se les retire el respirador.

¿Los seguros cubren las sesiones de rehabilitación?

Medicare, las aseguradoras de salud, la compensación laboral y los planes de Medicaid en algunos estados cubren las terapias de rehabilitación, pero los planes pueden negarse a pagar en ciertos entornos y limitar la cantidad de sesiones.

Algunas aseguradoras pueden pedir una preautorización y otras cancelar la cobertura si no se mejora. Las aseguradoras privadas suelen establecer límites anuales para la terapia ambulatoria.

El Medicare tradicional suele ser el menos restrictivo, mientras que los planes privados Medicare Advantage pueden supervisar de cerca el progreso y limitar los lugares en dónde los pacientes pueden recibir terapia.

¿Debería buscar rehabilitación hospitalaria?

Los pacientes que aún necesitan atención médica o de enfermería, pero que pueden tolerar tres horas de terapia cinco días a la semana, podrían calificar para ser admitidos en un hospital de rehabilitación especializado o en una unidad que funcione dentro de un hospital general.

Los pacientes suelen necesitar al menos dos de los principales tipos de terapia de rehabilitación: fisioterapia, terapia ocupacional o terapia del habla. Las estadías duran un promedio unos 12 días.

¿Cómo elijo?

Busca un centro especializado en el tratamiento de personas con tu diagnóstico; muchos hospitales enumeran las especialidades en sus sitios de internet. Las personas con afecciones médicas complejas o graves podrían preferir un hospital de rehabilitación conectado a un centro médico académico a la vanguardia de los nuevos tratamientos, incluso si está a un vuelo de distancia.

“Verás a pacientes jóvenes con lesiones catastróficas”, como daño de la médula espinal, viajando a otro estado para recibir tratamiento, dijo Cheri Blauwet, directora médica de Spaulding Rehabilitation en Boston, uno de los 15 hospitales que el gobierno federal ha elogiado por su trabajo de avanzada.

Sin embargo, elegir un hospital cerca de familiares y amigos que puedan ayudar después del alta tiene sus ventajas. Los terapeutas pueden ayudar a capacitar a los que serán cuidadores en casa.

¿Cómo encuentro hospitales de rehabilitación?

El planificador de altas o el trabajador social del hospital de agudos debería ofrecerte opciones. Puedes buscar centros de rehabilitación para pacientes internados por ubicación o nombre en el sitio web Care Compare de Medicare. Allí puedes ver cuántos pacientes con tu misma afección ha tratado ese hospital; cuantos más, mejor.

Puedes buscar por especialidad a través de la Asociación Americana de Proveedores de Rehabilitación Médica, un grupo comercial que publica una lista de sus miembros.

Averigüa qué tecnologías especializadas tiene un hospital, como simuladores de manejo (un auto o camión que permite al paciente practicar subir y bajar de un vehículo) o una mesa de cocina con utensilios para practicar cocinar.

¿Cómo puedo saber si un hospital de rehabilitación es confiable?

No es fácil: Medicare no analiza al personal ni publica en su sitio de internet los resultados de las inspecciones de seguridad como sí lo hace con las residencias de adultos mayores. Puedes pedir a la agencia de salud pública de tu estado o al hospital que te proporcionen informes de inspección de los últimos tres años. Estos informes pueden ser técnicos, pero te ayudarán a comprender lo esencial. Si el informe indica que se declaró un “riesgo inmediato”, significa que los inspectores identificaron problemas de seguridad que ponen en peligro a los pacientes.

La tasa de pacientes readmitidos en un hospital general por una razón potencialmente prevenible es una medida de seguridad clave. En general, los centros de rehabilitación con fines de lucro tienen tasas de readmisión más altas que los que son sin fines de lucro, pero hay algunos con tasas de readmisión más bajas y otros con tasas más altas. Puede que no tengas otra opción cerca: hay menos de 400 hospitales de rehabilitación y la mayoría de los hospitales generales no cuentan con una unidad de rehabilitación.

Puedes encontrar las tasas de readmisión de un hospital en la sección de calidad de Care Compare. Las tasas inferiores al promedio nacional son mejores.

Otra medida de calidad es la frecuencia con la que los pacientes son lo suficientemente funcionales como para irse a casa después de terminar la rehabilitación en lugar de ir a una residencia de adultos mayores, un hospital o una institución médica. Esta medida se denomina “alta a la comunidad” y se encuentra en la sección de calidad de Care Compare. Las tasas superiores al promedio nacional son mejores.

Busca reseñas del hospital en Yelp y otros sitios web. Pregunta si los pacientes ven al mismo terapeuta casi todos los días o no. Y si tienen certificaciones en la especialidad que necesitas.

Si es posible, visita el hospital y observa cómo opera. Si es posible, observa si las enfermeras responden rápido a las luces de llamada, si parecen estar sobrecargadas con demasiados pacientes o están mirando sus celulares. Pregunta a los pacientes actuales y a sus familiares si están satisfechos con la atención.

¿Qué pasa si no puedo tolerar tres horas de terapia al día?

Una residencia de personas mayores que ofrece rehabilitación podría ser adecuada para pacientes que no necesitan la supervisión de un médico, pero que no están listos para irse a casa. Las instalaciones generalmente brindan atención de enfermería las 24 horas. La duración de la rehabilitación varía según el paciente. Hay más de 14.500 centros de enfermería especializada en el país, 12 veces más que los hospitales que ofrecen rehabilitación, por lo que una de estas residencias podría ser tu mejor opción.

Puedes buscarlas a través del sitio web Care Compare de Medicare.

¿Qué sucede si los pacientes son demasiado frágiles incluso para una residencia de adultos mayores?

Podrían necesitar un hospital de cuidados de largo plazo. Estos se especializan en pacientes en coma, con respiradores y con afecciones médicas agudas que requieren la presencia de un médico. Los pacientes permanecen allí al menos cuatro semanas, y algunos meses. Care Compare te ayuda a buscar. Hay menos de 350 hospitales de este tipo.

Si tengo la fuerza suficiente para ir a casa. ¿Cómo recibo terapia?

Muchos hospitales de rehabilitación ofrecen terapia ambulatoria. También puedes ir a una clínica o un terapeuta puede ir a tu domicilio. Puedes contratar una agencia de atención médica a domicilio o encontrar un terapeuta que reciba tu seguro y haga visitas a domicilio.

Tu médico u hospital podría derivarte a otros profesionales. En Care Compare, las agencias de atención médica a domicilio indican si ofrecen fisioterapia, terapia ocupacional o terapia del habla. Puedes buscar terapeutas certificados en el sitio web de la Asociación Americana de Fisioterapia (APTA).

Durante la rehabilitación, los pacientes a veces se trasladan del hospital a un centro de enfermería y luego a su hogar, a menudo por insistencia de sus aseguradoras. Alice Bell, especialista senior de la APTA, señaló que los pacientes deberían intentar limitar el número de traslados, por su propia seguridad.

“Cada vez que un paciente cambia de un entorno a otro se encuentra en una zona de mayor riesgo”, afirmó.

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Every time Ashton Alexander sees an ad for Georgia Pathways to Coverage, it feels like a “kick in the face.”

Alexander tried signing up for Pathways, the state’s limited Medicaid expansion, multiple times and got denied each time, he said, even though he met the qualifying terms because he’s a full-time student.

Georgia is one of 10 states that haven’t expanded Medicaid health coverage to a broader pool of low-income adults. Instead, it offers coverage to those who can prove they’re working or completing 80 hours a month of other qualifying activities, like going to school or volunteering. And it is the only state currently doing so.

“Why is this marketing out here?” said the 20-year-old, who lives in Conyers, east of Atlanta. “It’s truly not accessible.”

Each denial used the same boilerplate language, Alexander said, and his calls to caseworkers were not returned. State offices couldn’t connect him with caseworkers assigned to him from the same state agency. And when he requested contact information for a supervisor to appeal his denial, he said, the number rang to a fax machine.

“It’s impenetrable,” Alexander said. “I’ve literally tried everything, and there’s no way.”

Millions of Americans trying to access Medicaid benefits could soon find themselves navigating similar byzantine state systems and work rules. Legislation signed into law by President Donald Trump on July 4 allocates $200 million to help states that expanded Medicaid create systems by the end of next year to verify whether some enrollees are meeting the requirements.

Conservative lawmakers have long argued that public benefits should go only to those actively working to get off of government assistance. But the nation’s only Medicaid work requirement program shows they can be costly for states to run, frustrating for enrollees to navigate, and disruptive to other public benefit systems. Georgia’s budget for marketing is nearly as much as it has spent on health benefits. Meanwhile, most enrollees under age 65 are already working or have a barrier that prevents them from doing so.

What Georgia shows is “just how costly setting up these administrative systems of red tape can be,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families.

Over the past two years, KFF Health News has documented the issues riddling Georgia’s Pathways program, launched in July 2023. More than 100,000 Georgians have applied to the program through March. Just over 8,000 were enrolled at the end of June, though about 300,000 would be eligible if the state fully expanded Medicaid under the terms of the Affordable Care Act.

The program has cost more than $100 million, with only $26 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a KFF Health News analysis of state reports.

“That was truly a pretty shocking waste of taxpayer dollars,” Alker said.

The Government Accountability Office is investigating the costs of the program after a group of Democratic senators — including both members of the Georgia delegation — asked the government watchdog to look into the program. Findings are expected this fall.

A state report to the federal government from March said Georgia couldn’t effectively determine if applicants meet the qualifying activities criteria. The report also said the state hadn’t suspended anyone for failing to work, a key philosophical pillar of the program. Meanwhile, as of March, more than 5,000 people were waiting to have their eligibility verified for Pathways.

The Pathways program has strained Georgia’s eligibility system for other public benefits, such as food stamps and cash assistance.

In April, the state applied to the federal government to renew Pathways. In its application, officials scaled back key elements, such as the requirement that enrollees document work every month. Critics of the program also say the red tape doesn’t help enrollees find jobs.

“Georgia’s experience shows that administrative complexity is the primary outcome, not job readiness,” said Natalie Crawford, executive director of Georgia First, which advocates for fiscal responsibility and access to affordable health care.

Despite the struggles, Garrison Douglas, a spokesperson for Georgia’s Republican governor, Brian Kemp, defended the program. “Georgia Pathways is doing what it was designed to do: provide free healthcare coverage to low-income, able-bodied Georgians who are willing to engage in one of our many qualifying activities,” he said in an emailed statement.

New federal requirements in the tax and spending legislation mean that the 40 states (plus Washington, D.C.) that expanded Medicaid will need to prepare technology to process the documentation some Medicaid recipients will now have to regularly file.

The federal law includes exemptions for people with disabilities, in addiction treatment, or caring for kids under 14, among others.

The Trump administration said other states won’t face a bumpy rollout like Georgia’s.

“We are fully confident that technology already exists that could enable all parties involved to implement work and community engagement requirements,” said Mehmet Oz, head of the Centers for Medicare & Medicaid Services, in an emailed statement.

In a written public comment on Georgia’s application to extend the program, Yvonne Taylor of Austell detailed the difficulties she faced trying to enroll.

She said she tried to sign up several times but that her application was not accepted. “Not once, not twice,  but 3 times. With no response from customer service,” she wrote in February. “So now I am without coverage.”

Victoria Helmly of Marietta wrote in a January comment that she and her family members take care of their dad, but the state law doesn’t exempt caregivers of older adults.

“Georgia should recognize their sacrifices by supporting them with health insurance,” she wrote. “Let’s simplify this system and in the end, save money and lives.”

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Jordan Rau, KFF Health News and Irena Hwang, The New York Times

Rehab hospitals that help people recover from major surgeries and injuries have become a highly lucrative slice of the health care business. But federal data and inspection reports show that some run by the dominant company, Encompass Health Corp., and other for-profit corporations have had rare but serious incidents of patient harm and perform below average on two key safety measures tracked by Medicare.

Yet even when inspections reveal grave cases of injury, federal health officials do not inform consumers or impose fines the way they do for nursing homes. And Medicare doesn’t provide easy-to-understand five-star ratings as it does for general hospitals.

In the most serious problems documented by regulators, rehab hospital errors involved patient deaths.

In Encompass Health’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak during construction at the facility.

At its hospital in Jackson, Tennessee, a patient, 68, was found dead overnight, lying on the floor in a “pool of blood” after an alarm that was supposed to alert nurses that he had gotten out of bed had been turned off.

In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the wrong drug, one of 26 medication errors the hospital made over six months. He died two days later at another hospital.

“I can still see Fred laying in the bed as they shut each little machine off,” said his widow, Susan Roufs. “They clicked four of them, and then the love of my life was gone.”

Encompass, which owns 168 hospitals and admitted 248,000 patients last year, has led the transformation of this niche industry. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits as the places where the majority of annual patient admissions occur, a KFF Health News and New York Times analysis found. A third of all admissions were to Encompass hospitals. Such facilities are required to provide three hours of therapy a day, five days a week.

Across the nation, there are now nearly 400 stand-alone rehab hospitals, the bulk of which are for-profit. These hospitals collectively generate profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency.

At the same time, the number of small, specialized units within acute care hospitals — where most rehab used to be provided — has dwindled. There are now around 800 of those, and most are nonprofits.

In its latest annual report, Encompass, which is publicly traded, reported an 11% net profit in 2024, earning $597 million last year on revenues of $5.4 billion.

Federal data on the performance of about 1,100 of the rehab facilities show Encompass tends to be better at helping most patients return home and remain there. In a two-year period ending in September 2023, Medicare rated 233 rehab facilities as performing better than the national rate for this major metric, called “discharge to community.” Most rehabs with better community discharge rates are for-profit, and Encompass owns 79 of them.

But data from Medicare also reveals Encompass owns many of the rehabs with worse rates of potentially preventable, unplanned readmissions to general hospitals. Medicare evaluates how often patients are rehospitalized for conditions that might have been averted with proper care, including infections, bedsores, dehydration, and kidney failures.

Encompass accounts for about 1 in 7 rehab facilities nationally, but owned 34 of the 41 inpatient rehab facilities that Medicare rated as having statistically significantly worse rates of potentially preventable readmissions for discharged patients. (Overall, rates of readmission after discharge ranged from 7% to 12%, with a median of 9%.)

And it owned 28 of the 87 rehab facilities — 65 of which were for-profit — that had worse rates of potentially preventable readmissions to general hospitals during patient stays. (The median for these kinds of readmissions was 5%, and rates for individual rehabs ranged from 3% to 9%.)

Patrick Darby, the executive vice president and general counsel of Encompass, strongly defended the company’s record in written responses to questions. He dismissed Medicare’s readmissions ratings of “better,” “worse,” and “no different than the national rate” as “a crude scoring measure” and said “performance is so similar across the board.” He called the violations found during health inspections “rare occurrences” that “do not support an inference of widespread quality concerns.”

“The simplest and most accurate reason for EHC’s success is that our hospitals provide superior care to patients,” he said, referring to Encompass by its corporate initials.

Chih-Ying Li, an associate professor of occupational therapy at the University of Texas Medical Branch at Galveston School of Health Professions, said in an interview that a research study she conducted found the profit status of a rehab facility was the only characteristic associated with higher unplanned readmissions.

“The finding is pretty robust,” she said. “It’s not like huge, huge differences, but there are differences.”

Alarming Mistakes

VanBibber was admitted to Encompass’ Huntington hospital in 2021 for therapy to strengthen her lungs. At the time, the hospital was undergoing a $3 million expansion, and state regulators had warned the company that areas of the hospital occupied by patients had to be isolated from the construction “using airtight barriers,” according to a health inspection report.

In her room, which was about 66 feet from the construction zone, she began having trouble breathing, the report said. When she told the staff, they ignored her and shut her door, according to a lawsuit brought by her estate. Staff members eventually noticed that she was “lethargic and gasping for air,” and called 911.

When the emergency medical squad arrived, the carbon monoxide detectors they wore sounded. By that time, VanBibber’s blood oxygen levels were dangerously low, the inspection report said. She died three days later from respiratory failure and carbon monoxide poisoning, according to the inspection report and the lawsuit. A plumber had been using a gas-powered saw in the construction area, but there were no carbon monoxide detectors in the hallways, the report said.

In court papers, Encompass and its construction contractors denied negligence for VanBibber’s death. The case is pending.

Inspectors determined Encompass failed to maintain a safe environment for all patients during construction and didn’t properly evaluate other patients for signs of poisoning, the report said.

Since 2021, the federal Centers for Medicare and Medicaid Services, or CMS, which oversees health inspections, has found that 10 Encompass hospitals, including the one that cared for VanBibber, had immediate jeopardy violations, federal records show. Such violations — like the ones that Medicare also found in connection with the deaths of Roufs and the patient who fell after leaving his bed — mean a hospital’s failure to comply with federal rules has put patients at risk for serious injury, serious harm, serious impairment, or death.

Darby, the general counsel for Encompass, said the company regretted any clinical problems and had promptly addressed all such findings to the satisfaction of inspectors. He said Encompass that has an “excellent compliance record,” including superior results from its accreditation agency, and that its overall number of health citations was tiny given how many hospitals Encompass owns and how many patients it treats.

Six other corporate-operated for-profit hospitals were also cited, while none of the 31 stand-alone nonprofit rehab hospitals received such violations from 2021 to 2024. (Inspection reports for general hospitals do not systematically specify in which part of the building a violation occurred, so rehab unit violations cannot be identified.)

An alert called a bed alarm was at the root of immediate jeopardies at Encompass hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The devices are pressure- and motion-sensitive and emit a sound and display a light to alert staff members that someone at a high risk of falls has left his or her bed.

In its Morgantown hospital, a nurse technician discovered a patient face down on the floor with a large gash on her head after a defective alarm did not go off, an inspection report said. After she died, the nurse told inspectors: “We are having a lot of problems with the bed alarms.”

Medicare is not authorized by law to fine rehab hospitals for safety rule violations, even ones involving deaths uncovered during inspections, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000.

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used because of its draconian consequences.

“Termination is typically a last resort after working with the provider to come back into compliance,” Catherine Howden, a CMS spokesperson, said in an email.

As a result, because there’s no graduated penalty, even the most serious — and rare — immediate jeopardy violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems.

“Only having a nuclear weapon has really hurt patient safety,” said Michael Millenson, a medical quality advocate.

One immediate jeopardy incident did result in a punishment, but only because the hospital was in California, which allows its health department to issue penalties. Encompass’ Bakersfield hospital paid a $75,000 fine last year for failing to control the blood sugar of a patient who died after her heart stopped.

Rapid Growth and a Troubled History

Encompass has accelerated its expansion in recent years and now operates in 38 states and Puerto Rico. It plans to open 17 more hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the end of 2027, according to its latest report.

It frequently moves into new markets by persuading local nonprofit hospitals to shutter their rehab units in exchange for an equity stake in a newly built Encompass hospital, company executives have told investors.

The president of Encompass, Mark Tarr, calls it a “win-win proposition”: The local hospitals can use their emptied space for a more lucrative line of service and Encompass gets a “jump start” into a new market, with partner hospitals often referring patients.

Tarr, who was paid $9.3 million in compensation last year, told investors that Encompass requires that the existing hospitals sign a noncompete deal. Sixty-seven Encompass hospitals are joint ventures, mostly with nonprofit hospitals as investors, according to the company’s June financial filing, the most recent available.

Darby said the company’s profits allow it to build hospitals in areas that lack intensive inpatient rehabilitation and improve existing hospitals. “High-quality patient care is not only consistent with shareholder return, but quality and shareholder return are in fact critical to one another,” he said.

The success of Encompass is particularly notable given that it barely survived what experts said was one of the largest modern accounting scandals in 2003.

The Securities and Exchange Commission charged that the company, then known as HealthSouth, overstated earnings by $2.7 billion to meet Wall Street analyst quarterly expectations, leading to the ouster of its founder and directors. In 2004, the company agreed to pay the government $325 million to settle Medicare fraud allegations without admitting wrongdoing. Darby credited the company’s new leaders for obtaining a $2.9 billion judgment on behalf of shareholders against the company’s founder.

The company changed its name to Encompass in 2018 after acquiring Encompass Home Health and Hospice. In 2019, the Justice Department announced the company had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed patients to get higher Medicare reimbursements, and admitted patients who were too sick to benefit from therapy. The company denied any wrongdoing, blaming independent physicians who worked at its hospitals. Darby said Encompass settled the case only to “avoid more years of expense and disruption.” He said the Justice Department never filed a lawsuit despite years of investigation.

Medication Harms

Rehab hospital inspection reports are not posted on Care Compare, Medicare’s online search tool for consumers. KFF Health News had to sue CMS under the Freedom of Information Act to obtain all its inspection reports for rehab hospitals. In contrast, Care Compare publishes all nursing home inspection reports and assigns each facility a star rating for its adherence to health and safety rules.

So people now choosing a rehab hospital would not know that at the Encompass hospital in Sioux Falls, South Dakota, in 2021, a nurse accidentally gave Roufs a blood pressure drug called hydralazine instead of hydroxyzine, his prescribed anti-anxiety medication, according to an inspection report. Roufs went into cardiac arrest. This type of error, called a “look-alike/sound-alike,” is one hospitals and staff members are supposed to be especially alert to.

Months before, an internal safety committee had identified a trend of medication errors, including when a nurse accidentally gave a patient 10 times the prescribed amount of insulin, sending him to the hospital, the inspection report said. The nurse had misread four units as 40. Since Roufs’s death, inspectors have faulted the hospital six times for various lapses, most recently in April 2024 for improper wound care.

An Encompass hospital in Texarkana, Texas, misused antipsychotic medications to pacify patients, resulting in an immediate jeopardy finding from CMS, the report said. And the company’s hospital in Erie, Pennsylvania, was issued an immediate jeopardy violation for not keeping track of medication orders in 2023, when a patient had a cardiac arrest after not receiving all of his drugs, according to the inspection report.

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues.

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities, according to a CMS spokesperson.

Deadly Bedsores

The family of Paul Webb Jr., 74, claimed in a lawsuit that the Encompass hospital in Erie left Webb unattended in a wheelchair for hours at a time, putting pressure on his tailbone, in 2021. His medical records, provided to reporters by the family, list a sitting tolerance of one hour.

Webb — who had been originally hospitalized after a brain bleed, a type of stroke — developed skin damage known as a pressure sore, or bedsore, on his bottom, the lawsuit said. The suit said the sore worsened after he was sent to a nursing home, which the family is also suing, then home, and he died later that year. In his final weeks, Webb was unable to stand, sit, or move much because of the injury, the lawsuit said.

In court papers, Encompass and the nursing home denied negligence, as Encompass has in some other pending and closed lawsuits that accused it of failing to prevent pressure sores because nurses and aides failed to regularly reposition patients, or notice and treat emerging sores. Darby said Webb’s death occurred three months after his Encompass stay and was not related to his care at Encompass. He said no hospital with long-term patients could prevent every new or worsening pressure sore, but that Encompass’ rates were similar to the 1% national average.

One of Webb’s sons, Darel Webb, recalled a warning given to the family as they left an appointment their father had with wound specialists: A doctor brought up Christopher Reeve, the actor who played Superman in movies in the 1970s and 1980s.

“He goes, ‘Remember, Superman was paralyzed from falling off the horse, but he died from a bedsore,’” he said.

Jordan Rau has been writing about hospital safety since 2008. Irena Hwang is a New York Times data reporter who uses computational tools to uncover hidden stories and illuminate the news.

METHODOLOGY

To examine the medical rehabilitation hospital industry, we obtained and analyzed a database of inspection reports of freestanding rehabilitation hospitals from the federal Centers for Medicare & Medicaid Services, or CMS. We also obtained inspection reports from several states through public records requests.

We analyzed inpatient rehabilitation facility characteristics and patient volume data contained in hospital data files from the Rand Corp., a nonprofit research organization. This dataset compiles cost reports all hospitals submit each year to CMS. For each facility for the years 2012 to 2023, we categorized annual discharges by facility type (freestanding rehabilitation hospital or unit within an acute care hospital); facility ownership status (for-profit, nonprofit, or government); and which hospitals were owned by Encompass Health under its current or prior name, HealthSouth.

Financial information about Encompass Health was obtained from the company’s Securities and Exchange Commission disclosure filings.

We examined the readmission rates for all inpatient rehabilitation facilities that CMS publishes in its quality data. CMS evaluates the frequency with which Medicare patients were readmitted for potentially preventable reasons to an acute care hospital during their rehab stay. Separately, CMS also evaluates the frequency of potentially preventable readmissions to an acute care hospital within 30 days of discharge from rehab. We also examined the rate of successful return to home or community. Figures for all three metrics were available for about 1,100 of the roughly 1,200 rehab facilities in the CMS data. The most recent readmission data covered Medicare discharges from October 2021 through September 2023.

We examined nursing home penalties from the last three years from CMS’ data on nursing homes.

The Host

Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie’s stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Senate has passed — and sent back to the House — a bill that would allow the Trump administration to claw back some $9 billion in previously approved funding for foreign aid and public broadcasting. But first, senators removed from the bill a request to cut funding for the President’s Emergency Plan for AIDS Relief, President George W. Bush’s international AIDS/HIV program. The House has until Friday to approve the bill, or else the funding remains in place.

Meanwhile, a federal appeals court has ruled that West Virginia can ban the abortion pill mifepristone despite its approval by the Food and Drug Administration. If the ruling is upheld by the Supreme Court, it could allow states to limit access to other FDA-approved drugs.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

@joannekenen.bsky.social

Read Joanne’s bio.

Shefali Luthra
The 19th

@shefali.bsky.social

Read Shefali’s stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

@SandhyaWrites.bsky.social

Read Sandhya’s stories.

Among the takeaways from this week’s episode:

• The Senate approved the Trump administration’s cuts to foreign aid and public broadcasting, a remarkable yielding of congressional spending power to the president. Before the vote, Senate GOP leaders removed President Donald Trump’s request to cut PEPFAR, sparing the funding for that global health effort, which has support from both parties.
• Next Congress will need to pass annual appropriations bills to keep the government funded, but that is expected to be a bigger challenge than the recent spending fights. Appropriations bills need 60 votes to pass in the Senate, meaning Republican leaders will have to make bipartisan compromises. House leaders are already delaying health spending bills until the fall, saying they need more time to work out deals — and those bills tend to attract culture-war issues that make it difficult to negotiate across the aisle.
• The Trump administration is planning to destroy — rather than distribute — food, medical supplies, contraceptives, and other items intended for foreign aid. The plan follows the removal of workers and dismantling of aid infrastructure around the world, but the waste of needed goods the U.S. government has already purchased is expected to further erode global trust.
• And soon after the passage of Trump’s tax and spending law, at least one Republican is proposing to reverse the cuts the party approved to health programs — specifically Medicaid. It’s hardly the first time lawmakers have tried to change course on their own policies, though time will tell whether it’s enough to mitigate any political (or actual) damage from the law.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: The New York Times’ “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich.

Joanne Kenen: The New Yorker’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” by Dhruv Khullar.

Shefali Luthra: The New York Times’ “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True,” by Apoorva Mandavilli.

Sandhya Raman: The Nation’s “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons from Sweden,” by Cecilia Nowell.

Also mentioned in this week’s podcast:

Click to open the transcript

Transcript: The Senate Saves PEPFAR Funding — For Now

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 17, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Hello, everyone. 

Rovner: Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: No interview this week, but more than enough news. So we will get right to it. 

We’re going to start on Capitol Hill, where in the very wee hours of Thursday morning, the Senate approved the $9 billion package of rescissions of money already appropriated. It was largely for foreign aid and the Corporation for Public Broadcasting, which oversees NPR and PBS. Now, this bill represents pennies compared to the entire federal budget and even to the total of dollars that are appropriated every year, but it’s still a big deal because it’s basically Congress ceding more of its spending power back to the president. And even this small package was controversial. Before even bringing it to the floor, senators took out the rescission of funds for PEPFAR [the President’s Emergency Plan for AIDS Relief], the bipartisanly popular international AIDS/HIV program begun under President George W. Bush. So now it has to go back to the House, and the clock on this whole process runs out on Friday. Sandhya, what’s likely to happen next? 

Raman: I think that the House has been more amenable. They got this through quicker, but if you look— 

Rovner: By one vote. 

Raman: Yeah. But I think if you look at what else has been happening in the House this week that isn’t in the health sphere, they’ve been having issues getting other things done, because of some pushback from the Freedom Caucus, who’s been kind of stalling the votes and having them to go back. And other things that should have been smoother are taking a lot longer and having a lot more issues. So it’s more difficult to say without seeing how all of that plays out, if those folks are going to make a stink again about something here because some of this money was taken out. It’s a work in progress this week in the House. 

Rovner: Yeah, that’s a very kind way to put it. The House has basically been stalled for the last 24 hours over, as you say, many things, completely unrelated, but there is actually a clock ticking on this. They had 45 days from when the administration sent up this rescission request, and we’re now on Day 43 because Congress is the world’s largest group of high school students that never do anything until the last minute. So Democrats warned that this bill represents yet another dangerous precedent. They reached a bipartisan agreement on this year of spending bills in the spring, and this basically rolls at least some of that back using a straight party-line vote. What does this bode for the rest of Congress’ appropriations work for the fiscal year that starts in just a couple of months? 

Raman: I think that the sense has been that once this goes through, I think a lot of people have just been assuming that it’ll take time but that things will get passed on rescissions. It really puts a damper on the bipartisan appropriations process, and it’s going to make it a lot harder to get people to come to the table. So earlier this week we had the chair of the Appropriations Committee and the chair of the Labor, HHS [Health and Human Services], Education subcommittee in the House say that the health appropriations they were going to do next week for the House are going to get pushed back until September because they’re not ready. And I think that health is also one of the hardest ones to get through. There’s a lot more controversial stuff. It’s setting us up to go, kind of like usual at this point, for another CR [continuing resolution], because it’s going to be a really short timeline before the end of the fiscal year. But if you look at some— 

Rovner: Every year they say they’re going to do the spending bills separately, and every year they don’t. 

Raman: Yeah, and I think if you look at how they’ve been approaching some of the things that have been generally a little bit less controversial and how much pushback and how much more difficulties they’ve been having with that, even this week, I think that it’s going to be much more difficult to get that done. And the rescissions, pulling back on Congress’ power of the purse, is not going to make that any easier. 

Rovner: I think what people don’t appreciate, and I don’t think I appreciated it either until this came up, is that the rescissions process is part of the budget act, which is one of these things that Congress can do on an expedited basis in the Senate with just a straight majority. But the regular appropriations bills, unlike the budget reconciliation bill that we just did, need 60 votes. They can be filibustered. So the only way to get appropriations done is on a bipartisan basis, and yet they’re using this rather partisan process to take back some of the deal that they made. The Democrats keep saying it, and everybody’s like, Oh, process, process. But that actually could be a gigantic roadblock, to stopping everything in its tracks, right? 

Raman: I really think so. And if you look at who are the two Republicans in the Senate that voted against the rescissions, one of them is the Senate Appropriations chair, Susan Collins. And throughout this, one of her main concerns was when we still had the PEPFAR in there. But it just takes back her power as the highest-ranking appropriator in the Senate to do it through this process, especially when she wasn’t in favor of the rescissions package. 

So it’s going to make things, I think, a lot more complicated, and one of her concerns throughout has just been that there wasn’t enough information. She was pulling out examples of rescissions in the past and how it was kind of a different process. They were really briefed on why this was necessary. And it was just different now. So I think what happens with appropriations and how long it’ll take this year is going to be interesting to watch. 

Rovner: And it’s worth remembering that it’s when the appropriations don’t happen that the government shuts down. So, but that doesn’t happen until October. Well, separately we learned that — oh, go ahead, Joanne. 

Kenen: There’s also sort of a whole new wrinkle, is that rescissions is, if you’re a Republican and you don’t like something and you end up, to avoid a government shutdown or whatever reason, you end up having to vote for a bill, you just have the president put out a statement saying, If this goes through, I’m going to cut it afterwards. And then the Republican who doesn’t like it can give a floor speech saying, I’m voting for it because I like this in it and I know that the president’s going to take care of that. It really — appropriations is always messy, but there’s this whole unknown. The constitutional balance of who does what in the American government is shifting. And at the end of the day, the only thing we do know after both the first term and what’s happened so far even more so in the second term, is what [President Donald] Trump wants, Trump tends to get. 

So, Labor-H [the appropriations for Labor, HHS, Education and related agencies], like Sandhya just pointed out, the health bill is one of the hardest because there’s so much culture-war stuff in it. But, although, the Supreme Court has put some of that off the table. But I just don’t know how things play out in the current dynamic, which is unprecedented. 

Rovner: And of course, Labor-HHS also has the Department of Education in it. 

Kenen: The former Department of Education. 

Rovner: To say, which is in the process of being dismantled. So that’s going to make that even more controversial this year. Moving back to the present, separately we learned this week that the administration plans to spend hundreds of thousands of dollars of taxpayer money to destroy stocks of food and contraceptives and other medical devices rather than distribute them through some of the international aid programs that they’re canceling. Now, in the case of an estimated 500 tons of high-energy biscuits bought by USAID [the U.S. Agency for International Development] at the end of the Biden administration, you can almost understand it because they’re literally about to expire next week. According to The Atlantic, which first reported this story, this is only a small part of 60,000 metric tons of food already purchased from U.S. farmers and sitting in warehouses around the world, where the personnel who’d be in charge of distributing them would’ve been fired or transferred or called back to the U.S. 

At the same time, there are apparently also plans to destroy an estimated $12 million worth of HIV prevention supplies and contraceptives originally purchased as part of foreign aid programs rather than turn them over or even sell them to other countries or nonprofits. This feels like maybe the not most efficient use of taxpayer dollars? 

Luthra: I think this is something we’ve talked about before, but it really bears repeating. As a media ecosphere, we’ve sort of moved on from the really rapid dismantling of USAID. And it was not only without precedent. It was incredibly wasteful with the sudden way it was done, all of these things that were already purchased no longer able to be used, leases literally broken. And people had to pay more to break leases for offices set up in other countries, all these sorts of things that really could have already been used because they had been paid for. And instead, the money is simply lost. 

And I think the important thing for us to remember here is not only the immense waste financially to taxpayers but the real trust that has been lost, because these were promises made, things purchased, programs initiated, and when other countries see us pulling back in such a, again, I keep saying wasteful, but truly wasteful manner, it’s just really hard to ever imagine that the U.S. will be a reliable partner moving forward. 

Rovner: Yeah, absolutely. I understand the food thing to some extent because the food’s going to expire, but the medical supplies that could be distributed by somebody else? I’m still sort of searching for why that would make any sense in any universe, but yeah I guess this is the continuation of, We’re going to get rid of this aid and pretend that it never happened. 

Well, meanwhile, it’s only been a couple of weeks, but we’re starting to see the politics of that big Trump tax and spending measure play out. One big question is: Why didn’t Republicans listen to the usually very powerful hospital industry that usually gets its way but did not this time? And relatedly, will those Republicans who voted with Trump but against those powerful hospital interests do an about-face between now and when these Medicaid cuts are supposed to take effect? We’ve already seen Sen. Josh Hawley, the Republican from Missouri who loudly proclaimed his opposition to those Medicaid cuts before he voted for them anyway, introduce legislation to rescind them. So is this the new normal? I think, Joanne, you were sort of alluding to this, that you can now sort of vote for something and then immediately say: Didn’t mean to vote for that. Let’s undo it. 

Kenen: You could even do it before you vote for it, if they play it right. If Congress passes these things, we’re not going to pay attention. We’re already in that moment. But also, when I was working on a Medicaid piece, the magazine piece like four or five months ago, one of the most cynical people I know in Washington told me, he said, Oh, they’ll pass these huge cuts because they need the budget score to get the taxes through, and then they’ll start repealing it. And it seemed so cynical at the time, only he might’ve been right. 

So I don’t think they’re going to cut all of it. Republicans ideologically want a smaller Medicaid program. They want less spending. They want work requirements. You’re not going to see the whole thing go away. Could you see some retroactive tinkering or postponement or something? Yeah, you could. It’s too soon to know. Hospitals are the biggest employer in many, many congressional districts. This is a power— 

Rovner: Most of them. 

Kenen: Most, yeah. I don’t think it’s quite all, but like a lot. It’s the biggest single employer, and Medicaid is a big part of their income. And they still by law have to stabilize people who come in sick, and there’s emergency care and all sorts of other things, right? They do charity care. They do uninsured people. They do all sorts. They still treat people under certain circumstances even when they can’t pay. But right now, the threat of a primary opponent is more powerful than the threat of your local hospital being mad at you and harming health care access in your community. So much in the Republican world revolves around not getting the president mad enough that he threatens to get you beaten in a primary. We’ve seen that time and again already. 

Rovner: Right. And I will also say there’s precedent for this, for passing something and then unpassing it. Joanne and I covered in 19— 

Kenen: But it wasn’t the plan. 

Rovner: Yeah, I know. But remember, back in 1997 when they passed the Balanced Budget Act, every year for the next — was it three or four years? They did what we came to call “give back” bills. 

Kenen: Or punting, right? 

Rovner: Yeah, where they basically undid, they unspooled, some of those cuts, mostly because they’d cut more deeply than they’d intended to. And then we know with the Affordable Care Act, I’ve said this several times, they passed all of these financing mechanisms for it and then one by one repealed them. 

Kenen: And the individual mandate — I mean everything- 

Rovner: And the individual mandate, right. 

Kenen: They kept the dessert and they gave away everything. They undid everything that paid for the dessert, basically. 

Rovner: Right. Right. 

Kenen: And so it was the Cadillac — because people don’t remember anymore — the Cadillac tax, the insurance tax, the device tax. They all were like, One at a time! And they were repealed because lobbying works. 

Rovner: The tanning tax just went. 

Kenen: Right, right. So that dynamic existed, passing something unpopular and then redoing it, but the dynamic now really just comes — basically this is Donald Trump’s town. He has had a remarkable success in not only getting Congress to do what he wants but getting Congress to surrender some of its own powers, which have been around since Congress began. This is the way our government was set up. So there’s a very, very different dynamic, and it’s still unpredictable. None of us thought that the biggest crisis would be the [Jeffrey] Epstein case, right? Which is not a health story, and we don’t have to spend any time on it except to acknowledge— 

Rovner: Please. 

Kenen: —that there’s stuff going on in the background that people who had been extremely loyal to the president are now mad. And we don’t know how long. He’s very good at neutralizing things, too. He’s blaming it on the Democrats. 

But there is a different dynamic. Congress has less power because Congress gave up some of its power. Are they going to want to reassert themselves? There is no sign of it right now, but who knows what happens. I thought they would cut Medicaid. I thought they would do work requirements. I thought they would let the enhanced ACA subsidies expire. But I did not think the cuts would go this deep and this extensive — really transformationally pretty historic cuts. 

Rovner: Shefali, you wanted to say something? 

Kenen: Not pretty historic cuts, very historic cuts. Unprecedented. 

Luthra: I was thinking Joanne made such a good point about how, for all of the talk now about trying to mitigate that backlash, a lot of this is in line ideologically with what Republicans want. They do want a smaller Medicaid program. And I think a really interesting and still open question is whether they are willing and able to actually create policy that does reverse some of these cuts or not, and even if they do, if it’s sufficient to change voters’ perception, because we know that these cuts are very unpopular. Democrats are talking about them a lot. Hospitals are talking about them a lot. And just the failed attempt to repeal the ACA led to the 2018 midterms. And I think there is a real chance that this is the dominant topic when we head into next year’s elections. And it’s hard to say if Josh Hawley putting out a bill can undo that damage, so—. 

Rovner: Well, I’m so glad you mentioned that, because The Washington Post has a really interesting story about a clinic closing in rural Nebraska, with its owners publicly blaming the impending Medicaid cuts. Yet its Trump-supporting patients are just not buying it. Now in 2010, Republicans managed to hang the Affordable Care Act around Democrats’ necks well before the vast majority of the changes took place. Are Democrats going to be able to do that now? There’s a lot of people saying, Oh, well, they’re not going to be able to blame this on the Republicans, because most of it won’t have happened yet. This is really going to be a who-manages-to-push-their-narrative, right? 

Kenen: This really striking thing about that story is that the people who were losing access, they’re not losing their Medicaid yet, but they’re losing access to the only clinic within several — they have to drive hours now to get medical care. And when they were told this was because the Republican Congress and President Trump, they said, Oh no, it can’t be. First of all, a lot of people just don’t pay attention to the news. We know that. And then if you’re paying attention to news that never says anything negative about the president, that blames everything on Joe Biden no matter — if it rains yesterday, it was his fault, right? 

So the sort of gap between — there are certain things that are matters of opinion and interpretation, and there are certain things that are matters of fact, but those facts are not getting through. And we do not know whether the Democrats will be able to get them through, because the resistance, it’s almost magical, right? My clinic closed because of a Republican Medicaid bill? Oh no, it’s hospital greed. They just don’t want to treat us anymore. They just, it doesn’t compute, because it doesn’t fit into what they have been reading and hearing, to the extent that they read and hear. 

Rovner: Sandhya, you want to add something? 

Raman: The one thing that as I’ve been asking around on Capitol Hill about the Hawley bill — and there was one from Sen. Rand Paul, and a House counterpart, from [Rep.] Greg Steube, does sort of the opposite — it wants to move up the timeline for one of the provisions. So one important thing to consider is neither of these bills have had a lot of buy-in from other members of Congress. They’ve been introduced, but the people that I’ve talked to have said, I’m not sure. 

And I think something interesting that Sen. Thom Tillis had said was: If Republicans had a problem with what some of the impacts would be, then why were they denying that there would be an effect on rural health or some of those things to begin with? And I think a lot of it will take some time to judge to see if people will move the needle, but if we’re going to change any of these deadlines through not reconciliation, you need 60 votes in the Senate and you’ll need Democrats on board as well as Republicans. And I think one interesting thing to watch there is that I think some of the Democrats are also looking at this in a political way. If there’s a Republican that has a bill that is trying to tamp down some of the effects of their signature reconciliation law, do they want to help them and sign on to that bill or kind of illustrate the effects of the bill before the midterms or whatever? 

Rovner: A lot more politics to come. 

Raman: Yeah. Yeah. 

Rovner: Meanwhile, over at HHS [the Department of Health and Human Services], there is also plenty of news. Many of the workers who’ve been basically in limbo since April when a judge temporarily halted the Trump administration’s efforts to downsize have now been formally let go after the Supreme Court last week lifted that injunction. What are we hearing about how things are going over at HHS? We’ve talked sort of every week about this sort of continuing chaos. I assume that the hammer falling is not helping. It’s not adding to things settling down. 

Kenen: No. And then Secretary [Robert F.] Kennedy [Jr.] just fired two top aides because — no one knows exactly the full story but it’s — and I certainly do not know the full story. But what I have read is that the personality conflict with his top aide — and that happens in offices, and he’s not the first person in the history of HHS to have people who don’t get along with one another. But it’s just more unsettled stuff in an agency already in flux, because now in addition to all these people being let go in all sorts of programs and programs being rolled back, you also have some leadership chaos at the top. 

Rovner: Well, meanwhile, HHS Secretary Kennedy took office with vows to eliminate the financial influence of Big Pharma, Big Food, and other industries with potential conflicts of interests. But shoutout here to my KFF Health News colleague Stephanie Armour, who has a story this week about how the new vested interests at HHS are the wellness industry. Kennedy and four top advisers, three of whom have been hired into the department, wrote Stephanie, quote, “earned at least $3.2 million in fees and salaries from their work opposing Big Pharma and promoting wellness in 2022 and 2023, according to a KFF Health News review of financial disclosure forms filed with the U.S. Office of Government Ethics and the Department of Health and Human Services; published media reports; and tax forms filed with the IRS. That total doesn’t include revenue from speaking fees, the sale of wellness products, or other income sources for which data is not publicly available.” Have we basically just traded one form of regulatory capture for another form of regulatory capture? 

Kenen: And one isn’t covered by insurance. Some of it is, but there’s a lot of stuff in the, quote, “wellness” industry that providers and so forth, certain services are covered if there’s licensed people and an evidence base for them, but a lot of it isn’t. And these providers charge a lot of money out-of-pocket, too. 

Rovner: And they make a lot of money. This is a totally — unlike Big Pharma, Big Food, and Big Medicine, which is regulated, Big Wellness is largely not regulated. 

Kenen: I think Stephanie — that was a really good piece — and I think Stephanie said it was, what, $6.3 trillion industry? Was that— 

Rovner: Yeah, it’s huge. 

Kenen: Am I remembering that number right? It’s largely unregulated. Many of the products have never gone through any review for safety or efficacy. And insurance doesn’t cover a lot of it. It doesn’t mean it’s all bad. There are certain things that are helpful, but as an industry overall, it leaves something for us to worry about. 

Rovner: Well, in HHS-adjacent breaking news that could turn out to be nothing or something really big, an appeals court in Richmond on Tuesday ruled 2-1 that West Virginia may in fact limit access to the abortion pill, even though it’s approved by the FDA [Food and Drug Administration]. It’s the first time a federal appeals court has basically said that states can effectively override the FDA’s nationwide drug approval authority. And it’s the question that the Supreme Court has already ducked once, in that case out of Texas last year where the justices ruled that the doctors who were suing didn’t have standing, so they didn’t have to get to that question. But, Shefali, this has implications well beyond abortion, right? 

Luthra: Oh, absolutely. We are seeing efforts across the country to restrict access to certain medications that are FDA-approved. Abortion pills are the obvious one, but, of course, we can think about gender-affirming care. We can think about access to all sorts of other therapeutics and even vaccines that are now sort of coming under political fire. And if FDA approval means less than state restrictions, as we are seeing in this case, as we very possibly could see as these kinds of arguments and challenges make their way to the Supreme Court. The case you alluded to earlier with the doctors who didn’t have standing is still alive, just with different plaintiffs now. And so these questions will probably come back. There are just such vast ramifications for any kind of medication that could be politicized, and it’s something that industry at large has been very worried about since this abortion pill became such a big question. And it is something that this decision is not going to alleviate. 

Rovner: Yes. Speaking of Big Pharma, they’re completely freaked out by this possibility because it does have implications for every FDA-approved drug. 

Luthra: And they invest so much money in trying to get products that have FDA approval. There’s a real promise that with this global gold standard, you will be able to keep a drug on the market and really make a lot of money on it. There’s also obviously concerns for birth control, which we aren’t seeing legally restricted in the same way as abortion yet, but it is something that is so deeply subject to politics and culture-war issues that that’s something that we could see coming down the line if trends continue the way they are. 

Rovner: Well, we will watch that space. Moving on. Wednesday was the third anniversary of the federal 988 federal crisis line, which has so far served an estimated 16 million people with mental health crises via call, text, or chat. An estimated 10% of those calls were routed through a special service for LGBTQ+ youth, which is being cut off today by the Trump administration, which accused the program, run by the Trevor Project, as, quote, “radical gender ideology.” Now, LGBTQ+ youth are among those at the highest risk for suicide, which is exactly what the 988 program was created to prevent. Yet there’s been very little coverage of this. I had to actually go searching to find out exactly what happened here. Is this just kind of another day in the Trump administration? 

Raman: I think a lot of it stems back to some of those initial executive orders related to gender ideology and DEI [diversity, equity, and inclusion] and things like that. The Trump administration’s kind of argument is that it shouldn’t be siloed. It should be all general. There shouldn’t be sort of special treatment, even though we do have specialized services for veterans who call in to these services and things. But I— 

Rovner: Although that was only saved when members of Congress complained. 

Raman: Yeah. But I do think that when we have so much happening in this space focused on LGBTQ issues, it’s easier for things to get missed. I think the one thing that I did notice was that California announced yesterday that they were going to step up to do a partnership with the Trevor Project to at least — the LGBTQ youth calling from California to any of those local 988 centers would be reaching people that have been trained a little bit more in cultural competency and dealing with LGBTQ youth. But that’s not going to be all the states and it’s going to take time. Yeah. 

Rovner: Yeah, we’re going to continue to see this cobbled together state by state. It feels like increasingly what services are available to you are going to be very much dependent on where you live. That’s always been true, but it feels like it’s getting more and more and more true. Shefali, I see you nodding. 

Luthra: Something you alluded to that I think bears making explicit is public health interventions are typically targeted toward people who are in greater danger or are at greater risk. That’s not discrimination — that’s public health efficiency. And suggesting that we shouldn’t have resources targeted toward people at higher risk of suicide is counter to what public health experts have been arguing for a very long time. And that’s just something that I think really bears noting and keeping in mind as we see what the impact of this is moving forward. 

Rovner: Yeah, I think that’s a very good point. Thank you. 

Well, speaking of popular things that are going away, a federal judge appointed by President Trump last week struck down the last-minute Biden administration rule from the Consumer Financial Protection Bureau that tried to bar medical debt from appearing on credit reports. This had been hailed as a major step for the 100 million Americans with medical debt, which is not exactly the same as buying a car or a TV that you really can’t afford. People don’t go into medical debt saying, Oh, I think I’m going to go run up a big medical bill that I can’t pay. But this strikes me as yet another way this administration is basically inflicting punishment on its own voters. Yes? 

Kenen: Yes, except we just don’t know. Some red states are so red that you don’t need every voter. We don’t know who actually votes, and we don’t know whether people make these connections, right? What we were talking about before with Medicaid — do they understand that this is something that President Trump not just urged but basically ordered Congress to do? So do people pay attention? How many people even know if their medical debt is or is not on their credit report? They know they have the medical debt, but I’m not sure everybody understands all the implication, particularly if you’re used to being in debt. You may be somebody who’s lost a job or couldn’t pay your mortgage or couldn’t pay your rent. Some of the people who have medical debt have so many other financial — not all — that it’s just part of a debt soup and it’s just one more ingredient. 

So how it plays out and how it’s perceived? It’s part of this unpredictable mix. Trump is openly talking about gerrymandering more, and so it won’t matter what voters do, because they’ll have more Republican seats. That’s just something he’s floating. We don’t know whether it’ll actually happen, but he floated it in public, so— 

Rovner: So much of this is flooding the zone, that people — there’s so much happening that people have no idea who’s responsible for what. There’s always the pollster question: Is your life better or worse than it was last year? Or four years ago, whatever. And I think that when you do so much so fast, it’s pretty hard to affix blame to anybody. 

Raman: And most people aren’t single-issue voters. They’re not going to the polls saying, My medical debt is back on my credit report. There’s so many other things, even if with the last election, health care was not the number one issue for most voters. So it’s difficult to say if it will be the top issue for the next election or the next one after that. 

And I guess just piggybacking that a lot of the times when there’s these big changes, they don’t take effect for a while. So it’s easier to rationalize, Oh, it may have been this person or that person or the senator then, or who was president at a different time, just because of how long it takes to see the effects in your daily life. 

Rovner: Politics is messy. All right, well, this is as much time for the news as we have this week? Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week? 

Luthra: Sure. My piece is from The New York Times, by Apoorva Mandavilli. The headline is “Trump Official Accused PEPFAR of Funding Abortions in Russia. It Wasn’t True.” And she takes a look at when the head of the OMB [Office of Management and Budget] told the Senate that PEPFAR had spent almost $10 million advising Russian doctors on abortions and gender analysis. And she goes through and says this isn’t true. PEPFAR hasn’t been in Russia. They cannot fund abortions. And she talks with people who were there and can say this simply isn’t true and this is very easy to disprove. And I like this piece because it’s just a reminder that a lot of things are being said about government spending that are not true. And it is a public service to remind readers that they are very easily disproven. 

Rovner: Yeah, and to go ahead and do that. Sandhya. 

Raman: My extra credit is “‘We’re Creating Miscarriages With Medicine’: Abortion Lessons From Sweden,” and it’s from Cecilia Nowell for The Nation, my co-fellow through AHCJ [the Association of Health Care Journalists] this year. Cecilia went to Kiruna, which is an Arctic village in Sweden, to look at how they’re using mifepristone for abortions up to 22 weeks in pregnancy, compared to up to 10 weeks in the U.S. And it’s a really interesting look at how they’re navigating rural access to abortion in very remote areas. Almost all abortions in Sweden are done through medication abortion, and while the majority here are in the 60% versus high 90s. So just interesting how they’re taking their approach there as rural access is limited here. 

Rovner: Really interesting story. Joanne. 

Kenen: This is a piece in The New Yorker by Dhruv Khullar, and it’s “Can A.I. Find Cures for Untreatable Diseases — Using Drugs We Already Have?” And what I found interesting, we’ve been hearing about: Can AI do this? It’s sort of been in the air since AI came around. But what was so interesting about this article is there’s a nonprofit that is actually doing it, and they have this sort of whole sort of hierarchy of why a drug may be promising and why a disease may be a good target. And then the AI look at genetics and diseases, and they have four or five factors they look at. And then there’s this just sort of hierarchy of which are the ones we can make accessible. 

So A, it’s actually happening. B, it has promise. It’s not a panacea, but there’s promise. And C, it’s being done by a nonprofit. It’s not a cocktail for an individual patient. It’s trying to figure out: What are the smartest drugs to be looking at and what can they treat? And they give examples of people who have gone into remission from rare diseases. And also it says there are 18,000 diseases and only 9,000 have treatment. So this is huge, right? Rare diseases may only affect a few people, but there are lots of rare diseases. So cumulatively some of the people they strike are young. So for someone who doesn’t always read about AI, I found this one interesting. 

Rovner: Also, we read somebody’s story about how AI is terrible for this, that, and the other thing. It is very promising for an awful lot of things. 

Kenen: No. Right. 

Rovner: There’s a reason that everybody’s looking at it. 

All right, my extra credit this week is also from The New York Times. It’s called “UnitedHealth’s Campaign to Quiet Critics,” by David Enrich, who’s The Times’ deputy investigations editor and, notably, author of a book on attacks on press freedoms. That’s because the story chronicles how UnitedHealth, the mega health company we have talked about a lot on this show, is taking a cue from President Trump and increasingly taking its critics to court, in part by claiming that critical reporting about the company risks inciting further violence like the Midtown Manhattan murder of United executive Brian Thompson last year. 

I hasten to add, this isn’t a matter of publications making stuff up. United, as we have pointed out, is a subject of myriad civil and criminal investigations into potential Medicare fraud as well as antitrust violations. This is still another chapter unfolding in the big United story. 

OK, that is this week’s show. Thanks as always to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us to review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at [email protected]. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Shefali? 

Raman: I’m at Bluesky, @shefali. 

Rovner: Sandhya. 

Raman: I’m at X and at Bluesky, @SandhyaWrites. 

Rovner: Joanne? 

Kenen: I’m mostly at Bluesky, @joannekenen.bsky, and I’ve been posting things more on LinkedIn, and there are more health people hanging out there. 

Rovner: So we are hearing. We will be back in your feed next week. Until then, be healthy. 

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Elisabeth Rosenthal

Last year in Massachusetts, after finding lumps in her breast, Jessica Chen went to Lowell General Hospital-Saints Campus, part of Tufts Medicine, for a mammogram and sonogram. Before the screenings, she asked the hospital for the estimated patient responsibility for the bill using her insurance, Tufts Health Plan. Her portion, she was told, would be $359 — and she paid it. She was more than a little surprised weeks later to receive a bill asking her to pay an additional $1,677.51. “I was already trying to stomach $359, and this was many times higher,” Chen, a physician assistant, told me.

The No Surprises Act, which took effect in 2022, was rightly heralded as a landmark piece of legislation, which “protects people covered under group and individual health plans from receiving surprise medical bills,” according to the Centers for Medicare & Medicaid Services. And yet bills that take patients like Chen by surprise just keep coming.

With the help of her software-wise boyfriend, she found the complicated “machine-readable” master price list that hospitals are required to post online and looked up the negotiated rate between Lowell General and her insurer. It was $302.56 — less than she had paid out-of-pocket.

CMS is charged with enforcing the law, so Chen sent a complaint about the surprising bill to the agency. She received a terse email in return: “We have reviewed your complaint and have determined that the rights and protections of the No Surprises Act do not apply.”

When I asked the health system to explain how such a surprising off-estimate bill could be generated, Tufts Medicine spokesperson Jeremy Lechan responded by email: “Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause.”

Here’s the problem: While the No Surprises Act has been a phenomenal success in taking on some unfair practices in the wild West of medical billing, it was hardly a panacea.

In fact, the measure protected patients primarily from only one particularly egregious type of surprise bill that had become increasingly common before the law’s enactment: When patients unknowingly got out-of-network care at an in-network facility, or when they had no choice but to get out-of-network care in an emergency. In either case, before President Donald Trump signed the law late in his first term, patients could be hit with tens or hundreds of thousands of dollars in out-of-network bills that their insurance wouldn’t pay.

The No Surprises Act also provided some protection from above-estimate bills, but at the moment, the protection is only for uninsured and self-pay patients, so it wouldn’t apply in Chen’s case since she was using health insurance.

But patients who do qualify generally are entitled to an up-front, good-faith estimate for treatment they schedule at least three business days in advance or if they request one. Patients can dispute a bill if it is more than $400 over the estimate. (The No Surprises Act also required what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not been implemented, since, nearly five years later, the government still has not issued rules about exactly what form it should take.)

So, surprising medical bills — bills that the patient could not have anticipated and never consented to — are still stunning countless Americans.

Jessica Robbins, who works in product development in Chicago, was certainly surprised when, out of the blue, she was recently billed $3,300 by Endeavor Health for a breast MRI she had received two years earlier, with prior authorization from her then-insurer, Blue Cross and Blue Shield of Illinois. In trying to resolve the problem, she found herself caught in a Kafkaesque circle involving dozens of calls and emails. The clinic where she had the procedure no longer existed, having been bought by Endeavor. And she no longer had Blue Cross.

“We are actively working with the patient and their insurer to resolve this matter,” Endeavor spokesperson Allie Burke said in an emailed response to my questions.

Mary Ann Bonita of Fresno, California, was starting school this year to become a nursing assistant when, on a Friday, she received a positive skin test for tuberculosis. Her school’s administration said she couldn’t return to class until she had a negative chest X-ray. When her doctor from Kaiser Permanente didn’t answer requests to order the test for several days, Bonita went to an emergency room and paid $595 up front for the X-ray, which showed no TB. So she and her husband were surprised to receive another bill, for $1,039, a month later, “with no explanation of what it was for,” said Joel Pickford, Bonita’s husband.

In the cases above, each patient questioned an expensive, unexpected medical charge that came as a shock — only to find that the No Surprises Act didn’t apply.

“There are many billing problems out there that are surprising but are not technically surprise bills,” Zack Cooper, an associate professor of economics at Yale University, told me. The No Surprises Act fixed a specific kind of charge, he said, “and that’s great. But, of course, we need to address others.”

Cooper’s research has found that before the No Surprises Act was passed, more than 25% of emergency room visits yielded a surprise out-of-network bill.

CMS’ official No Surprises Help Desk has received tens of thousands of complaints, which it investigates, said Catherine Howden, a CMS spokesperson. “While some billing practices, such as delayed bills, are not currently regulated” by the No Surprises Act, Howden said, complaint trends nonetheless help “inform potential areas for future improvements.” And they are needed.

Michelle Rodio, a teacher in Lakewood, Ohio, had a lingering cough weeks after a bout of pneumonia that required treatment with a course of antibiotics. She went to Cleveland Clinic’s Lakewood Family Health Center for an examination. Her X-ray was fine. As was her nasal swab — except for the stunning $2,700 bill it generated.

“I said, ‘This is a surprise bill!’” Rodio recalled telling the provider’s finance office. The agent said it was not.

“So I said, ‘Next time I’ll be sure to ask the doctor for an estimate when I get a nose swab.’”

“The doctors wouldn’t know that,” the agent replied, as Rodio recalled — and indeed physicians generally have no idea how much the tests they order will cost. And in any case, Rodio was not legally entitled to a binding estimate, since the part of the No Surprises Act that grants patients with insurance that right has not been implemented yet.

So she was stuck with a bill of $471 (the patient responsibility portion of the $2,700 charge) that she couldn’t have consented to (or rejected) in advance. It was surprising — shocking to her, even — but not a “surprise bill,” according to the current law. But shouldn’t it be?

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Jordan Rau, KFF Health News

Federal health officials do not inform consumers about severe safety violations in hospitals that specialize in physical rehabilitation. Nor does Medicare impose fines as it does for nursing homes, or provide easy-to-understand five-star ratings as it does for general hospitals, according to an investigation by KFF Health News and The New York Times. 

Medical rehab hospitals have become a highly lucrative niche within the health care industry, collectively generating profits of 10%, more than general hospitals, which earn about 6%, and far more than skilled nursing homes, which make less than 0.5%, according to the most recent data from the Medicare Payment Advisory Commission, an independent congressional agency known as MedPAC. 

But MedPAC and independent researchers have found that for-profit rehabs tend to have higher rates of patients being readmitted to general hospitals than nonprofits do. 

In 2023, stand-alone for-profit rehabilitation hospitals overtook nonprofits as the places where most annual patient admissions occur, a KFF Health News and New York Times analysis found. These facilities are required to provide three hours of physical, occupational, or speech therapy a day, five days a week. 

Congress has not authorized Medicare to fine rehab hospitals for violations uncovered during inspections, even ones that resulted in death, as it has done with nearly 8,000 nursing homes during the last three years, imposing average fines of about $28,000. 

The only option is to entirely cut off a rehab hospital’s reimbursement for all services by Medicare and Medicaid, which cover most patients. That step would most likely put it out of business and is almost never used. Even the most serious violations effectively carry no punishments so long as the hospital puts steps in place to avert future problems. 

The federal government’s overall quality oversight efforts are limited. Medicare docks payment to rehab facilities for patients readmitted to a general hospital during shorter-than-average rehab stays, but unlike at general hospitals, there are no financial penalties when recently discharged rehab patients are hospitalized for critical health issues. 

The Biden administration announced last year it intended to develop a rating scale of 1 to 5 stars for rehab facilities on its Care Compare website. The industry’s trade association, the American Medical Rehabilitation Providers Association, requested a delay in the creation of star ratings until the current quality measures were refined. The Trump administration has not determined whether it will continue the effort to rate rehab facilities. 

Also read our consumer guide to finding the right place to get physical, occupational or speech therapy.

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Julie Appleby, KFF Health News

Most of the 24 million people in Affordable Care Act health plans face a potential one-two punch next year — double-digit premium increases along with a sharp drop in the federal subsidies that most consumers depend on to buy the coverage, also known as Obamacare.

Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, covid-era ACA tax subsidies to expire at the end of December.

“The out-of-pocket change for individuals will be immense, and many won’t actually be able to make ends meet and pay premiums, so they will go uninsured,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Donald Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won’t occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions.

“I am hearing on both sides — more from Republicans, but from both the House and Senate” — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups.

In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, according to an analysis for the Peterson-KFF Health System Tracker covering 19 states and the District of Columbia. KFF is a national health information nonprofit that includes KFF Health News.

That’s up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%.

Health insurers “are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes,” wrote Chris Bond, a spokesperson for AHIP, the industry’s lobbying group. The emailed response also called on lawmakers “to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026.”

Neither the White House nor the Department of Health and Human Services responded to requests for comment.

These are initial numbers and insurance commissioners in some states may alter requests before approval.

Still, “it’s the biggest increase we’ve seen in over five years,” said analysis co-author Cynthia Cox, a KFF vice president and director of its Program on the ACA.

Premiums will vary based on where consumers live, the type of plan they choose, and their insurer.

For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, according to an analysis of a smaller set of insurers by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA’s enhanced tax credits are extended.

Most insurers are asking for 10% to 20% increases, the KFF report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed.

But rising premiums are just part of the picture.

A bigger potential change for consumers’ pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden’s term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022.

Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to chip in 8.5% of their household income toward the premiums.

Across the board, but especially among lower-income policyholders, bigger subsidies helped fuel record enrollment in ACA plans.

But they’re also costly.

A permanent extension could cost $335 billion over the next decade, according to the Congressional Budget Office.

Such an extension was left out of the policy law Trump signed on July 4 that he called the “One Big Beautiful Bill.” Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels.

That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds four times the federal poverty level — $84,600 for a couple or $128,600 for a family of four this year — won’t get any subsidies at all.

If the subsidies expire, policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%. In some states, ACA premiums could double.

“There will be sticker shock,” said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses.

And enrollment could fall sharply. The Wakely Consulting Group estimates that the combination of expiring tax credits, the Trump law’s new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%.

According to KFF, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members.

Less common in the filings submitted so far, but noticeable, are increases pegged to Trump administration tariffs, Cox said.

“What they are assuming is tariffs will drive drug costs up significantly, with some saying that can have around a 3-percentage-point increase” in premiums as a result, she said.

Consumers will learn their new premium prices only late in the fall, or when open enrollment for the ACA begins on Nov. 1 and they can start shopping around.

Congress could still act, and discussions are ongoing, said insurance broker Brooker.

Some lawmakers, he said, are consulting with the CBO about the fiscal and coverage effects of various scenarios that don’t extend the subsidies as they currently exist but may offer a middle ground. One possibility involves allowing subsidies for families earning as much as five or six times the poverty level, he said.

But any such effort will draw pushback.

Some conservative think tanks, such as the Paragon Health Institute, say the more generous subsides led people to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization.

But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. In 2024, 56% of ACA enrollees lived in Republican congressional districts, and 76% were in states won by Trump.

Allowing the enhanced subsidies to expire could also reshape the market.

Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Trump’s new tax law allows people enrolled in either “bronze” or “catastrophic”-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs.

“Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options,” Brooker said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Rehabilitation therapy can be a godsend after hospitalization for a stroke, a fall, an accident, a joint replacement, a severe burn, or a spinal cord injury, among other conditions. Physical, occupational, and speech therapy are offered in a variety of settings, including at hospitals, nursing homes, clinics, and at home. It’s crucial to identify a high-quality, safe option with professionals experienced in treating your condition.

What kinds of rehab therapy might I need?

Physical therapy helps patients improve their strength, stability, and movement and reduce pain, usually through targeted exercises. Some physical therapists specialize in neurological, cardiovascular, or orthopedic issues. There are also geriatric and pediatric specialists. Occupational therapy focuses on specific activities (referred to as “occupations”), often ones that require fine motor skills, like brushing teeth, cutting food with a knife, and getting dressed. Speech and language therapy help people communicate. Some patients may need respiratory therapy if they have trouble breathing or need to be weaned from a ventilator.

Will insurance cover rehab?

Medicare, health insurers, workers’ compensation, and Medicaid plans in some states cover rehab therapy, but plans may refuse to pay for certain settings and may limit the amount of therapy you receive. Some insurers may require preauthorization, and some may terminate coverage if you’re not improving. Private insurers often place annual limits on outpatient therapy. Traditional Medicare is generally the least restrictive, while private Medicare Advantage plans may monitor progress closely and limit where patients can obtain therapy.

Should I seek inpatient rehabilitation?

Patients who still need nursing or a doctor’s care but can tolerate three hours of therapy five days a week may qualify for admission to a specialized rehab hospital or to a unit within a general hospital. Patients usually need at least two of the main types of rehab therapy: physical, occupational, or speech. Stays average around 12 days.

How do I choose?

Look for a place that is skilled in treating people with your diagnosis; many inpatient hospitals list specialties on their websites. People with complex or severe medical conditions may want a rehab hospital connected to an academic medical center at the vanguard of new treatments, even if it’s a plane ride away.

“You’ll see youngish patients with these life-changing, fairly catastrophic injuries,” like spinal cord damage, travel to another state for treatment, said Cheri Blauwet, chief medical officer of Spaulding Rehabilitation in Boston, one of 15 hospitals the federal government has praised for cutting-edge work.

But there are advantages in selecting a hospital close to family and friends who can help after you are discharged. Therapists can help train at-home caregivers.

How do I find rehab hospitals?

The discharge planner or caseworker at the acute care hospital should provide options. You can search for inpatient rehabilitation facilities by location or name through Medicare’s Care Compare website. There you can see how many patients the rehab hospital has treated with your condition — the more the better. You can search by specialty through the American Medical Rehabilitation Providers Association, a trade group that lists its members.

Find out what specialized technologies a hospital has, like driving simulators — a car or truck that enable a patient to practice getting in and out of a vehicle — or a kitchen table with utensils to practice making a meal.

How can I be confident a rehab hospital is reliable?

It’s not easy: Medicare doesn’t analyze staffing levels or post on its website results of safety inspections as it does for nursing homes. You can ask your state public health agency or the hospital to provide inspection reports for the last three years. Such reports can be technical, but you should get the gist. If the report says an “immediate jeopardy” was called, that means inspectors identified safety problems that put patients in danger.

The rate of patients readmitted to a general hospital for a potentially preventable reason is a key safety measure. Overall, for-profit rehabs have higher readmission rates than nonprofits do, but there are some with lower readmission rates and some with higher ones. You may not have a nearby choice: There are fewer than 400 rehab hospitals, and most general hospitals don’t have a rehab unit.

You can find a hospital’s readmission rates under Care Compare’s quality section. Rates lower than the national average are better.

Another measure of quality is how often patients are functional enough to go home after finishing rehab rather than to a nursing home, hospital, or health care institution. That measure is called “discharge to community” and is listed under Care Compare’s quality section. Rates higher than the national average are better.

Look for reviews of the hospital on Yelp and other sites. Ask if the patient will see the same therapist most days or a rotating cast of characters. Ask if the therapists have board certifications earned after intensive training to treat a patient’s particular condition.

Visit if possible, and don’t look only at the rooms in the hospital where therapy exercises take place. Injuries often occur in the 21 hours when a patient is not in therapy, but in his or her room or another part of the building. Infections, falls, bedsores, and medication errors are risks. If possible, observe whether nurses promptly respond to call lights, seem overloaded with too many patients, or are apathetically playing on their phones. Ask current patients and their family members if they are satisfied with the care.

What if I can’t handle three hours of therapy a day?

A nursing home that provides rehab might be appropriate for patients who don’t need the supervision of a doctor but aren’t ready to go home. The facilities generally provide round-the-clock nursing care. The amount of rehab varies based on the patient. There are more than 14,500 skilled nursing facilities in the United States, 12 times as many as hospitals offering rehab, so a nursing home may be the only option near you.

You can look for them through Medicare’s Care Compare website. (Read our previous guide to finding a good, well-staffed home to know how to assess the overall staffing.)

What if patients are too frail even for a nursing home?

They might need a long-term care hospital. Those specialize in patients who are in comas, on ventilators, and have acute medical conditions that require the presence of a physician. Patients stay at least four weeks, and some are there for months. Care Compare helps you search. There are fewer than 350 such hospitals.

I’m strong enough to go home. How do I receive therapy?

Many rehab hospitals offer outpatient therapy. You also can go to a clinic, or a therapist can come to you. You can hire a home health agency or find a therapist who takes your insurance and makes house calls. Your doctor or hospital may give you referrals. On Care Compare, home health agencies list whether they offer physical, occupational, or speech therapy. You can search for board-certified therapists on the American Physical Therapy Association’s website.

While undergoing rehab, patients sometimes move from hospital to nursing facility to home, often at the insistence of their insurers. Alice Bell, a senior specialist at the APTA, said patients should try to limit the number of transitions, for their own safety.

“Every time a patient moves from one setting to another,” she said, “they’re in a higher risk zone.”

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Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, industry leaders often also warn of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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Lauren Sausser and Katheryn Houghton

As a postpartum doula, Dawn Oliver does her best work in the middle of the night.

During a typical shift, she shows up at her clients’ home at 10 p.m. She answers questions they may have about basic infant care and keeps an eye out for signs of postpartum depression.

After bedtime, she may feed the baby a bottle or wake the mother to breastfeed. She soothes the infant back to sleep. Sometimes, she prepares meals for the family in a Crock-Pot or empties the dishwasher.

She leaves the following morning and returns, often nightly, for two or three weeks in a row.

“I’m certified to do all of it,” said Oliver, of Hardeeville, South Carolina, who runs Compassionate Care Doula Services. It takes a village to raise a child, as the adage goes, but “the village is not what it used to be,” Oliver said.

Doulas are trained to offer critical support for families — before delivery, during childbirth, and in those daunting early days when parents are desperate for sleep and infants still wake up around the clock. While doulas typically don’t hold a medical or nursing degree, research shows they can improve health outcomes and reduce racial health disparities.

Yet their services remain out of reach for many families. Oliver charges $45 an hour overnight, and health insurance plans often don’t cover her fees. That’s partly why business “ebbs and flows,” Oliver said. Sometimes, she’s fully booked for months. Other times, she goes several weeks without a client.

That may soon change.

Two bipartisan bills, introduced in separate chambers of the South Carolina General Assembly, would require both Medicaid, which pays for more than half of all births in the state, and private insurers to cover the cost of doula services for patients who choose to use one.

South Carolina isn’t an outlier. Even as states brace for significant reductions in federal Medicaid funding over the next decade, legislatures across the country continue to pass laws that grant doula access to Medicaid beneficiaries. Some state laws already require private health insurers to do the same. Since the start of 2025, Vermont lawmakers, alongside Republican-controlled legislatures in Arkansas, Utah, Louisiana, and Montana, have passed laws to facilitate Medicaid coverage of doula services.

All told, more than 30 states are reimbursing doulas through Medicaid or are implementing laws to do so.

Notably, these coverage requirements align with one of the goals of Project 2025, whose “Mandate for Leadership” report, published in 2023 by the conservative Heritage Foundation, offered a blueprint for President Donald Trump’s second term. The document calls for increasing access to doulas “for all women whether they are giving birth in a traditional hospital, through midwifery, or at home,” citing concerns about maternal mortality and postpartum depression, which may be “worsened by poor birth experiences.” The report also recommends that federal money not be used to train doctors, nurses, or doulas to perform abortions.

The Heritage Foundation did not respond to an interview request.

Meanwhile, the idea that doulas can benefit babies, parents, and state Medicaid budgets by reducing costly cesarean sections and preterm birth complications is supported by a growing body of research and is gaining traction among conservatives.

A study published last year in the American Journal of Public Health found that women enrolled in Medicaid who used a doula faced a 47% lower risk of delivering by C-section and a 29% lower risk of preterm birth. They were also 46% more likely to attend a postpartum checkup.

“Why wouldn’t you want somebody to avail themselves of that type of care?” said Republican state Rep. Tommy Pope, who co-sponsored the doula reimbursement bill in the South Carolina House of Representatives. “I don’t see any reason we shouldn’t be doing that.”

Pope said his daughter-in-law gave birth with the assistance of a doula. “It opened my eyes to the positive aspects,” he said.

Amy Chen, a senior attorney with the National Health Law Program, which tracks doula reimbursement legislation around the country as part of its Doula Medicaid Project, said lawmakers tend to support these efforts when they have a personal connection to the issue.

“It’s something that a lot of people resonate with,” Chen said, “even if they, themselves, have never been pregnant.”

Conservative lawmakers who endorse state-level abortion bans, she said, often vote in favor of measures that support pregnancy, motherhood, and infant health, all of which these doula reimbursement bills are intended to do.

Some Republicans feel as if “they have to come out in favor of that,” Chen said.

Health care research also suggests that Black patients, who suffer significantly higher maternal and infant mortality rates than white patients, may particularly benefit from doula care. In 2022, Black infants in South Carolina were more than twice as likely to die from all causes before their 1st birthday as white infants.

That holds true for women in rural parts of the country where labor and delivery services have either closed or never existed.

That’s why Montana lawmakers passed a doula reimbursement bill this year — to narrow health care gaps for rural and Indigenous communities. To that end, in 2023, the state enacted a bill that requires Medicaid to reimburse midwives for home births.

Montana state Sen. Mike Yakawich, a Republican who backed the Democratic-sponsored doula reimbursement bill, said pregnant women should have someone to call outside of a hospital, where health care services can be costly and intimidating.

“What help can we provide for moms who are expecting? My feeling is, it’s never enough,” Yakawich said.

Britney WolfVoice lives on the Northern Cheyenne Indian Reservation in southeastern Montana, about two hours from the closest birthing hospital. In early July, she was seven months pregnant with her fourth child, a son, and said she planned to have a doula by her side for the second time in the delivery room. During WolfVoice’s previous pregnancy, an Indigenous doula named Misty Pipe brought cedar oil and spray into the delivery room, rubbed WolfVoice’s back through contractions, and helped ensure WolfVoice’s husband was the first person their daughter saw.

“Being in a hospital, I felt heard for the very first time,” WolfVoice said. “I just can’t explain it any better than I felt at home. She was my safe place.”

Pipe said hospitals are still associated with the government forcibly removing children from Native American homes as a consequence of colonization. Her goal is to help give people a voice during their pregnancy and delivery.

Most of her clients can’t afford to pay for doula services out-of-pocket, Pipe said, so she doesn’t charge anything for her birth services, balancing her role as a doula with her day job at a post office.

“If a mom is vulnerable, she could miss a prenatal appointment or go alone, or I can take time off of work and take her myself,” Pipe said. “No mom should have to birth in fear.”

The new state law will allow her to get paid for her work as a doula for the first time.

In some states that have enacted such laws, initial participation by doulas was low because Medicaid reimbursement rates weren’t high enough. Nationally, doula reimbursement rates are improving, Chen said.

For example, in Minnesota, where in 2013 lawmakers passed one of the first doula reimbursement bills, Medicaid initially paid only $411 per client for their services. Ten years later, the state had raised the reimbursement rate to a maximum of $3,200 a client.

But Chen said it is unclear how federal Medicaid cuts might affect the fate of these state laws.

Some states that haven’t passed doula reimbursement bills, including South Carolina, might be hesitant to do so in this environment, she said. “It’s just a really uncertain time.”

As he had wanted, President Donald Trump signed his big budget bill into a big budget law in a White House ceremony on July 4, cementing, among other things, billions of dollars in cuts to health programs such as Medicaid. The new law will also reshape rules for the Affordable Care Act, Medicare, and other health programs. 

Meanwhile, the threat of layoffs continues to hang over the heads of employees at the Department of Health and Human Services, and funding for health-related contracts and grants remains stalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Rachel Roubein of The Washington Post, and Tami Luhby of CNN.

Among the takeaways from this week’s episode:

• As details of Trump’s tax and domestic policy law come into focus, it’s clear that many immigrants in the country legally stand to lose government benefits, especially health coverage. While the GOP described the legislation as targeting “illegal immigrants,” the law as written bars many individuals living here with the government’s permission — including refugees and victims of domestic abuse and trafficking — from signing up for Medicaid, receiving Affordable Care Act marketplace subsidies, and more.
• Other aspects of Trump’s priority-laden law received extra attention following its hastened passage. In an unusually political move, the Social Security Administration touted to beneficiaries the law’s cuts to taxes on Social Security benefits — which is neither what the law does nor what a federal agency traditionally does when Congress passes a law.
• This week, the Supreme Court issued a decision from its shadow docket supporting the Trump administration’s ability to lay off federal workers using only his executive authority. That opinion is the latest curve on this year’s employment roller coaster for government employees, suggesting many people could soon lose their jobs.
• In health agency news, public health groups are suing the Trump administration over the withdrawn recommendations on covid-19 vaccines — as insurers and others in the health industry sort out how to handle a federal shift in immunization recommendations. And HHS Secretary Robert F. Kennedy Jr. canceled a meeting of the U.S. Preventive Services Task Force. The abrupt cancellation suggests Kennedy could soon remake the panel, as he did last month with the panel on vaccines.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, who reported the latest KFF Health News’ “Bill of the Month” feature, about some very expensive childhood immunizations. If you have a medical bill that’s exorbitant, baffling, or confusing, send it to us here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New England Journal of Medicine’s “The Corporatization of U.S. Health Care — A New Perspective Series,” by Debra Malina, et al.

Rachel Roubein: The Associated Press’ “RFK Jr. Promoted a Food Company He Says Will Make Americans Healthy. Their Meals Are Ultraprocessed,” by Amanda Seitz and JoNel Aleccia.

Rachel Cohrs Zhang: The Wall Street Journal’s “Prosecutors Question Doctors About UnitedHealth’s Medicare Billing Practices,” by Christopher Weaver and Anna Wilde Mathews.

Tami Luhby: The Washington Post’s “A New D.C. Hospital Grapples With Too Many Patients and Too Few Nurses,” by Jenna Portnoy.

Also mentioned in this week’s podcast:

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Nicole Silva’s 4-year-old daughter was headed to a relative’s house near the southern Colorado town of La Jara when a vehicle T-boned the car she was riding in. A cascade of ambulance rides ensued — a ground ambulance to a local hospital, an air ambulance to Denver, and another ground ambulance to Children’s Hospital Colorado.

Silva’s daughter was on Medicaid, which was supposed to cover the cost of the ambulances. But one of the three ambulance companies, Northglenn Ambulance, a public company since acquired by a private one, sent Silva’s bill to a debt collector. It was for $2,181.60, which grew to more than $3,000 with court fees and interest, court records show. The preschool teacher couldn’t pay, and the collector garnished Silva’s wages.

“It put us so behind on bills — our house payment, electric, phone bills, food for the kids,” said Silva, whose daughter recovered fully from the 2015 crash. “It took away from everything.”

Some state legislators are looking to curb bills like the one she received — surprise bills for ground ambulance rides.

When an ambulance company charges more than an insurer is willing to pay, patients can be left with a big bill they probably had no choice in.

States are trying to fill a gap left by the federal No Surprises Act, which covers air ambulances but not ground services, including ambulances that travel by road and water. This year, Utah and North Dakota joined 18 other states that have passed protections against surprise billing for such rides.

Those protections often include setting a minimum for insurers to pay out if someone they cover needs a ride. But the sticking point is where to set that bar. Legislation in Colorado and Montana stalled this year because policymakers worried that forcing insurers to pay more would lead to higher health coverage costs for everyone.

Surprise ambulance bills are one piece of a health care system that systematically saddles Americans with medical debt, straining their finances, preventing them from accessing care, and increasing racial disparities, as KFF Health News has reported.

“If people are hesitating to call the ambulance because they’re worried about putting a huge financial burden on their family, it means we’re going to get stroke victims who don’t get to the hospital on time,” said Patricia Kelmar, who directs health care campaigns at PIRG, a national consumer advocacy group. “It means that person who’s worried it might be a heart attack won’t call.”

The No Surprises Act, signed into law by President Donald Trump in 2020, says that for most emergency services, patients can be billed for out-of-network care only for the same amount they would have been billed if it were in-network. Like doctors or hospitals, ambulance companies can contract with insurers, making them in-network. Those that don’t remain out-of-network.

But unlike when making an appointment with a doctor or planning a surgery, a patient generally can’t choose the ambulance company that will respond to their 911 call. This means they can get hit with large out-of-network bills.

Federal lawmakers punted on including ground ambulances, in part because of the variety of business models — from private companies to volunteer fire departments — and a lack of data on how much rides cost.

Instead, Congress created an advisory committee that issued recommendations last year. Its overarching conclusion — that patients shouldn’t be stuck in the crossfire between providers and payers — was not controversial or partisan. In Colorado, a measure aimed at expanding protections from surprise ambulance bills got a unanimous thumbs-up in both legislative chambers.

Colorado had previously passed a law protecting people from surprise bills from private ambulance companies. This new measure was aimed at providing similar protections against bills from public ambulance services and for transfers between hospitals.

“We knew it had bipartisan support, but there are some people that vote no on everything,” said a pleasantly surprised Karen McCormick, a Democratic state representative.

A less pleasant surprise came later, when Gov. Jared Polis, who is also a Democrat, vetoed it, citing the fear of rising premiums.

States can do only so much on this issue, because state laws apply only to state-regulated health plans. That leaves out a lot of workers. According to a 2024 national survey by KFF, a health information nonprofit that includes KFF Health News, 63% of people who work for private employers and get health insurance through their jobs have self-funded plans, which aren’t state-regulated.

“It’s why we need a federal ambulance protection law, even if we passed 50 state laws,” Kelmar said.

According to data from the Colorado secretary of state’s office, the only lobbying groups registered as “opposing” the bill were Anthem and UnitedHealth Group, plus UnitedHealth subsidiaries Optum and UnitedHealthcare.

As soon as the legislative session ended in May, Kevin McFatridge, executive director of the Colorado Association of Health Plans, a trade group representing health insurance companies in the state, sent a letter to the governor requesting a veto, with an estimate that the legislation would result in premiums rising 0.4%.

The Colorado bill said local governments — such as cities, counties, or special districts — would set rates.

“We are in a much better place by not having local entities set their own rates,” McFatridge told KFF Health News. “That’s almost like the fox managing the henhouse.”

Jack Hoadley, an emeritus research professor with Georgetown University’s McCourt School of Public Policy, said it isn’t clear whether state laws approved elsewhere are raising premiums, or if so by how much. Hoadley said Washington state is expected to come out with an impact analysis of its law in a couple of years.

The national trade association for insurance companies declined to provide a comment for this article. Instead, AHIP forwarded letters that its leaders submitted to lawmakers in Ohio, West Virginia, and North Dakota this year opposing measures in each state to set base ambulance rates. AHIP leadership described the proposals as inflated, government-mandated pricing that would reduce insurers’ chance to negotiate fair prices. Ultimately, the association warned, the proposed minimums would increase health care costs.

In Montana, legislators were considering a minimum reimbursement for ground ambulances of 400% of what Medicare pays, or at a set local rate if one exists. The proposal was sponsored by two Republicans and backed by ambulance companies. Health insurers successfully lobbied against it, arguing that the price was too steep.

Sarah Clerget, a lobbyist representing AHIP, told Montana lawmakers in a legislative hearing that it’s already hard to get ambulance companies to go in-network with insurers, “because folks are going to need ambulance care regardless of whether their insurance company will cover it.” She said the state’s proposal would leave those paying for health coverage with the burden of the new price.

“None of us like our insurance rates to move,” Republican state Sen. Mark Noland said during a legislative meeting as a committee tabled the bill. He equated the proposed minimum to a mandate that could lead to people having to pay more for health coverage for an important but nonetheless niche service.

Colorado’s governor was similarly focused on premiums. Polis said in his veto letter that the legislation would have raised premiums between 73 cents and $2.15 per member per month.

“I agree that filling this gap in enforcement is crucial to saving people money on health care,” he wrote. “However, those cost savings are outweighed in my view by the premium increases.”

Isabel Cruz, policy director at the Colorado Consumer Health Initiative, which supported the bill, said that even if premiums did rise, Coloradans might be OK with the change. After all, she said, they’d be trading the threat of a big ambulance bill for the price of half a cup of coffee per month.

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Dan Weissmann

In response to the high price of prescription drugs, “An Arm and a Leg” asked listeners to share their strategies for getting the medicine they need at prices they can manage.

Host Dan Weissmann and producers Emily Pisacreta and Claire Davenport share tips from a retired hospital manager who now helps seniors find the right Medicare plans, a pharmaceutical sales rep, an employee benefits adviser, and a battle-worn hospital caseworker. Each brings surprising, maybe even lifesaving, information to the table.

Explore the full crowdsourced series, including five installments of the “First Aid Kit” newsletter: The Prescription Drug Playbook.

Dan Weissmann

@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: The Prescription Drug Playbook, Part II

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. Let’s meet Jeanne Chamberlin from North Carolina. She regularly talks with folks who take like 15 different meds every day. 

Jeanne Chamberlin: You are like, oh my gosh. And literally the retail costs are $20,000 a month. 

Dan: Jeanne’s an expert, twice over. Since retiring from a career managing hospitals and medical groups, she’s been helping her fellow seniors figure out how to manage what they pay for health care — as a county-level volunteer coordinator for a program called SHIP. 

Jeanne: And SHIP stands for Seniors Health Insurance Information Program. 

Dan: Actually in some cases it stands for State Health Insurance Assistance Program. 

Whatever you wanna call it — It’s a federally funded program that helps seniors with all things Medicare. Every state has its own version of SHIP. 

During the busy season — that’s in the fall, when people can pick new insurance for the coming year– Jeanne says she and her team speak to more than a hundred people a week. 

And one thing that comes up in basically ALL of those conversations: Can I change things to get my meds for less next year? 

She says one year, her team added up the impact of those conversations. Half of the people changed plans, and on average, they saved 300 dollars. Not bad… 

Jeanne: But there were many, many people who saved a thousand, 2000, even $10,000 by changing from one Medicare plan to another based entirely on the cost of their drugs. 

Dan: Jeanne’s gonna tell us how she helps people get those kinds of savings– with strategies that aren’t just for people on Medicare. 

And Jeanne is just one person who wrote to us when we asked for you, our listeners, to tell us about your tactics and tricks for dealing with the high cost of prescription drugs.

The result: two podcast episodes– this is number two — and four installments of our First Aid Kit newsletter. 

In this episode, we’re gonna hear from Jeanne and three other *incredible* sources who came to us with crucial insider knowledge. Knowledge that — now they we have it– we have to share with you. 

Jeanne’s gonna help us get set up. She’s gonna share what she tells those seniors, and how it can apply to anyone, at any age. 

… Then, a pharma insider is gonna air an open secret. 

An employee benefits advisor — a kind of scout for deals — will tell us where she’d send someone struggling to pay for meds. 

Finally, we’ll meet a battle-worn hospital caseworker. And beyond the specific tip she wrote in with, her work – and life story – are gonna bring us some deeper perspective. 

These people kick ass. 

And for all their advice, there is, of course, a BIG caveat: 

like we said last episode — your mileage will vary. There is no one solution for everyone. This is a set of patches, workarounds, bandaids. 

To be honest, a lot of them are actually weird byproducts of the profit-making machine. Which is a big reason they’re so patchy and unreliable. 

We deserve SO much better. But in the meantime, we can help each other. That’s what this project is about. Including the four newsletter installments I mentioned. And we’ll link to those from wherever you’re listening — so: you don’t need a pencil and paper here. We’ve got you. 

Our hope is that you walk away from all of this armed with a *little* more knowledge that could help you or someone you care about get the meds they need. A kind of leg up. An Arm and a Leg-leg-up. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann– I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the

most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. 

So, first: Jeanne wrote to us about what she knows from helping people enroll in Medicare. But she also had an instructive personal story to share. Because even experts have to scramble sometimes. 

A while ago, when Jeanne’s husband had a gut infection, he got prescribed two antibiotics. His insurance coverage meant one was gonna cost him thirty bucks. But the other one? His plan didn’t cover it And… . 

Jeanne: It was $1,200. For a 14 day supply it was just obscenely expensive. 

Dan: So immediately, Jeanne says she went into problem solving mode. And her order of operations provides a great template for any of us. 

Step one: Google for discounts. Just taking a quick first pass at the kind of thing we talked about in our last episode. Maybe that’s GoodRx. Maybe that’s a coupon from the drug maker. Results for Jeanne: Not great. 

Jeanne: I could get it down to $800. It’s like, still, you’re like $800. Really? 

Dan: So, on to step two: Tell your provider there’s a problem and ask for advice. 

Jeanne: We went back to the doctor and said, is there something else that you know you can do? 

Dan: Jeanne was thinking: Maybe the doc could recommend another antibiotic — one that insurance would cover. Or help them fight her husband’s insurance to get this drug covered. 

But actually, the doc’s proposal was much simpler. 

Jeanne: She said just take the other one. 

Dan: Just take the one Jeanne’s husband could get for thirty bucks. Skip the second drug. 

Jeanne: So he did, and he was fine!

Dan: END OF STORY. In this case. It’s not always that easy. But the moral is: ASK. If your insurance covers a different drug, your doc can tell you if it’s a good bet for you. If not… well… we’ll come back to other ways your doc could help. 

But right now let’s move on to the biggest, most valuable advice Jeanne gives to seniors– and that applies to everybody. 

Especially anybody with meds they’re taking long term, like blood pressure or cholesterol meds, or whatever. 

And the advice is this: Look ahead, every year. 

In the fall, when it’s time to sign up for next year’s insurance plan: Get a look at the list of which drugs your insurance will cover, and how much they expect you to pay for them. It’s called the formulary. 

Because even if you don’t change anything about your insurance, your insurance could change the formulary. That can happen to anybody. 

Jeanne sees it all the time with seniors, when their plans reboot at New Year’s. 

Jeanne: People come in in January and this happens every year, and say, I just went to the pharmacy and. They want $300 for my medicine. And last year, or last month in December, it was $30. 

Dan: These folks didn’t plan to change anything about their insurance — but their insurance plan changed on them– and stopped covering a drug they’ve been taking. Now they’re getting charged sticker price. 

And Jeanne’s like, ‘Man, I wish you’d have come to see us during the fall sign-up– open enrollment.’ 

Jeanne: We could have probably found a plan that covered that drug still.. 

Dan: Now, it’s true that folks on Medicare tend to have more choices than the rest of us here. In Medicare, drug coverage is its own separate plan — called Part D — and seniors in Jeanne’s county have more than a dozen to pick from. 

If you get insurance from work — and maybe there’s just one plan — this thing of looking ahead is maybe even more important.

At some point, maybe a couple months before the new year, you should get a chance to see that next year’s formulary 

And it could say, “Hey, your drug is gonna be more expensive for you next year” 

That’s your cue to start problem-solving right away. Get a plan in place before that new price kicks in. 

Step one: Check: Can you find discounts online that make this drug affordable? Cool. 

No? Time to get in touch with your provider’s office: start tapping their expertise. 

Jeanne: The provider normally has a lot of people with your condition and probably prescribes this medication a lot. 

Dan: And so, if your insurance company says they’ve got some other drug you could take, one they’ll pay for– your provider will know: could that drug work for you? 

And if you’ve got a choice of plans — but they all require a special approval process now for your drug — your provider will know: Is one of them more likely to actually issue that approval? 

Jeanne: Ask them about a plan where they have an easy time getting it approved for somebody with your condition where it always goes through. 

Dan: And that’s the plan you want to pick. And, speaking of getting your insurance company’s approval: 

We’re about to move from Jeanne’s advice– plan ahead, get your provider to help — to the next step. Because you can’t plan everything. Sometimes you get sick, with something new. No planning for that. 

And sometimes, your insurance is definitely not gonna say yes right away to the drug your doc thinks you need. And your doc thinks you need this particular drug. So, how ELSE can your provider help?

John: I work, uh — work for an industry with an approval rating below Congress. 

Dan: He’s a pharmaceutical sales rep! He asked us to keep his full name and employer confidential. 

He’s also an Arm and a Leg fan. 

John: I love it when, uh, I hear stories of average people just sticking it to the insurance company. It’s nice when the patient wins, cause they don’t get a lot of wins. 

Dan: We reached John in his primary office — also known as his car. 

When we asked listeners a few months ago to share lessons about getting prescription meds without paying an arm and a leg, he wrote right in with tips. 

And one, I love just for the attitude. Here’s John reading from the email he sent us: 

John: Step therapies. Uh, denials and price at pharmacy should be viewed as suggestions. 

Dan: Suggestions. Perfect. The other is much more specific. As a salesman, a big part of John’s job is prepping doctors for the fights they’re gonna have with insurance companies, to get approvals for drugs. He does that because approvals for them mean sales for John. 

Of course, approvals take time. 

John: But one thing that you know doesn’t care about time is diseases. 

The disease of Crohn’s or Bipolar disorder, whatever, isn’t like, look, I’ll hold off on affecting you until this prior authorization is done. 

Dan: So here’s John’s advice: while you’re fighting for that approval– pushing back on the insurance company’s “suggestion” that you try something else– Ask your provider if they can get free samples from the pharma company — from a rep like him.

John: And the provider hopefully will say, yeah, let me call the rep and we’ll leave some at front for you. 

Dan: Actually, your provider may already have some on hand. A study from a few years ago found that TWO THIRDS of primary-care practices had CLOSETS of pharmaceutical samples. Which, wow. 

So, let’s address something big: Like John joked about as we introduced him, pharma sales reps are NOT generally looked upon as model citizens. 

The rap is: Some of them use less-than-scrupulous tactics to encourage doctors to prescribe expensive drugs… even to patients who might not get extra benefit from a specific drug. Or, in the case of opioids — which got pushed really hard — might cause harm. And free samples are part of that process. 

So, some providers won’t meet with sales reps at all. Some health systems don’t allow any of their staff to meet with them. 

But you don’t have to approve of how pharmaceutical companies do their business to take advantage of John’s suggestion. And neither does your doctor. 

John says, to get free samples, your doctor might not even need to talk to anyone. 

They can just make a request online, at the manufacturer’s website. John says it definitely happens. 

John: So even with providers or doctors that I’ve never seen in my nine years, I know that they’ve gotten samples before. 

Dan: But here too, there will be limits. 

John: Some manufacturers don’t even do samples. So it really varies a lot. Dan: But a lot of these samples do exist — 

And the idea of using them as a stopgap while you fight to get your insurance to pay for the meds you need — I had never thought of it until we asked you, our listeners, for your tips.

And you also sent us this: Could a local clinic supply the meds you need for a price you can actually afford? That’s next.. 

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues. 

OK, a whole new kind of expert here. Like Jeanne, who we heard from earlier. Cristy Gupton also lives in North Carolina. She works as an independent employee benefits designer. You’re probably like, what the hell is that? Here’s how she describes her work. 

Cristy Gupton: Imagine you’re a kid in high school, in shop class, and your teacher puts an old engine on the table, and says, take it apart and put it back together again and make sure it works. 

Dan: Except, the machine is a health benefit program for workers. And– back to the shop-class metaphor — Cristy says she’s the real gear-head in the room . 

Cristy Gupton: By the time I put the engine back together, it works twice as good, but at half the cost. 

Dan: Cristy says she does it by ditching expensive, off-the-shelf parts — standard insurance policies from big companies — for custom solutions. It’s a WHOLE THING, and super-interesting, and worth going into. 

For now, she’s got one big tip that *some* of us could use to get access to meds at super-low prices. Basically it’s this: Look for a community health center that offers a sliding scale. They can get drugs at extremely low prices, through a federal program called 340B. 

How low? 

Cristy Gupton: The drug Humira is one of the most prescribed drugs in America. And the list price is probably somewhere in the neighborhood of 5,000 a month. But a 340B covered entity could purchase it for a penny. 

Dan: So we checked, and actually: Humira’s list price isn’t 5,000 dollars. It’s 7,000 dollars. But YES, a 340B clinic can get it for a penny. Now, they don’t get every drug that cheap, but..

And look: although this is all very much worth knowing about, it’s not guaranteed to work for you. 

340B is complicated in all kinds of ways. Here’s my colleague Emily Pisacreta asking Christy about it. 

Emily: Help me understand what 340B is. 

Cristy Gupton: I’ll give you my best, um, like only know enough to be dangerous answer. 

Dan: After checking some actual experts, here’s what we think you need to know: 

A federal law from the 1990s — section 340B of that law — basically requires drug-makers to give some hospitals and health centers that serve low-income folks super-duper discounts on meds. 

Those discounts don’t always get passed along to patients. The feds say hospitals and clinics can take a profit, to subsidize their other work . 

But the rules say: community health centers DO need to make drugs affordable to people with lower incomes. Specifically, to people who make less than two times the federal poverty level. 

For 2025, that’s just over 64 thousand dollars for a family of four. Not a lot. 

But it’s a lot of people: More than 28 percent of Americans qualify. And some clinics may have sliding scales for people with higher incomes than that. 

So: There’s a search tool. We’ve got a link wherever you’re listening to this. Find a clinic in your area, call them, and see what the deal is. 

One last thing to know: You’ve gotta actually be a patient at the clinic in order to use this program. And actually, if you meet the income requirements, all the clinic’s services are gonna be super-subidized. 

But if you don’t want to engage too deeply with the clinic– don’t want to switch over all your care to a new team — Cristy says, in her experience, you may not have to.

Cristy Gupton: It can be as loose as they just have a virtual visit. I mean, that’s pretty simple. 

Dan: Again, we’ve got a link to the search tool for finding a health center near you. Which of course…near you… not everybody is gonna have. Your mileage may vary, literally. But is it worth checking? Yeah, I think so. 

OK we’ve thrown a LOT at you. I know, I know. And we do have one more set of expert tips. From someone we are really glad to have met. So here’s Erika — and her expertise is part of a lifelong project. 

Erika: You know, as a child with Type one diabetes, I had a very dysfunctional household and I had to take care of myself from a very young age. I have learned that the skills that I developed as a child with a chronic illness are transferable into a career to help people be taken care of. 

Dan: So now, she works as a patient navigator– a kind of case worker, at a hospital in rural Oregon. 

When my colleague Emily talked with Erika, they bonded a little. 

Emily: I live with Type One Diabetes and I really wish that I had had a patient navigator, um, when I was diagnosed. 

Erika: Yeah, I wish I had me as a patient navigator too. 

Dan: Most of the patients Erika does work with are managing chronic conditions and other serious health problems, under tough circumstances. 

Erika: For example, let’s say a patient has an amputation and they’re told on discharge to keep it elevated and keep it clean. Well if they’re living in their car, that can be a challenge. So in that case, case management would try to find them a hotel for a couple weeks. 

Dan: And of course, one of the most common problems she tackles: helping people get their meds at prices they can afford. 

Erika: There are weeks where that’s all I’ll do.

Dan: For insured patients, Erika he starts with drugs-and-insurance 101: Helping them figure out which drugs their insurance covers, at what price to them, and coaching them before they call their insurance company. 

Erika:I offer to be on the call with them if they want. And I will tell you right now that we’re gonna be on hold with that insurance company for 30 minutes 

Dan: Yeah, that sounds familiar. Also, for some patients on Medicaid, Erika runs interference with bureaucracies. 

And, when there’s no way that insurance will make the right drugs affordable for her patients– including folks with no insurance at all– Erika helps them explore one of the options she wrote in to us about. 

“Patient Assistance Programs” based on income. Some are from manufacturers, others come from private foundations. 

Erika: It’s such a matter of somebody knowing who to ask and where to get the stuff. 

Dan: And there are websites to find this kind of thing — we’ve got links and guides for you — and she says the applications aren’t complicated. 

But the people she works with, they need extra help. 

Erika: A lot of my patients don’t even know how to use a computer or to get onto the internet, or they don’t have smart phones, they just have cell phones. So a lot of them, I meet with them. I take my laptop, and we do an online application. I help them fill it out. 

Dan: And then hope it works. Some programs only give out so much assistance per year, so not everybody gets help. 

Erika: It’s a frustrating fight. I feel bad that people have to wage this, you know, to get what they need to be healthy. It’s, it’s not like people are asking for BMW or new clothing. People are asking for, oftentimes medications they need to keep themselves alive. It’s, it’s like asking for oxygen. Like what if you were told you you couldn’t afford oxygen? That’s the way people feel sometimes.

Dan: And that’s why, even though Erika wrote to us about practical specifics, it’s her approach, her presence that we especially wanted to share with you. 

Erika: I advised all my patients to get a tattoo that says, be persistent. I mean, seriously, I don’t expect them to get tattoos. But as a patient who manages a chronic condition, you just have to be. 

Dan: Oh yeah. The ongoing burden of dealing with all this, it’s a bear. And it came up again and again when you wrote in to us. 

Erika: Yeah. Stress management, whew. 

Dan: For Erika’s patients, and for herself too. 

Erika: I have to remember to like, stop, step away, do some breathing. And these are things I teach to my patients a little bit too. Like, okay, let’s stop and do some breathing together on the phone. Okay. 

Dan: She calls her strategy “self compassion.” It’s about helping people see how much they’re already doing. 

Erika: I encourage people to take a moment and appreciate that about yourself. Okay? you’ve been on the phone with your insurance company for 30 minutes. 

You’re trying to get this done. You really need to appreciate that you’re doing that for your health. For your health. Feel good about that, at least. 

Dan: You are taking time to listen to this podcast. We are here, right now, together, doing our best. 

For the practical lessons — all the things to try, that may or may not work — we’ve done our best to write them down for you, and organize them so they’re useful, in our First Aid Kit newsletter. Four installments. 

You can find those newsletters — and these episodes — at Arm and a Leg show, dot com, slash, drugs. 

That’s the address where we first asked you to share what you’d learned by walking through this maze. Now we’re inviting you to come and see what we’ve learned from you.

Arm and a Leg show dot com, slash drugs. There’ll be a link wherever you’re listening to this. 

And you’ll find one more thing there, too. 

To honor the endless and ridiculous process that we sometimes have to go through to get our medicines… my colleague Claire Davenport, who has led the reporting for so much of this series, made an endless and ridiculous song. Well, with the help of an AI. Stay tuned after the credits for a little taste of that. 

We’ll be back with a new episode in a few weeks. 

Till next time, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta and Claire Davenport with help from me, Dan Weissmann, and Lauren Gould. 

And edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Weiner and Blue Dot Sessions. 

Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show. 

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. 

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support. 

And NOW….a little treat. 

So: At one point, we were like, “What if we could make like a jingle to help people remember all the tactics we’re talking about?” 

But when our producer Claire tried actually writing one, with AI supplying the melody and the band — it just kinda showed us how endless and ridiculous the list actually is. 

And we found that just adorable. Here’s how it starts… 

AI Song: I am a prescription – medication. And as you might know, I’m Expensive in this nation. Getting me can be confusing. And often quite scary. Since when it comes to meds. The prices can vary. Luckily, there’s some tricks you can try. When you’re in this situation and the price is high… 

Dan: Alright, I think you get the idea — and if you want more, it’s all at Arm and a Leg show dot com, slash, drugs. Along with these podcast episodes and First Aid Kit newsletter installments, and everything we hope you’ll actually find useful. Thanks.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

Phil Galewitz, KFF Health News and Julie Appleby, KFF Health News and Renuka Rayasam and Bernard J. Wolfson

The tax and spending legislation the House voted to send to President Donald Trump’s desk on Thursday, enacting much of his domestic agenda, cuts federal health spending by about $1 trillion over a decade in ways that will jeopardize the physical and financial health of tens of millions of Americans.

The bill, passed in both the House and the Senate without a single Democratic vote, is expected to reverse many of the health coverage gains of the Biden and Obama administrations. Their policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows, though Republicans say the trade-off was far higher costs borne by taxpayers and increased fraud.

Under the legislation Trump’s expected to sign on Friday, Independence Day, reductions in federal support for Medicaid and Affordable Care Act marketplaces will cause nearly 12 million more people to be without insurance by 2034, the Congressional Budget Office estimates. That in turn is expected to undermine the finances of hospitals, nursing homes, and community health centers — which will have to absorb more of the cost of treating uninsured people. Some may reduce services and employees or close altogether.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.

The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.

Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF, a health information nonprofit that includes KFF Health News.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that targets states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan curtails a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. Medicaid generally pays lower fees for care than Medicare, the program for people over 65 and some with disabilities, and private insurance. But thanks to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on payments from Medicaid taxes to sustain them. Researchers from the Cecil G. Sheps Center for Health Services Research who examined the original House version of the bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republicans in the Senate tacked a $50 billion fund onto the legislation to cushion the blow to rural hospitals. The money will be distributed starting in 2027 and continue for five years.

Harder To Get, and Keep, ACA Coverage

For those with Obamacare plans, the new legislation will make it harder to enroll and to retain their coverage.

ACA marketplace policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.

The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

Trump’s legislation requires states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for certain services.

The policy won’t apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction won’t apply to green-card holders.

Because the immigrants who will lose subsidies under the legislation tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said in a statement.

The bill reflects the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation doesn’t include a proposal that would have reduced federal Medicaid payments to states such as California that use their own money to cover immigrants without legal status.

KFF Health News chief Washington correspondent Julie Rovner contributed reporting.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Bram Sable-Smith

Four years before Kimberly Gallagher enrolled in Medicaid herself, the public health insurance program’s rules prompted her to make an excruciating choice — to give up guardianship of her son so she could work as his caregiver.

Now, another proposed twist in the rules could mean that, even though Missouri pays her to do that work, she might still have to prove to the state that she’s not unemployed.

The Kansas City, Missouri, resident has cared for her disabled son, Daniel, for all 31 years of his life. A rare genetic condition called Prader-Willi syndrome, in addition to autism, left him with an intellectual disability; a constant, excessive hunger; and an inability to speak. His needs left Gallagher, an elementary school teacher by training, with little opportunity to work outside her home.

As congressional Republicans slash about $1 trillion in federal Medicaid spending, Gallagher is among the 18.5 million Americans who could be required to prove that they work enough to keep their health insurance.

A budget bill that passed the House and Senate would require 80 hours of work or community service a month for adults who are insured through the Affordable Care Act’s Medicaid expansion program, which has allowed states to extend Medicaid coverage to more adults with low incomes. Forty states, plus Washington, D.C., have expanded their programs, additions that now cover about 20 million Americans, including Gallagher.

She enrolled in the coverage in December 2023, after she could no longer afford her private insurance. Before her husband died of cancer in 2019, the couple paid for private insurance and supported themselves on the income he earned as a master watchmaker. After his death, Gallagher was left to earn a living and find insurance on her own. At 59, she’s too young to collect her husband’s Social Security survivor benefit.

The Medicaid program that pays for in-home care for Daniel and 8,000 other Missourians with disabilities allows family members to be compensated for caregiving, but only if they’re not the legal guardian of the person they care for. So, Gallagher went to court to give up her rights to make decisions for her son and transfer authority to her parents.

“I think it’s appalling that it’s required, but it was necessary,” she said. “There was no way I could work outside of taking care of Daniel.”

Republicans have touted Medicaid work requirements both as a way to reduce federal spending on the program and as a moral imperative for Americans.

“Go out there. Do entry-level jobs. Get into the workforce. Prove that you matter. Get agency into your own life,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said in a recent interview on Fox Business.

Democrats, meanwhile, have cast the requirements as bureaucratic red tape that won’t meaningfully increase employment but will cause eligible people to lose their health insurance because of administrative hurdles.

Indeed, the vast majority of Americans enrolled in Medicaid expansion are already working, caregiving, attending school, or have a disability, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

And while the Congressional Budget Office estimates the work requirement included in the House bill would cause 4.8 million Americans to lose their insurance, only about 300,000 of those people are unemployed because of lack of interest in working, according to the Urban Institute, a nonprofit research group. Recent history in states that have tried work requirements suggests technical and paperwork problems have caused a substantial portion of coverage losses.

Still, the provisions are generally popular among Republican lawmakers and the public. Sen. Josh Hawley (R-Mo.), who has repeatedly cautioned against cutting people off from Medicaid, has signaled support for adding work requirements.

And 68% of Americans favor the requirement described in the House bill, according to a recent poll conducted by KFF. But support for work requirements dropped as low as 35% when respondents learned that most Medicaid recipients already work and could lose their coverage because of paperwork requirements.

That’s what happened in Arkansas, where 18,000 people lost their Medicaid coverage in 2018 after the state phased in a work requirement. Thousands more were on pace to lose coverage in 2019 before a federal judge halted the requirement, largely over concerns about coverage losses. In discussions with focus groups, KFF found that many Arkansas Medicaid participants did not fully understand the requirements, despite the state’s outreach efforts, and some people didn’t receive mailed notices. Others were confused because the work-reporting paperwork and separate forms to renew Medicaid coverage asked for similar information.

Many family caregivers would be exempt from the work requirements proposed in Congress, but Gallagher probably would not, since she had to relinquish guardianship of her son to be paid for the work. While the hours she already logs should be enough to satisfy the requirement, she’ll need to report them again — unless the state can identify her through its existing data. But Missouri has a history of procedural problems in the state agency that administers Medicaid.

In early 2022, for example, Missouri was taking more than 100 days on average to process applications for Medicaid expansion, a wait that prompted patients to put off needed care and was more than twice the processing time allowed by federal law.

And 79% of the more than 378,000 Missourians who lost Medicaid coverage when covid-era enrollment protections ended in 2023 did so because of procedural reasons.

The next year, a federal judge ruled that Missourians were illegally being denied food aid by the state, in part because insufficient staffing at call centers left eligible people without assistance.

“They’re historically understaffed,” Timothy McBride, a health economist at Washington University in St. Louis, said of the state agency that administers Medicaid and food assistance. “I think that’s really the underlying problem.”

McBride’s analysis of Missouri’s Medicaid recipients found that fewer than 45,000 of the people enrolled in expansion in 2023 were unemployed for reasons other than caregiving, disability, attending school, or retirement. But more than twice that many Missourians could lose their insurance if work requirements prompt disenrollment rates similar to Arkansas’ implementation, according to a study from the Center on Budget and Policy Priorities, a left-leaning think tank that analyzes government policies.

The estimate assumes many otherwise eligible people would still lose coverage as a result of falling through the cracks, McBride said.

Hawley, who backed the Senate bill, declined to comment for this article. The senator previously told reporters that “we can sort that out” when asked about eligible people inadvertently losing Medicaid because of work requirements.

Gallagher worries about her coverage, because she recently was diagnosed with Hashimoto’s disease, an autoimmune disorder that attacks the thyroid gland. She said she had to search for her Medicaid card to fill the prescription that followed, having barely used it in the year in a half she’s been covered.

She also worries about her son’s Medicaid. A nursing home is not a realistic option, considering his needs. His coverage doubles as Gallagher’s only source of income and also pays for other caregivers, when she can find them, who give her breaks to tend to her own health and to her aging parents.

But nearly all in-home services like those Daniel receives are optional programs that states are not required to include in their Medicaid programs. And the magnitude of the cuts being proposed have prompted fears that the optional programs could be chopped.

“It would destroy our lives,” Gallagher said. “The only income we would have would be Daniel’s Social Security.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).

Bram Sable-Smith

Four years before Kimberly Gallagher enrolled in Medicaid herself, the public health insurance program’s rules prompted her to make an excruciating choice — to give up guardianship of her son so she could work as his caregiver.

Now, another proposed twist in the rules could mean that, even though Missouri pays her to do that work, she might still have to prove to the state that she’s not unemployed.

The Kansas City, Missouri, resident has cared for her disabled son, Daniel, for all 31 years of his life. A rare genetic condition called Prader-Willi syndrome, in addition to autism, left him with an intellectual disability; a constant, excessive hunger; and an inability to speak. His needs left Gallagher, an elementary school teacher by training, with little opportunity to work outside her home.

As congressional Republicans slash about $1 trillion in federal Medicaid spending, Gallagher is among the 18.5 million Americans who could be required to prove that they work enough to keep their health insurance.

A budget bill that passed the House and Senate would require 80 hours of work or community service a month for adults who are insured through the Affordable Care Act’s Medicaid expansion program, which has allowed states to extend Medicaid coverage to more adults with low incomes. Forty states, plus Washington, D.C., have expanded their programs, additions that now cover about 20 million Americans, including Gallagher.

She enrolled in the coverage in December 2023, after she could no longer afford her private insurance. Before her husband died of cancer in 2019, the couple paid for private insurance and supported themselves on the income he earned as a master watchmaker. After his death, Gallagher was left to earn a living and find insurance on her own. At 59, she’s too young to collect her husband’s Social Security survivor benefit.

The Medicaid program that pays for in-home care for Daniel and 8,000 other Missourians with disabilities allows family members to be compensated for caregiving, but only if they’re not the legal guardian of the person they care for. So, Gallagher went to court to give up her rights to make decisions for her son and transfer authority to her parents.

“I think it’s appalling that it’s required, but it was necessary,” she said. “There was no way I could work outside of taking care of Daniel.”

Republicans have touted Medicaid work requirements both as a way to reduce federal spending on the program and as a moral imperative for Americans.

“Go out there. Do entry-level jobs. Get into the workforce. Prove that you matter. Get agency into your own life,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said in a recent interview on Fox Business.

Democrats, meanwhile, have cast the requirements as bureaucratic red tape that won’t meaningfully increase employment but will cause eligible people to lose their health insurance because of administrative hurdles.

Indeed, the vast majority of Americans enrolled in Medicaid expansion are already working, caregiving, attending school, or have a disability, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

And while the Congressional Budget Office estimates the work requirement included in the House bill would cause 4.8 million Americans to lose their insurance, only about 300,000 of those people are unemployed because of lack of interest in working, according to the Urban Institute, a nonprofit research group. Recent history in states that have tried work requirements suggests technical and paperwork problems have caused a substantial portion of coverage losses.

Still, the provisions are generally popular among Republican lawmakers and the public. Sen. Josh Hawley (R-Mo.), who has repeatedly cautioned against cutting people off from Medicaid, has signaled support for adding work requirements.

And 68% of Americans favor the requirement described in the House bill, according to a recent poll conducted by KFF. But support for work requirements dropped as low as 35% when respondents learned that most Medicaid recipients already work and could lose their coverage because of paperwork requirements.

That’s what happened in Arkansas, where 18,000 people lost their Medicaid coverage in 2018 after the state phased in a work requirement. Thousands more were on pace to lose coverage in 2019 before a federal judge halted the requirement, largely over concerns about coverage losses. In discussions with focus groups, KFF found that many Arkansas Medicaid participants did not fully understand the requirements, despite the state’s outreach efforts, and some people didn’t receive mailed notices. Others were confused because the work-reporting paperwork and separate forms to renew Medicaid coverage asked for similar information.

Many family caregivers would be exempt from the work requirements proposed in Congress, but Gallagher probably would not, since she had to relinquish guardianship of her son to be paid for the work. While the hours she already logs should be enough to satisfy the requirement, she’ll need to report them again — unless the state can identify her through its existing data. But Missouri has a history of procedural problems in the state agency that administers Medicaid.

In early 2022, for example, Missouri was taking more than 100 days on average to process applications for Medicaid expansion, a wait that prompted patients to put off needed care and was more than twice the processing time allowed by federal law.

And 79% of the more than 378,000 Missourians who lost Medicaid coverage when covid-era enrollment protections ended in 2023 did so because of procedural reasons.

The next year, a federal judge ruled that Missourians were illegally being denied food aid by the state, in part because insufficient staffing at call centers left eligible people without assistance.

“They’re historically understaffed,” Timothy McBride, a health economist at Washington University in St. Louis, said of the state agency that administers Medicaid and food assistance. “I think that’s really the underlying problem.”

McBride’s analysis of Missouri’s Medicaid recipients found that fewer than 45,000 of the people enrolled in expansion in 2023 were unemployed for reasons other than caregiving, disability, attending school, or retirement. But more than twice that many Missourians could lose their insurance if work requirements prompt disenrollment rates similar to Arkansas’ implementation, according to a study from the Center on Budget and Policy Priorities, a left-leaning think tank that analyzes government policies.

The estimate assumes many otherwise eligible people would still lose coverage as a result of falling through the cracks, McBride said.

Hawley, who backed the Senate bill, declined to comment for this article. The senator previously told reporters that “we can sort that out” when asked about eligible people inadvertently losing Medicaid because of work requirements.

Gallagher worries about her coverage, because she recently was diagnosed with Hashimoto’s disease, an autoimmune disorder that attacks the thyroid gland. She said she had to search for her Medicaid card to fill the prescription that followed, having barely used it in the year in a half she’s been covered.

She also worries about her son’s Medicaid. A nursing home is not a realistic option, considering his needs. His coverage doubles as Gallagher’s only source of income and also pays for other caregivers, when she can find them, who give her breaks to tend to her own health and to her aging parents.

But nearly all in-home services like those Daniel receives are optional programs that states are not required to include in their Medicaid programs. And the magnitude of the cuts being proposed have prompted fears that the optional programs could be chopped.

“It would destroy our lives,” Gallagher said. “The only income we would have would be Daniel’s Social Security.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The last time a Republican-controlled Congress and President Donald Trump moved to slash Medicaid spending, in 2017, a key political force stood in their way: GOP governors.

Now, as Congress steamrolls toward passing historic Medicaid cuts of about $1 trillion over 10 years through Trump’s tax and spending legislation, red-state governors are saying little publicly about what it does to health care — even as they face reductions that will punch multibillion-dollar holes in their states’ budgets.

Medicaid, a program jointly run by states and the federal government, covers more than 70 million low-income or disabled people, including nearly half of the nation’s children. Republicans say the $900 billion-a-year program was allowed to grow too large under Democrats Barack Obama and Joe Biden by adding nondisabled adults they say don’t deserve government assistance, and they have long sought to scale it back.

Some of the biggest health cuts in the legislation Trump calls the “One Big Beautiful Bill” are achieved through new policies that would reduce enrollment by imposing more paperwork demands on enrollees, including a requirement that many prove they’re working. Those policies would affect only states that expanded Medicaid to more low-income people under the Affordable Care Act.

Nineteen of those states are led by Republican governors. Their silence on the bill’s health measures is giving political cover to GOP lawmakers from their states as they seek to cut Medicaid coverage for millions of people who gained it within the last decade.

KFF Health News contacted all 19 governors for comment on the legislation’s Medicaid cuts. Only six responded. Most said they backed imposing a work requirement on adult Medicaid enrollees.

“Implementing work requirements for able-bodied adults is a good and necessary reform so that Medicaid is being used for temporary assistance and not a permanent entitlement,” said Drew Galang, a spokesperson for Gov. Patrick Morrisey of West Virginia.

“Governor Rhoden supports workforce participation as a requirement of Medicaid expansion eligibility,” said Josie Harms, a spokesperson for South Dakota Gov. Larry Rhoden, adding that congressional lawmakers have the governor’s support: “South Dakota has an excellent federal delegation, and Governor Rhoden trusts them to fight for South Dakota’s priorities while delivering on President Trump’s promises.”

In a sign of how the political winds have changed, none of the governors said anything about another of the legislation’s significant cuts, to provider taxes — a tool that nearly all of their states use to help pay their share of Medicaid and gain additional funds from the federal government. That change is expected to cost states billions.

No Longer a Bipartisan Issue

In contrast to the radio silence from GOP governors, Democratic governors have campaigned against the megabill for weeks.

Pennsylvania Gov. Josh Shapiro posted on the social platform X that Trump and congressional Republicans were misleading Americans by saying they were cutting only waste, fraud, and abuse in Medicaid.

“They’re rushing to kick hundreds of thousands of Pennsylvanians off their healthcare — and lying about it,” he posted. “The damage this will do here in Pennsylvania and across America is staggering and will be felt for years to come.”

In New York, Gov. Kathy Hochul on July 1 charged that Trump’s legislation would devastate hospitals and could lead to more than 34,000 job cuts in her state.

“The collective impact of the GOP reconciliation bill in Washington, D.C., could force hospitals to curtail critically needed services such as maternity care and psychiatric treatment, not to mention to downsize operations, and even close entirely,” she said in a statement.

In 2017, the chorus was bipartisan, as Republican governors in Ohio, Nevada, and Massachusetts spoke out against cutting Medicaid. Trump’s bill to repeal much of the Affordable Care Act and roll back its Medicaid expansion narrowly failed in the Senate.

“It’s been surprising that red-state governors, particularly those in Medicaid expansion states, haven’t spoken out against Medicaid cuts,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Republican governors were a potent political force in the failed 2017 effort to repeal and replace the ACA, including Medicaid expansion.”

What’s changed since 2017, policy experts say, is that there are fewer moderate Republican governors, and GOP state executives who advocated for Medicaid expansion over a decade ago are no longer in office.

Additionally, seven of the then-red states that expanded Medicaid did so via ballot initiative, mostly over opposition from their governors.

In fact, the Medicaid work requirement is backed by many Republican governors, even if it means less federal Medicaid money and leads to fewer people covered.

Several states, including Arkansas and Ohio, have already passed state laws to implement a requirement that adults enrolled under the ACA’s Medicaid expansion work, volunteer, go to school, or participate in job training. Most states have yet to bring work requirement programs to fruition because they are waiting for federal government approval.

Charles “Chip” Kahn, president of the Federation of American Hospitals, a trade group of investor-owned hospitals, said that while fewer governors have engaged publicly in trying to block Medicaid cuts under the bill, federal lawmakers are hearing from legislators in their states.

A political dilemma for Republican governors is that, unlike in 2017, the bill before Congress is not legislation aimed expressly at repealing Obamacare. With a scope broader than health care, it would extend many of Trump’s tax cuts and direct billions in new spending toward border security, immigration enforcement, and the military, while also cutting health care spending.

“It’s like playing multidimensional chess rather than focusing on one issue,” Kahn said.

Larry Jacobs, director of the Center for the Study of Politics and Governance at the University of Minnesota, said some Republican governors may have expressed concerns privately to their states’ GOP senators but are not speaking out publicly for fear of drawing Trump’s wrath.

“Why are they being cagey? Trump and not wanting to be ‘Liz Cheney’d,’” Jacobs said, referring to the Republican former Wyoming lawmaker whom Trump helped oust after she served as vice chair of an inquiry into his attempts to overturn the results of the 2020 election.

Walking Political Tightropes

The political peril Republican lawmakers face in publicly challenging Trump remains explicit. On June 29, Sen. Thom Tillis (R-N.C.) announced he would not run for reelection after he voiced concerns about the bill and the president threatened to back a primary challenger. Tillis was one of three GOP senators to vote against it on July 1, though it still narrowly passed.

In addition to the work requirement, the biggest Medicaid cuts in the bill stem from its restrictions on provider taxes — levies that states impose on hospitals, nursing homes, and other health care institutions to help increase their federal reimbursement. Much of the additional money is then returned to the health care providers in the form of higher payments for their Medicaid patients.

The practice, which has been adopted in every state but Alaska, has been criticized by some Beltway Republicans as “money laundering” — even though the taxes are approved by state lawmakers and the federal Centers for Medicare & Medicaid Services and have been allowed under federal law for decades.

The Senate bill would limit the money states could raise — a move that would mean billions in funding cuts to states and their hospitals.

The states with Republican governors that expanded Medicaid are Alaska, Arkansas, Idaho, Indiana, Iowa, Louisiana, Missouri, Montana, Nebraska, New Hampshire, Nevada, North Dakota, Ohio, Oklahoma, South Dakota, Vermont, Virginia, West Virginia, and Utah.

One of the governors who expressed concerns about repealing the Obamacare Medicaid expansion in 2017 was Jim Justice of West Virginia, a Democrat at the time.

In a June 2017 letter to West Virginia Sen. Shelley Moore Capito, a Republican, Justice wrote: “Since so many of our people count on Medicaid, any cut to Medicaid would destroy families in West Virginia.” He added that “the consequences would be beyond catastrophic.”

On July 1, Justice — elected to the Senate as a Republican last year — voted for Trump’s megabill, including its Medicaid cuts.

“The Senator believes this bill strikes a good balance between protecting the most vulnerable and those who rely on the program while rooting out waste, fraud, and abuse to ensure the program is run efficiently for those deserving,” William O’Grady, a Justice spokesperson, said in an email July 2.

KFF Health News correspondent Arielle Zionts contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Early Thursday afternoon, the House approved a budget reconciliation bill that not only would make permanent many of President Donald Trump’s 2017 tax cuts, but also impose deep cuts to Medicaid, the Affordable Care Act, and, indirectly, Medicare.

Meanwhile, those appointed by Health and Human Services Secretary Robert F. Kennedy Jr. to a key vaccine advisory panel used their first official meeting to cast doubt on a preservative that has been used in flu vaccines for decades — with studies showing no evidence of its harm in low doses.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Maya Goldman of Axios, and Sarah Karlin-Smith of the Pink Sheet.

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Maya Goldman
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Sarah Karlin-Smith
Pink Sheet

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Alice Miranda Ollstein
Politico

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Among the takeaways from this week’s episode:

• This week the GOP steamrolled toward a major constriction of the nation’s social safety net, pushing through Trump’s tax and spending bill. The legislation contains significant changes to the way Medicaid is funded and delivered — in particular, through imposing the program’s first federal work requirement on many enrollees. Hospitals say the changes would be devastating, potentially resulting in the loss of services and facilities that could touch all patients, not only those on Medicaid.
• Some proposals in Trump’s bill were dropped during the Senate’s consideration, including a ban on Medicaid coverage for gender-affirming care and federal funding cuts for states that use their own Medicaid funds to cover immigrants without legal status. And for all the talk of not touching Medicare, the legislation’s repercussions for the deficit are expected to trigger spending cuts to the program that covers those over 65 and some with disabilities — potentially as soon as the next fiscal year.
• The newly reconstituted Advisory Committee on Immunization Practices met last week, and it looked pretty different from previous meetings: In addition to new members, there were fewer staffers on hand from the Centers for Disease Control and Prevention — and the notable presence of vaccine critics. The panel’s vote to reverse the recommendation of flu shots containing a mercury-based preservative — plus its plans to review the childhood vaccine schedule — hint at what’s to come.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Lancet’s “Evaluating the Impact of Two Decades of USAID Interventions and Projecting the Effects of Defunding on Mortality up to 2030: A Retrospective Impact Evaluation and Forecasting Analysis,” by Daniella Medeiros Cavalcanti, et al.

Alice Miranda Ollstein: The New York Times’ “‘I Feel Like I’ve Been Lied To’: When a Measles Outbreak Hits Home,” by Eli Saslow.

Maya Goldman: Axios’ “New Docs Get Schooled in Old Diseases as Vax Rates Fall,” by Tina Reed.

Sarah Karlin-Smith: Wired’s “Snake Venom, Urine, and a Quest to Live Forever: Inside a Biohacking Conference Emboldened by MAHA,” by Will Bahr.

Also mentioned in this week’s episode:

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Shorter enrollment periods. More paperwork. Higher premiums. The sweeping tax and spending bill pushed by President Donald Trump includes provisions that would not only reshape people’s experience with the Affordable Care Act but, according to some policy analysts, also sharply undermine the gains in health insurance coverage associated with it.

The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges.

Many of those states fear that the additional red tape — especially requirements that would end automatic reenrollment — would have an outsize impact on their policyholders. That’s because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal healthcare.gov marketplace.

“The federal marketplace always had a message of, ‘Come back in and shop,’ while the state-based markets, on average, have a message of, ‘Hey, here’s what you’re going to have next year, here’s what it will cost; if you like it, you don’t have to do anything,’” said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director with the Manatt Health consulting group.

Millions — perhaps up to half of enrollees in some states — may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule from the Trump administration and the likely expiration at year’s end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year. That’s starting to happen already, based on some early state rate requests for next year, which are hitting double digits.

“We estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,” said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees this year, a record.

Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the “One Big Beautiful Bill,” could undo inroads made in the nation’s uninsured rate, which dropped by about half from the time most of the ACA’s provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data.

Premiums would rise along with the uninsured rate, because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage — and are thus less expensive — would not.

After a dramatic all-night session, House Republicans passed the bill, meeting the president’s July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration.

The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round.

In addition, automatic reenrollment, used by more than 10 million people for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently.

That’s a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era’s “lax verification requirements.”

He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers’ being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers.

In testimony to Congress on June 25, Blase wrote that “this simple step will close a massive loophole and significantly reduce improper enrollment and spending.”

States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal healthcare.gov.

The state-run marketplaces credit their additional security measures and tighter control over broker access than healthcare.gov for the relative lack of problems.

“If you look at California and the other states that have expanded their Medicaid programs, you don’t see that kind of fraud problem,” said Jessica Altman, executive director of Covered California, the state’s Obamacare marketplace. “I don’t have a single case of a consumer calling Covered California saying, ‘I was enrolled without consent.’”

Such rollovers are common with other forms of health insurance, such as job-based coverage.

“By requiring everyone to come back in and provide additional information, and the fact that they can’t get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,” said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

Federal data shows about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF.

States do check income and other eligibility information for all enrollees — including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they’ve experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period.

“We have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,” Altman said.

If flagged for mismatched data, applicants are asked for additional information. Under current law, “we have 90 days for them to have a tax credit while they submit paperwork,” Altman said.

That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information.

A white paper written for Capital Policy Analytics, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes.

While “tighter verification can curb improper enrollments,” the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, “would push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,” wrote free market economists Ike Brannon and Anthony LoSasso.

“Insurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,” they wrote.

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President Donald Trump’s “One Big Beautiful” budget reconciliation bill would make some of the most sweeping changes in health policy in years, largely affecting Medicaid and Affordable Care Act plans — with reverberations felt throughout the health care system.

With only a few exceptions, the budget reconciliation process — which allows the political party in control to pass a bill with only 51 votes in the Senate, rather than the usual 60 — is how nearly every major piece of health legislation has passed Congress since the 1980s.

But using reconciliation to constrict rather than expand health coverage, as the GOP is attempting now? That is unusual.

One of the best-known programs born via reconciliation is the “COBRA” health insurance continuation, which allows people who leave jobs with employer-provided insurance to keep it for a time, as long as they pay the full premium.

That is one of dozens of health provisions tucked into COBRA, or the Consolidated Omnibus Budget Reconciliation Act of 1985. Also included was the Emergency Medical Treatment and Active Labor Act, which requires hospitals that take Medicare to treat or transfer patients with medical emergencies, regardless of their insurance status — a law that’s become a focus of abortion opponents as they seek to limit access to the procedure.

A key reason so much health policy has passed this way has to do with how Congress manages the federal budget. Federal government spending falls into two categories: mandatory, or spending required by existing law, and discretionary, which traditionally is allocated and renewed each year as part of the appropriations process.

Lawmakers use the reconciliation process to make changes to mandatory spending programs — Medicare and Medicaid are among the largest — as well as tax policy. (For complicated political reasons, reconciliation bills cannot touch Social Security, the last prong in the entitlement program trifecta.)

Reconciliation comes into play only if it is needed to reconcile taxes or mandatory spending to comply with the terms Congress sets for itself each year, through the annual budget resolution. This year the GOP’s focus is finding the cash to renew Trump’s expiring tax cuts, which largely benefit wealthier Americans, and boost military and border security spending.

In years when Congress orders a reconciliation bill, health policy almost always plays a major part. Usually, reconciliation instructions call for reductions in payments to health providers under Medicare — which costs the most of the federal health programs.

For much of the 1980s and 1990s, Democrats in Congress quietly used reconciliation to expand eligibility for the Medicaid program, often by cutting more than the budget called for from Medicare. For every $5 cut from Medicare, about $1 would be redirected to provide Medicaid to more low-income people.

But budget reconciliation has also become a convenient way to make policy changes to the nation’s major health programs, as it is usually considered a “must-pass” bill likely to be signed by the president and not subject to filibuster in the Senate.

As a result, all manner of now-familiar health programs were created by budget reconciliation bills, many of which provided health coverage to more Americans.

The 1989 reconciliation bill created a new system for paying doctors who treat Medicare patients, as well as a new federal agency to study the cost, quality, and effectiveness of health care, today known as the Agency for Healthcare Research and Quality.

Children’s health has been a popular add-on over the years, including the gradual expansion of Medicaid coverage to more children based on family income. The 1993 reconciliation bill created the Vaccines for Children program, which ensures the availability and affordability of vaccines nationwide for uninsured and underinsured kids. The 1997 reconciliation bill created the Children’s Health Insurance Program, which today provides insurance to more than 7 million children.

In fact, the list of major health bills of the past 50 years not passed using budget reconciliation is short. For instance, the 2003 Medicare Modernization Act, which added a prescription drug benefit to the program for the first time, attracted just enough bipartisan support to pass on its own.

The biggest health care law of recent decades — the Affordable Care Act — didn’t start out as a reconciliation bill, but it ended up using the process to clear its final hurdles.

After initial passage of the bill in December 2009, a special election cost Democrats their 60th seat in the Senate — and with it, the supermajority they needed to pass the bill without Republican votes. In the end, the two chambers used a separate reconciliation measure, the Health Care and Education Reconciliation Act of 2010, to negotiate a compromise that included the ACA.

HealthBent, a regular feature of KFF Health News, offers insight into and analysis of policies and politics from KFF Health News chief Washington correspondent Julie Rovner, who has covered health care for more than 30 years.

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El “One Big Beautiful Bill” del presidente Donald Trump recorta el gasto federal en los mercados de Medicaid y la Ley de Cuidado de Salud a Bajo precio (ACA) en aproximadamente $1.000 millones a lo largo de una década, según la Oficina de Presupuesto del Congreso (CBO), una entidad no partidista. Esto amenaza la salud física y financiera de decenas de millones de estadounidenses.

El proyecto de ley, aprobado por el Senado el martes 1 de julio, revertiría muchos de los avances en cobertura médica de las administraciones Biden y Obama, cuyas políticas facilitaron el acceso a la atención médica a millones de personas y redujeron la tasa de personas sin seguro en el país a mínimos históricos.

El plan del Senado para recortar drásticamente la financiación de Medicaid y los mercados de ACA podría hacer que unas 12 millones de personas más no tuvieran seguro para 2034, según estima la CBO.

Esto, a su vez, perjudicaría las finanzas de hospitales, residencias de adultos mayores y centros de salud comunitarios —que tendrían que absorber una mayor parte del costo del tratamiento de las personas sin cobertura— y podría obligarlos a reducir servicios y personal, hasta a cerrar instalaciones.

La legislación está en el escritorio de Trump a la espera de su firma, aunque primero el Senado y la Cámara de Representantes deben aprobar la misma versión. La Cámara de Representantes aprobó su propia versión en mayo y se espera que considere la versión del Senado hoy (2 de julio), según Tom Emmer, líder de la mayoría en la Cámara.

A continuación, se presentan cinco maneras en que los planes del Partido Republicano podrían afectar el acceso a la atención médica.

¿Necesita Medicaid? Entonces consigue un trabajo

Los recortes más profundos al gasto en atención médica provienen de la propuesta de un requisito de trabajo para Medicaid, que cortaría la cobertura a millones de afiliados que no cumplen con estos nuevos estándares.

En 40 estados y Washington, D.C., que han ampliado Medicaid bajo ACA, algunos beneficiarios de Medicaid tendrían que presentar regularmente documentación que demuestre que trabajan, hacen voluntariado o asisten a la escuela al menos 80 horas al mes, o que califican para una exención, como por ejemplos el cuidado de un niño pequeño.

El requisito del proyecto de ley no se aplicaría a las personas en los 10 estados, mayoritariamente republicanos, que no han ampliado Medicaid.

Investigadores de salud afirman que la política tendría poco impacto en el empleo. Según KFF, la mayoría de los beneficiarios de Medicaid en edad laboral que no reciben prestaciones por discapacidad ya trabajan o buscan trabajo, o no pueden hacerlo porque tienen una discapacidad, asisten a la escuela o cuidan a un familiar.

Los experimentos estatales con requisitos de trabajo se han visto plagados de problemas administrativos, como la pérdida de cobertura de los beneficiarios elegibles por problemas con el papeleo, y más gasto.

El requisito de trabajo de Georgia, que se implementó oficialmente en julio de 2023, ha costado más de $90 millones, de los cuales solo 26 millones se han destinado a prestaciones de salud, según el  Georgia Budget & Policy Institute, una organización de investigación no partidista.

“Los costos ocultos son astronómicos”, afirmó Chima Ndumele, profesor de la Escuela de Salud Pública de Yale.

Menos dinero significa menos atención en las comunidades rurales

Las medidas de ajuste que se aplicarían a los estados podrían traducirse en una disminución de los servicios de salud, profesionales médicos e incluso hospitales, especialmente en las comunidades rurales.

El plan del Partido Republicano reduciría una práctica conocida como impuestos a los proveedores, que casi todos los estados han utilizado durante décadas para aumentar los pagos de Medicaid a hospitales, residencias de adultos mayores y otros proveedores, así como a empresas privadas de atención médica administrada.

Los estados suelen utilizar el dinero federal generado a través de los impuestos para pagar a las instituciones más de lo que Medicaid pagaría de otra manera. (Medicaid generalmente paga las tarifas más bajas por la atención médica, en comparación con Medicare, el programa para personas mayores de 65 años y algunas personas con discapacidad, y los seguros privados).

Los hospitales y residencias de adultos mayores afirman que utilizan estos fondos adicionales de Medicaid para ampliar o añadir nuevos servicios y mejorar la atención para todos los pacientes.

Los hospitales rurales suelen operar con márgenes de ganancia reducidos y dependen de los pagos de impuestos de Medicaid para sostenerlos. Investigadores del Cecil G. Sheps Center for Health Services Research que examinaron el proyecto de ley de la Cámara concluyeron que este obligaría a más de 300 hospitales rurales, muchos de ellos en Kentucky, Louisiana, California y Oklahoma, a reducir sus servicios o cerrar.

Los senadores republicanos agregaron un fondo de $50 mil millones a su versión del proyecto de ley para amortiguar el impacto en los hospitales rurales.

Más dificultad para obtener, y mantener, la cobertura de ACA

Para quienes tienen cobertura del mercado de seguros de salud de ACA, el plan republicano dificultaría la inscripción y el conservar los planes.

Los asegurados del mercado de seguros estarían obligados a actualizar sus ingresos, estatus migratorio y otra información cada año, en lugar de reinscribirse automáticamente, algo que más de 10 millones de personas hicieron este año.

También tendrían menos tiempo para inscribirse; el proyecto de ley acorta el período anual de inscripción abierta en aproximadamente un mes.

Las personas que soliciten cobertura fuera de ese período —por ejemplo, porque pierden su trabajo u otro seguro, o necesitan agregar a un recién nacido o cónyuge a una póliza existente— tendrían que esperar a que se procesen todos sus documentos antes de recibir subsidios del gobierno para ayudar a pagar sus primas mensuales. Actualmente, reciben hasta 90 días de ayuda con las primas durante el proceso de solicitud, que puede tardar semanas.

Los legisladores republicanos y algunos centros de estudios de políticas conservadoras, incluido el Paragon Health Institute, afirman que los cambios son necesarios para reducir las inscripciones fraudulentas, mientras que los opositores afirman que son el último intento de desmantelar el Obamacare.

La legislación tampoco contempla una extensión de los subsidios mejorados implementados durante la pandemia de covid-19. Si el Congreso no actúa, estos subsidios expirarán a finales de año, lo que resultará en un aumento promedio del 75% en las primas el próximo año, según KFF.

¿Tienes Medicaid? Se pagará más por las consultas médicas

Muchos beneficiarios de Medicaid podrían tener que pagar más de su bolsillo por las citas.

El proyecto de ley exigiría a los estados que han ampliado Medicaid cobrar a los beneficiarios hasta $35 por algunos servicios si sus ingresos se encuentran entre el nivel federal de pobreza (este año, $15.650 por persona) y el 138% de esa cantidad ($21.597).

Los beneficiarios de Medicaid generalmente no pagan nada cuando buscan servicios médicos, ya que estudios han demostrado que cobrar incluso copagos pequeños lleva a las personas de bajos ingresos a renunciar a atención necesaria. En los últimos años, algunos estados han agregado cargos inferiores a $10 por algunos servicios.

Esta política no se aplicaría a las personas que buscan atención primaria, atención de salud mental o tratamiento de adicciones.

Recortes para inmigrantes con residencia legal

El plan republicano podría provocar que al menos cientos de miles de inmigrantes con residencia legal —incluyendo solicitantes de asilo, víctimas de tráfico humano y refugiados— pierdan su cobertura del mercado de seguros al eliminar los subsidios que hacen que las primas sean asequibles. La restricción no se aplicaría a los titulares de tarjetas de residencia permanente (Green Card o tarjeta verde).

Dado que los inmigrantes que perderían subsidios bajo este plan tienden a ser más jóvenes que la población general, su salida dejaría una población de afiliados de mayor edad, con mayor riesgo de enfermedad y costos más elevados, lo que incrementaría aún más las primas del mercado, según directores de los mercados de seguros de salud en California, Maryland y Massachusetts, y analistas de salud.

Quitar el acceso a la atención médica a los inmigrantes que viven legalmente en el país “causará un daño irreparable a las personas que hemos prometido proteger e impondrá costos innecesarios a los sistemas locales que ya están sobrecargados”, declaró John Slocum, director ejecutivo del Refugee Council USA, un grupo de defensa, en un comunicado.

Tanto la versión de la Cámara de Representantes como la del Senado del proyecto de ley reflejan el enfoque restrictivo de la administración Trump hacia la inmigración.

Sin embargo, debido a que contravenía las normas del Senado, la legislación no incluirá una propuesta que habría reducido los pagos federales de Medicaid a estados como California, que utilizan sus propios fondos para cubrir a inmigrantes sin papeles.

La corresponsal principal de KFF Health News en Washington, Julie Rovner, contribuyó con este artículo.

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Claudia Boyd-Barrett

For months, Maria, 55, a caregiver to older adults in California’s Orange County, has been trying not to smile.

If she opens her mouth too wide, she worries, people will see her chipped, plaque-covered front teeth. An immigrant without legal status, Maria doesn’t have health or dental insurance. When her teeth start to throb, she swallows pain pills. Last summer, a dentist said it would cost $2,400 to fix her teeth. That’s more than she can afford.

“It’s so expensive,” said Maria, who often works 12-hour days lifting clients in and out of bed and helping them with hygiene, medication management, and housework. “I need money for my kids, for my rent, for transport, for food. Sometimes, there’s nothing left for me.”

KFF Health News connected with Maria through an advocacy organization for immigrant workers. Fearing deportation, she asked that only her first name be used.

Maria is among what the federal government estimates are 2.6 million immigrants living in California without legal status. The state had gradually sought to bring these immigrants into its Medicaid program, known as Medi-Cal. But now, facing a state enrollment freeze, low-income California residents in the U.S. without legal permission — along with the providers and community workers that help them — are anxiously weighing the benefits of pushing forward with Medi-Cal applications against the risks of discovery and deportation by the federal government.

Seeking to close a projected $12 billion budget deficit, California Gov. Gavin Newsom, a Democrat, signed a balanced state budget on June 27 that will end new Medi-Cal enrollment in January 2026 for those over 19 without legal status.

Meanwhile, federal immigration raids — which appear to have targeted at least one health clinic in the state — are already making some people afraid to seek medical care, say immigrant advocates and health providers. And the recent news that Trump administration officials are sharing Medicaid enrollee data, including immigration status, with deportation authorities is expected to further erode trust in the program.

U.S. Department of Health and Human Services spokesperson Andrew Nixon said the agency, which oversees the Centers for Medicare & Medicaid Services, had the legal authority to share the data to address “unprecedented systemic neglect under the Biden-Harris administration that allowed illegal immigrants to exploit Medicaid while millions of Americans struggle to access care, particularly in states like California.”

Further complicating matters, the Trump administration has threatened to withhold funds from states that provide health coverage to people without legal status. Currently, about 1.6 million people in the country without authorization are enrolled in Medi-Cal.

In 2016, California began opening Medi-Cal to low-income people lacking legal status, starting with children, then gradually expanded it to young people, older adults, and — in January 2024 — those ages 26 to 49. The state Department of Health Care Services, which oversees Medi-Cal, partnered with community health clinics to help get eligible people enrolled.

It’s too early to tell what impact the latest state and federal developments are having on enrollment numbers, since data is available only through March. But many health care providers and advocates said they expect a chilling effect on immigrant enrollment.

Seciah Aquino is executive director of the Latino Coalition for a Healthy California, which supports community health workers — also called promotores — who help spread awareness about Medi-Cal’s expansion to adults lacking legal status. Just over half of public health insurance recipients in California are Latino, compared with just 30% of Medicaid enrollees nationwide.

Aquino said her coalition will tell promotores to disclose data-sharing risks so community members can make informed decisions. 

“They take it very personally that advice that they provided to a fellow community member could now hurt them,” Aquino said.

Newsom condemned the data sharing, calling the move “legally dubious,” while U.S. Sens. Adam Schiff and Alex Padilla, both Democrats, have demanded that the Department of Homeland Security destroy any data shared.  

California’s Department of Health Care Services announced June 13 that it is seeking more information from the federal government. The agency said it submitted monthly reports to CMS with demographic and eligibility information, including name and address, as required by law.

Medicaid enrollee data from Illinois, Washington state, and Washington, D.C., was also reportedly shared with DHS. Jamie Munks, a spokesperson for the Illinois Department of Healthcare and Family Services, the state’s Medicaid agency, said the department was “deeply concerned” by the news and that the data was regularly passed along to CMS with the understanding that it was protected.

In Sacramento, Democratic lawmakers found themselves in the uncomfortable position of rolling back health benefits for low-income residents with unsatisfactory immigration status, including people without legal status, people who’ve held green cards for under five years, and some others who are in the process of applying for legal status or have statuses meant to protect them from deportation. In addition to the Medi-Cal enrollment freeze for immigrants 19 and older in the country without authorization, all enrolled residents with unsatisfactory immigration status from 19 to 59 years old will be charged $30 monthly premiums starting in July 2027.

“What I’m hearing on the ground is folks are telling me they’re going to have a really hard time making these premium payments,” said Carlos Alarcon, health and public benefits policy analyst with the California Immigrant Policy Center, an advocacy group. “The reality is most people already have limited budgets.”

The legislature rejected a proposal from the governor to bar immigrants with unsatisfactory immigration status from receiving long-term nursing home and in-home care through Medi-Cal but went along with eliminating dental benefits starting in July 2026.

Health care providers said that without Medi-Cal coverage, many immigrants will be forced to seek emergency care, which is more expensive for taxpayers than preventive and primary-level care. Sepideh Taghvaei, chief dental officer at Santa Cruz County’s Dientes Community Dental Care, saw this play out in 2009 when the state cut adult Medi-Cal dental benefits. Patients came in with swollen faces and excruciating pain, with conditions so advanced that they required hospital treatment. “It’s not cost-effective,” she said.

State Sen. Roger Niello, a Republican who serves as vice chair of the Senate budget committee, said he believes California shouldn’t be funding Medi-Cal for people who lack legal status, particularly given the state’s fiscal challenges. He also said he worries that coverage of people in the country without authorization could encourage others to move to California.

“If we maintain that expense to the noncitizen,” he said, “we’re going to have to cut someplace else, and that’s undoubtedly going to affect citizens.”

Californians, too, are going through a change of heart. In a May poll conducted by the Public Policy Institute of California, 58% of adults opposed the benefit.

For Maria, shifting health care policies have left her feeling paralyzed. Since she arrived here five years ago, the caregiver’s focus has been on earning money to support her three children, whom she left with her parents in her home country, she said.

Maria didn’t learn she might be eligible for Medi-Cal until earlier this year and hadn’t yet found time to complete the paperwork. After a friend told her that the state could freeze enrollment in January, she began rushing to finish the sign-up process. But then she learned that Medi-Cal data had been shared with immigration authorities.

“Disappointed and scared” was how she described her reaction.

Suddenly, she said, enrolling in Medi-Cal doesn’t seem like a good idea.

Phil Galewitz and Bram Sable-Smith contributed to this report.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Durante meses, María, de 55 años, cuidadora de adultos mayores en el condado de Orange, se ha esforzado por no sonreír.

Le preocupa que si abre demasiado la boca, la gente vea sus dientes astillados y cubiertos de placa. Inmigrante sin papeles, María no tiene seguro médico ni dental. Cuando le empiezan a doler los dientes, toma analgésicos. El verano pasado, un dentista le dijo que arreglarle la dentadura le costaría $2.400. Es más de lo que puede permitirse.

“Es carísimo”, dijo María, quien generalmente trabaja 12 horas al día subiendo y bajando de la cama a clientes y ayudándolos con la higiene, a tomar los medicamentos y con las tareas del hogar. “Necesito dinero para mis hijos, para el alquiler, para el transporte, para la comida. A veces, no me queda nada para mí”.

Una organización de defensa de los trabajadores inmigrantes puso en contactó a KFF Health News con María. Por temor a la deportación, pidió que solo se usara su nombre de pila en este artículo.

María se encuentra entre los 2.6 millones de inmigrantes que viven en California sin estatus legal, según estimaciones del gobierno federal.

El estado había buscado gradualmente incorporar a estos inmigrantes a su programa de Medicaid, conocido como Medi-Cal.

Pero ahora, ante el congelamiento de las inscripciones estatales, los residentes californianos de bajos ingresos que se encuentran en el país sin papeles, junto con los proveedores y trabajadores comunitarios que los ayudan, evalúan con inquietud los beneficios de avanzar con las solicitudes de Medi-Cal frente a los riesgos de ser descubiertos y deportados por el gobierno federal.

La Legislatura de California, que busca cerrar un déficit presupuestario proyectado de $12 mil millones, aprobó una propuesta del gobernador demócrata Gavin Newsom para finalizar la inscripción en Medi-Cal en enero de 2026 para los mayores de 19 años sin estatus legal. Los legisladores están en proceso de definir los detalles finales del acuerdo presupuestario antes de que entre en marcha el nuevo año fiscal.

Mientras tanto, las redadas federales de inmigración, que parecen haber afectado al menos a una clínica de salud en el estado, ya están provocando que algunas personas teman buscar atención médica, según defensores de los inmigrantes y proveedores de salud.

Y se espera que la reciente noticia de que funcionarios de la administración Trump están compartiendo datos de los beneficiarios de Medicaid, incluyendo su estatus migratorio, con las autoridades de inmigración erosione aún más la confianza en el programa.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS), afirmó que la agencia, que supervisa los Centros de Servicios de Medicare y Medicaid (CMS), tenía la autoridad legal para compartir los datos y abordar la “negligencia sistémica sin precedentes bajo la administración Biden-Harris, que permitió que inmigrantes indocumentados explotaran Medicaid mientras millones de estadounidenses luchaban por acceder a la atención médica, particularmente en estados como California”.

Para complicar aún más la situación, la administración Trump ha amenazado con retener los fondos de estados que ofrecen cobertura médica a personas sin estatus legal.

Actualmente, alrededor de 1.6 millones de personas que residen en el país sin documentos están inscritas en Medi-Cal.

En 2016, California comenzó a ampliar Medi-Cal a personas de bajos ingresos sin estatus legal, comenzando con los niños, y luego lo expandió gradualmente a jóvenes, adultos mayores y, en enero de este año, a personas de entre 26 y 49 años. El Departamento de Servicios de Atención Médica del estado, que supervisa Medi-Cal, se asoció con clínicas de salud comunitarias para ayudar a inscribir a las personas elegibles.

Es demasiado pronto para determinar el impacto que las últimas acciones estatales y federales estén teniendo en las cifras de inscripción, ya que los datos solo están disponibles hasta marzo. Sin embargo, muchos proveedores y defensores afirmaron que prevén un efecto negativo en la inscripción de inmigrantes, por miedo.

Seciah Aquino es directora ejecutiva de la Latino Coalition for a Healthy California, que apoya a los promotores de salud comunitarios, quienes ayudan a difundir la expansión de Medi-Cal a los adultos sin papeles. Poco más de la mitad de los beneficiarios del seguro médico público en California son latinos, en comparación con solo el 30% de los beneficiarios de Medicaid en todo el país.

Aquino afirmó que su coalición les pedirá a los promotores que informen sobre los riesgos de compartir datos para que los miembros de la comunidad puedan tomar decisiones informadas. “Se toman muy en serio que el consejo que le dieron a un miembro de la comunidad ahora pueda perjudicarlos”, expresó.

Newsom condenó el intercambio de datos, calificándolo de “legalmente dudoso”, mientras que los senadores nacionales Adam Schiff y Alex Padilla, ambos demócratas, han exigido que el Departamento de Seguridad Nacional (DHS) destruya cualquier dato compartido.

El Departamento de Servicios de Atención Médica de California anunció el 13 de junio que estaba solicitando más información al gobierno federal. La agencia dijo que enviaba informes mensuales a los CMS con información demográfica y de elegibilidad, incluyendo nombre y dirección, según lo exige la ley.

De acuerdo a lo informado, también se compartieron con el DHS datos de los afiliados a Medicaid de Illinois, el estado de Washington y Washington, D.C.

Jamie Munks, vocera del Departamento de Atención Médica y Servicios de Familia de Illinois, la agencia estatal de Medicaid, afirmó que el departamento estaba “profundamente preocupado” por la noticia, y que los datos se transmitían regularmente a los CMS con el entendimiento de que estaban protegidos.

En Sacramento, los legisladores demócratas se encontraron en la incómoda situación de tener que reducir los beneficios de salud para residentes de bajos ingresos con un estatus migratorio insatisfactorio, incluyendo personas sin estatus legal, personas con residencia permanente (green card o tarjeta verde) por menos de cinco años, y algunas otras que están en proceso de solicitar un estatus legal o tienen estatus que los protege de la deportación.

Además de apoyar el congelamiento de la inscripción a Medi-Cal para inmigrantes mayores de 19 años que residen en el país sin documentos, los legisladores acordaron cobrar primas mensuales a todos los residentes con un estatus migratorio insatisfactorio de entre 19 y 59 años. Newsom propuso una prima mensual de $100 a partir de enero de 2027; los legisladores estatales contraofertaron una de $30 a partir de julio de 2027.

“Lo que escucho en los sitios es que la gente me dice que les va a resultar muy difícil realizar estos pagos de primas, ya sean de $100 o $30”, dijo Carlos Alarcón, analista de políticas de salud y beneficios públicos del California Immigrant Policy Center, un grupo de defensa. “La realidad es que la mayoría de la gente ya tiene presupuestos limitados”.

La Legislatura rechazó una propuesta del gobernador para prohibir que los inmigrantes con un estatus migratorio insatisfactorio reciban atención de largo plazo en residencias de adultos mayores y atención domiciliaria a través de Medi-Cal, pero aceptó la eliminación de los beneficios dentales a partir de julio de 2026.

Los proveedores de atención médica afirmaron que, sin cobertura de Medi-Cal, muchos inmigrantes se verán obligados a buscar atención de emergencia, que es más costosa para los contribuyentes que la atención preventiva y de nivel primario.

Sepideh Taghvaei, directora dental de Dientes Community Dental Care del condado de Santa Cruz, presenció este fenómeno en 2009, cuando el estado recortó los beneficios dentales de Medi-Cal para adultos. Los pacientes llegaban con la cara hinchada y un dolor insoportable, con afecciones tan avanzadas que requerían tratamiento hospitalario. “No es rentable”, afirmó.

El senador estatal Roger Niello, republicano y vicepresidente del comité de presupuesto del Senado, afirmó que cree que California no debería financiar Medi-Cal para personas sin estatus legal, especialmente considerando los desafíos fiscales del estado. También expresó su preocupación por la posibilidad de que la cobertura para quienes residen en el país sin papeles anime a otros a mudarse a California.

“Si mantenemos ese gasto para los no ciudadanos, tendremos que recortar en otras áreas, y eso sin duda afectará a los ciudadanos”, aseguró.

Los californianos también están cambiando de opinión. En una encuesta realizada en mayo por el Public Policy Institute of California, el 58% de los adultos se opuso al beneficio.

Para María, los cambios en las políticas de salud la han dejado paralizada. Desde que llegó aquí hace cinco años, su prioridad ha sido ganar dinero para mantener a sus tres hijos, a quienes dejó con sus padres en su país de origen, contó.

La mujer no se enteró de que podría ser elegible para Medi-Cal hasta principios de este año y no había tenido tiempo de completar el papeleo. Después que una amiga le dijera que el estado podría congelar la inscripción en enero, comenzó a apresurarse para completar el proceso de inscripción.

Pero entonces se enteró de que los datos de Medi-Cal se habían compartido con las autoridades de inmigración. “Decepcionada y asustada”, así describió su reacción.

De repente, inscribirse en Medi-Cal ya no le parece buena idea, dijo.

Phil Galewitz y Bram Sable-Smith contribuyeron con este artículo.

Esta historia fue producida por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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CLARKESVILLE, Ga. — Last September, Alton Fry went to the doctor concerned he had high blood pressure. The trip would result in a prostate cancer diagnosis.

So began the stress of trying to pay for tens of thousands of dollars in treatment — without health insurance.

“I’ve never been sick in my life, so I’ve never needed insurance before,” said Fry, a 54-year-old self-employed masonry contractor who restores old buildings in the rural Appalachian community he’s called home nearly all his life.

Making sure he had insurance was the last thing on his mind, until recently, Fry said. He had been rebuilding his life after a prison stay, maintaining his sobriety, restarting his business, and remarrying his wife. “Things got busy,” he said.

Now, with a household income of about $48,000, Fry and his wife earn too much to qualify for Georgia’s limited Medicaid expansion. And he said he found that the health plans sold on the state’s Affordable Care Act exchange were too expensive or the coverage too limited.

In late April, a friend launched a crowdfunding campaign to help Fry cover some of the costs. To save money, Fry said, he’s taking a less aggressive treatment route than his doctor recommended.

“There is no help for middle-class America,” he said.

More than 26 million Americans lacked health insurance in the first six months of 2024, according to the Centers for Disease Control and Prevention.

The uninsured are mostly low-income adults under age 65, and people of color, and most live in the South and West. The uninsured rate in the 10 states that, like Georgia, have not expanded Medicaid to nearly all low-income adults was 14.1% in 2023, compared with 7.6% in expansion states, according to KFF, a health information nonprofit that includes KFF Health News.

Health policy researchers expect the number of uninsured to swell as the second Trump administration and a GOP-controlled Congress try to enact policies that explicitly roll back health coverage for the first time since the advent of the modern U.S. health system in the early 20th century.

Under the “One Big Beautiful Bill Act” — budget legislation that would achieve some of President Donald Trump’s priorities, like extending tax cuts mainly benefiting the wealthy — some 10.9 million Americans would lose health insurance by 2034, according to estimates by the nonpartisan Congressional Budget Office based on a House version of the budget bill.

A Senate version of the bill could result in more people losing Medicaid coverage, with reductions in federal spending and rules that would make it harder for people to qualify. But that bill suffered a major blow June 26 when the Senate parliamentarian, a nonpartisan official who enforces the chamber’s rules, rejected several health provisions — including the proposal to gradually reduce provider taxes, a mechanism that nearly every state uses to increase its federal Medicaid funding.

The number could rise to 16 million if proposed rule changes to the ACA take effect and tax credits that help people pay for ACA plans expire at the end of the year, according to the CBO. In KFF poll results released in June, nearly two-thirds of people surveyed viewed the bill unfavorably and more than half said they were worried federal funding cuts would hurt their family’s ability to obtain and afford health care.

Like Fry, more people would be forced to pay for health expenses out-of-pocket, leading to delays in care, lost access to needed doctors and medications, and poorer physical and financial health.

“The effects could be catastrophic,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured.

The House-passed bill would represent the largest reduction in federal support for Medicaid and health coverage in history, she said. If the Senate approves it, it would be the first time Congress moved to eliminate coverage for millions of people.

“This would take us back,” Tolbert said.

A Patchwork System

The United States is the only wealthy country where a substantial number of citizens lack health insurance, due to nearly a century of pushback against universal coverage from doctors, insurance companies, and elected officials.

“The complexity is everywhere throughout the system,” said Sherry Glied, dean of New York University’s Wagner School of Public Service, who worked in the George H.W. Bush, Clinton, and Obama administrations. “The big bug is that people fall between the cracks.”

This year, KFF Health News is speaking to Americans about the challenges they face in finding health insurance and the effects on their ability to get care; to providers who serve the uninsured; and to policy experts about why, even when the nation hit its lowest recorded uninsured rate in 2023, nearly a tenth of the U.S. population still lacked health coverage.

So far, the reporting has found that despite decades of policies designed to increase access to care, the very structure of the nation’s health insurance system creates the opposite effect.

Government-backed universal coverage has eluded U.S. policymakers for decades.

After lobbying from physician groups, President Franklin D. Roosevelt abandoned plans to include universal health coverage in the Social Security Act of 1935. Then, because of a wage and salary cap used to control inflation during World War II, more employers offered health insurance to lure workers. In 1954, health coverage was formally exempted from income tax requirements, which led more employers to offer the benefit as part of compensation packages.

Insurance coverage offered by employers came to form the foundation of the U.S. health system. But eventually, problems with linking health insurance to employment emerged.

“We realized, well, wait, not everybody is working,” said Heidi Allen, an associate professor at the Columbia School of Social Work who studies the impact of social policies on access to care. “Children aren’t working. People who are elderly are not working. People with disabilities are not working.”

Yet subsequent efforts to expand coverage to all Americans were met with backlash from unions who wanted health insurance as a bargaining chip, providers who didn’t want government oversight, and those who had coverage through their employers.

That led policymakers to add programs piecemeal to make health insurance accessible to more Americans.

There’s Medicare for older adults and Medicaid for people with low incomes and disabilities, both created in 1965; the Children’s Health Insurance Program, created in 1997; the ACA’s exchange plans and Medicaid expansion for people who can’t access job-based coverage, created in 2010.

As a result, the U.S. has a patchwork of health insurance programs with numerous interest groups vying for dollars, rather than a cohesive system, health policy researchers say.

Falling Through the Cracks

The lack of a cohesive system means that, even though Americans are eligible for health insurance, they struggle to access it, said Mark Shepard, an associate professor of public policy at the Harvard Kennedy School of Government. No central entity exists in the U.S. to ensure that all people have a plan, he said.

Over half of the uninsured might qualify for Medicaid or subsidies that can help cover the costs of an ACA plan, according to KFF. But many people aren’t aware of their options or can’t navigate overlapping programs — and even subsidized coverage can be unaffordable.

Those who have fallen through the cracks said it feels like the system has failed them.

Yorjeny Almonte of Allentown, Pennsylvania, earns about $2,600 a month as an inspector in a cabinet warehouse. When she started her job in December 2023, she didn’t want to spend nearly 10% of her income on health insurance.

But, last year, her uninsured mom chose to fly to the Dominican Republic to get care for a health concern. So Almonte, 23, who also needed to see a doctor, investigated her employer’s health offerings. By then she had missed the deadline to sign up.

“Now I have to wait another year,” she said.

In January, Camden, Alabama, resident Kiana George, who’s uninsured, landed in an intensive care unit months after she stopped seeing a nurse practitioner and taking blood pressure medications — an ordeal that saddled her with nearly $7,000 in medical bills.

George, 30, was kicked off Medicaid in 2023 after she got hired by an after-school program. It pays $800 a month, an income too high to qualify her for Medicaid in Alabama, which hasn’t expanded to cover most low-income adults. She also doesn’t make enough for a free or reduced-cost ACA plan.

George, who has a 9-year-old daughter, said she “has no idea” how she can repay the debt from the emergency room visit. And because she fears more bills, she has given up on treatment for ovarian cysts.

“It hurts, but I’m just gonna take my chances,” she said.

Widening the Gaps

Health insurance is fundamentally a financial product, intended to protect the policyholder’s pocketbook from accidents or illnesses.

Researchers have known for decades that a lack of insurance coverage leads to poor access to health care, said Tom Buchmueller, a health economist at the University of Michigan Ross School of Business.

“It’s only more recently we’ve had really good, strong evidence that shows that health insurance really does improve health outcomes,” Buchmueller said.

Research released this spring by the National Bureau of Economic Research found that expanding Medicaid reduced low-income adults’ chances of dying by 2.5%. In 2019, a separate study published by that nonpartisan think tank provided experimental evidence that health insurance coverage reduced mortality among middle-aged adults.

In late May, the House narrowly advanced the budget legislation that independent government analysts said would result in millions of Americans losing health insurance coverage and reduce federal spending on programs like Medicaid by billions of dollars.

A key provision would require some Medicaid enrollees to work, volunteer, or complete other qualifying activities for 80 hours a month, starting at the end of 2026. Most Medicaid enrollees already work or have some reason they can’t, such as a disability, according to KFF.

House Speaker Mike Johnson has defended the requirement as “moral.”

“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system,” he told CBS News in the wake of the bill’s passage.

A Senate version of the bill also includes work requirements and more frequent eligibility checks for Medicaid recipients.

Fiscal conservatives argue a solution is needed to curb health care’s rising costs.

The U.S. spends about twice as much per capita on health care as other wealthy nations, and that spending would grow under the GOP’s budget bill, said Michael Cannon, director of health policy studies at the Cato Institute, a think tank that supports less government spending on health care.

But the bill doesn’t address the root causes of administrative complexity or unaffordable care, Cannon said. To do that would entail, for instance, doing away with the tax break for employer-sponsored care, which he said fuels excessive spending, raises prices, and ties health insurance to employment. He said the bill should cut federal funding for Medicaid, not just limit its growth.

The bill would throw more people into a high-cost health care landscape with little protection, said Aaron Carroll, president and CEO of AcademyHealth, a nonpartisan health policy research nonprofit.

“There’s a ton of evidence that shows that if you make people pay more for health care, they get less health care,” he said. “There’s lots of evidence that shows that disproportionately affects poor, sicker people.”

Labon McKenzie, 45, lives in Georgia, the only state that requires some Medicaid enrollees to work or complete other qualifying activities to obtain coverage.

He hasn’t been able to work since he broke multiple bones after he fell through a skylight while on the job three years ago. He got fired from a county road and bridge crew after the accident and hasn’t been approved for Social Security or disability benefits.

“I can’t stand up too long,” he said. “I can’t sit down too long.”

In February, McKenzie started seeing double, but canceled an appointment with an ophthalmologist because he couldn’t come up with the $300 the doctor wanted in advance. His cousin gave him an eye patch to tide him over, and, in desperation, he took expired eye drops his daughter gave him. “I had to try something,” he said.

McKenzie, who lives in rural Fort Gaines, wants to work again. But without benefits, he can’t get the care he needs to become well enough.

“I just want my body fixed,” he said.

Have you recently lost your health insurance coverage? Have you been uninsured for a while? Click here to contact KFF Health News and share your story.

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Arielle Zionts

“A lot of times, health care comes with a job.”

Sen. John Thune (R-S.D.), in an interview with KOTA on May 30, 2025

Millions of people are expected to lose access to Medicaid and Affordable Care Act marketplace health insurance plans if federal lawmakers approve the One Big Beautiful Bill Act, President Donald Trump’s domestic policy package, which is now moving through the Senate.

Senate Majority Leader John Thune discussed health care and the pending legislation in an interview with KOTA, a South Dakota TV station. But he focused on a different kind of health insurance — employer-sponsored insurance.

“A lot of times, health care comes with a job,” Thune said.

Thune’s comments in the interview were made in the context of highlighting part of the GOP’s economic policy objective. “Creating those better-paying jobs that come with benefits is ultimately the goal here,” he said.

KFF Health News reached out to Thune’s office to find out the basis for this comment. His communications director, Ryan Wrasse, responded by reiterating Thune’s message: “Getting a job has the potential to lead a worker to acquiring health care.”

Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute, said Thune’s comment may also be alluding to discussions surrounding Medicaid work requirements. The One Big Beautiful Bill Act would let nondisabled adults enroll in Medicaid only if they prove they’re volunteering, working, or searching or training for work.

Medicaid, funded by the federal government and states, is the country’s main health insurance program for people with low incomes. Some people with disabilities also qualify.

Some Republicans have built on the jobs talking point in defending the Medicaid cuts and work requirements. Sen. James Lankford (R-Okla.), for instance, told CNBC the bill isn’t about “kicking people off Medicaid. It’s transitioning from Medicaid to employer-provided health care.”

But the health policy experts we checked with made clear that getting a job isn’t a guarantee for getting work-sponsored insurance.

Employer-Sponsored Health Insurance: The Basics

These experts said most jobs do offer health insurance. But they also said the link between employment and work-based coverage is not always straightforward.

“When I see this statement, I’m like, ‘I’ve got so much more to say about this.’ But I’m not arguing with the statement,” Fronstin said.

Matthew Rae, an associate director focused on researching private insurance at KFF, a health information nonprofit that includes KFF Health News, also weighed in.

“Employer-sponsored coverage remains the bedrock of how people get health insurance in the United States,” Rae said. “I would say that getting a job is not a guarantee you’re going to have health insurance. It just increases your chances of getting it.”

About 60% of Americans younger than 65 receive health insurance through their job or as the spouse, child, or other dependent of someone insured through their work, according to 2023 KFF data.

Among workers ages 18 to 64 who were eligible but didn’t sign up for their workplace insurance, 28% said the reason they decided not to enroll was that the plans were too expensive, 2023 KFF data showed.

Most of these workers found health insurance elsewhere, such as through a relative’s workplace plan. But a small percentage of eligible employees, 3.7%, were uninsured.

Health insurance has been “the most valued benefit in the workplace” since businesses began offering it to recruit employees in a tight labor market during World War II, Fronstin said.

Federal law also encourages companies to offer plans. Under the Affordable Care Act, employers with 50 or more full-time workers are penalized if they don’t offer most employees insurance that the federal government considers affordable.

As of last year, 54% of companies offered health insurance to at least some employees, according to KFF.

But that’s not the main way the ACA helped lower the rate of people without health insurance, said Melissa Thomasson, a professor at Miami University in Ohio who specializes in the economic history of health insurance. “Nearly all of that” change, she said, came from the ACA creating private marketplace plans and allowing states to expand Medicaid eligibility.

Health policy analysts say the One Big Beautiful Bill would make it more difficult for people to qualify or afford marketplace plans, with proposals that would increase paperwork, shorten enrollment periods, and allow enhanced tax credits to fizzle out. Thomasson also noted that political rhetoric surrounding jobs and health insurance doesn’t always align.

“We often talk about small businesses being the engine of job creation,” but those are the businesses that often can’t afford to offer workplace insurance, she said.

So Who Isn’t Insured Through Workplace Insurance?

The most obvious category of people who don’t have workplace insurance are those who don’t have a job. This group includes children and retirees, people searching for work, people who choose not to work, and those who can’t work, because of a disability or illness.

Another group without employer-provided insurance is the 25% of people ages 18 to 64 who have a job but are unable to obtain such insurance, according to 2023 data from KFF.

Some of these people work for companies that don’t offer health insurance. These employers tend to be small businesses or part of certain industries, such as farming and construction.

Others are part-time, temporary, or seasonal workers at companies that offer health insurance only to full-time employees. Workers with low incomes are significantly less likely than those with higher incomes to be eligible for workplace insurance, according to 2023 KFF data.

People who aren’t employed or don’t get insurance through their job can get coverage in other ways. Some are insured through a relative’s workplace plan, while others purchase plans and may qualify for subsidies on the ACA marketplace.

Others get insurance through Medicaid or Medicare, the federal health insurance program for people 65 or older and some people with disabilities.

Cost and Quality — And Therefore Access to Care — Vary

Just because someone has health insurance doesn’t mean they’ll get the health care they need. People may skip or delay care if their plans are unaffordable or if they limit in-network providers.

“Health benefits come in all shapes and sizes,” Fronstin said. “Some employers offer very generous benefits, and others less so.”

KFF data shows that premiums and enrollees’ cost-sharing expenses grew faster than wages from 2008 to 2018 but have slowed in recent years.

Whether workplace insurance is affordable significantly varies by income. According to 2020 KFF data, lower-income families insured through a full-time worker spent, on average, 10.4% of their income on premiums and out-of-pocket costs. That’s more than twice the rate when looking at families across all incomes.

Our Ruling

Thune said, “A lot of times, health care comes with a job.”

This statement is partially accurate. Most workers in the U.S. get health coverage through work. But it glosses over aspects of our nation’s job-based health insurance system — such as how costs and coverage, especially for those with lower incomes, can make an employer plan out of reach even if it is available.

Bottom line: Not all jobs provide health insurance or offer plans to all their workers. When they do, cost and quality vary widely — making Thune’s statement an oversimplification.

We rate this statement Half True.

Sources

KOTA interview with Sen. John Thune, May 30, 2025.

CNBC interview with Sen. James Lankford, June 5, 2025.

KFF, “2024 Employer Health Benefits Survey,” Oct. 9, 2024.

KFF, “Employer Responsibility Under the Affordable Care Act,” Feb. 29, 2024.

KFF, “Employer-Sponsored Health Insurance 101,” May 28, 2024.

Peterson-KFF Health System Tracker, “What Are the Recent Trends in Employer-Based Health Coverage?” Dec. 22, 2023.

Peterson-KFF Health System Tracker, “How Affordability of Employer Coverage Varies by Family Income,”March 10, 2022.

Peterson-KFF Health System Tracker, “Tracking the Rise in Premium Contributions and Cost-Sharing for Families With Large Employer Coverage,” Aug. 14, 2019.

Manhattan Institute, “Put Employees in Control of Health Insurance with ‘Worker’s Choice ICHRA,’” May 22, 2025.

Brookings, “Uninsurance Rates Have Fallen Significantly Following the Affordable Care Act,” July 22, 2024.

Harvard Business Review, “Why Do Employers Provide Health Care in the First Place?” March 15, 2019.

Congressional Budget Office letter on the One Big Beautiful Bill Act increasing the number of uninsured people, June 4, 2025.

Phone interview with Paul Fronstin, director of health benefits research at the Employee Benefit Research Institute and a member of the Commonwealth Fund’s National Task Force on the Future Role of Employers in the U.S. Health System, June 6, 2025. 

Phone interview with Melissa Thomasson, professor and health economist at Miami University, June 6, 2025.

Phone interview with Maanasa Kona, associate research professor at the Center on Health Insurance Reforms at Georgetown University, June 6, 2025. 

Phone interview with Matthew Rae, associate director for the Health Care Marketplace Program at KFF, June 10, 2025. 

Phone interview with Sally Pipes, president and CEO of the Pacific Research Institute, June 11, 2025.

Email correspondence with Ryan Wrasse, communications director for Sen. John Thune, June 10, 2025.

KFF Health News, “Some Employers Test Arrangement To Give Workers Allowance for Coverage,” Oct. 2, 2024.

KFF Health News, “Trump’s ‘One Big Beautiful Bill’ Continues Assault on Obamacare,” June 3, 2025.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Stephanie Ivory counts on Medicaid to get treated for gastrointestinal conditions and a bulging disc that makes standing or sitting for long periods painful. Her disabilities keep her from working, she said.

Ivory, 58, of Columbus, Ohio, believes she would be exempt from a requirement that adult Medicaid recipients work, but she worries about the reporting process. “It’s hard enough just renewing Medicaid coverage every six months with the phone calls and paperwork,” she said.

In Warrenton, Missouri, Denise Sommer hasn’t worked in five years and relies on Medicaid to get care for anxiety, high blood pressure, and severe arthritis in her back and knees.

Sommer, 58, assumes she could easily qualify for an exemption with a doctor’s note. “There’s too much abuse in the system,” she said. She added that she doesn’t worry about others losing coverage for failing to meet reporting requirements.

“That’s their own fault, because they should just keep their address updated with the state and read their mail,” she said.

President Donald Trump’s One Big Beautiful Bill Act, sprawling legislation to extend his tax cuts and enact much of his domestic agenda, would require 40 states and the District of Columbia, all of which expanded Medicaid, to add a work requirement to the program. Enrollees would have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption.

Many Republicans say nondisabled adults should not be on Medicaid, arguing the work requirement will incentivize more people to get jobs. House Speaker Mike Johnson has said it would help preserve Medicaid “for people who rightly deserve” coverage, “not for 29-year-old males sitting on their couches playing video games.”

Last month, Johnson claimed 4.8 million Medicaid enrollees are choosing not to work, a figure disputed by health policy experts. Spokespeople for Johnson did not respond to a request for comment.

Studies by the Urban Institute and KFF show that, among working-age enrollees who do not receive federal disability benefits, more than 90% already work or are looking for work, or have a disability, go to school, or care for a family member and are unable to work.

Most Medicaid enrollees who are employed hold low-wage jobs, often with long or irregular hours and limited benefits, if any. Notably, their jobs often do not provide health insurance.

A new Urban Institute study found 2% of Medicaid expansion enrollees without dependents, about 300,000 people, report a lack of interest in working as the reason for not having employment.

The nonpartisan Congressional Budget Office estimates the work requirement in the House version of the legislation would lead to about 5 million adults losing Medicaid coverage by 2034; it has not yet analyzed the Senate bill. The Center for Budget and Policy Priorities, a left-leaning research organization, estimates that the Senate’s version could cause as many as 380,000 more people to lose coverage.

According to the CBO, the work-requirement provision represents the largest cut to Medicaid in the House bill — about $300 billion over a decade, reflecting the savings from no longer covering millions of current enrollees.

The projected savings are telling, said Anthony Wright, executive director of Families USA, a consumer policy and advocacy organization. “That gives a sense of the order of its magnitude and harshness,” he said.

Wright said that Republican-led states are likely to impose more burdensome reporting requirements. But even a less stringent approach, he said, will impose paperwork mandates that cause eligible beneficiaries to lose coverage.

Stephanie Carlton, chief of staff for the Centers for Medicare & Medicaid Services, said June 24 at Aspen Ideas: Health in Colorado that Trump administration officials believe the CBO is overstating the impact of the work requirement.

“We’re making it easy” for people to report their work hours using technology, she said. She defended the proposed requirement as a way of better integrating Medicaid beneficiaries into their communities.

“We’re a society, especially through covid, that disengaged from communities. We spend a lot of time online, on social media, and we lose that human-to-human interaction,” Carlton said. “We’re asking folks to engage in their communities. That’s a fundamentally good thing to do that’s part of getting benefits.”

Under the GOP proposal, people would have to meet the new work requirements when they initially sign up for Medicaid, then report their work or exemption status at least every six months — and potentially as frequently as every month.

“This is not a conversation America should be in,” said Leslie Dach, founder and chair of Protect Our Care, an advocacy group that supports the Affordable Care Act. “Think of real life. People are seasonal workers, or they work in retail, and it goes out of business or hours change. If you miss one month, you’re kicked off.”

The GOP legislation lists disability as an exemption, along with circumstances such as being incarcerated or being the parent of a dependent child. (The Senate bill, released on June 16, would exempt only the parents of children 14 and under.)

But even existing state and federal programs serving those with disabilities have different standards for determining eligibility.

Kevin Corinth, a senior fellow at the conservative American Enterprise Institute, said states may face challenges because many Medicaid enrollees with disabilities do not get Social Security Disability Insurance.

The federal government provides what’s called Supplemental Security Income to those who meet certain thresholds for being low-income and disabled, and states are required to enroll SSI recipients in Medicaid.

But about two-thirds of adult enrollees who are under age 65 and disabled — that is, have difficulties with vision, hearing, mobility, or cognitive function, or in other areas — do not receive SSI, according to KFF.

“It’s hard to know where to draw the line on who is disabled enough” to be exempt from the work requirement, Corinth said. “Some people will fall through the cracks, and states will have to do the best job they can.”

He said states will be expected to rely on government databases, such as those maintained by their labor departments, to determine whether enrollees are working. But proving a disability could be more taxing for enrollees themselves, he said.

Two states that previously tried enacting Medicaid work requirements created strict rules for people with disabilities to get an exemption.

In Arkansas, the Medicaid work requirement had a 10-step online exemption process for individuals who were not automatically exempted by the state.

Consequently, although 30% of people subject to the requirement reported one or more serious health limitations, only 11% obtained a long-term exemption, according to the National Health Law Program.

Medicaid enrollees in Arkansas described a poorly functioning web-based reporting portal, inadequate outreach, and widespread confusion, according to focus-group interviews conducted by KFF.

Georgia’s Medicaid work requirement also has presented challenges for people seeking an exemption based on a disability. They must request a “modification” from the state on its online portal, then wait for a phone call from the state to set up an interview to review the application. Then they must enroll in the state’s job-training program before being allowed to sign up for Medicaid, according to the National Health Law Program.

Georgia has not disclosed how many people have applied for an exemption because of a disability or how many were approved.

Over 1 in 5 Medicaid enrollees have a disability, including 22% of those ages 19 to 49 and 43% of those 50 to 64, according to KFF.

Michael Karpman, principal research associate for the Urban Institute, said his group’s findings — that only a small fraction of Medicaid enrollees are unemployed because they aren’t interested in a job — explain why work-requirement programs in Arkansas and Georgia had no significant effect on employment even as they increased the number of uninsured adults.

“Many people fall off the Medicaid rolls due to red-tape reasons,” he said, noting challenges requesting exemptions or reporting work. “People struggle with the documentation process.”

Karpman said many people rely on Medicaid when they lose jobs that provide health coverage. The GOP work requirement, though, would deny them coverage while they’re seeking new jobs.

Chris Bryant, a Medicaid enrollee in Lexington, Kentucky, has a bleeding disorder and lives in government housing on $1,100 per month in federal disability payments. He said adding a work requirement to Medicaid will only add barriers for people whose health issues prevent them from working. “It will be messy,” he said.

Bryant, 39, said he knows people on Medicaid who could work but don’t, though he surmises it’s a small portion of the population. “People are on Medicaid because they have to have it and have no other option.”

Emmarie Huetteman contributed to this report.

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It’s not exactly news that our nation’s health care system is only a “system” in the most generous sense of the word and that no one entity is really in charge of it. Notwithstanding, there are some specific responsibilities that belong to the federal government, others that belong to the states, and still others that are shared between them. And sometimes people and programs fall through the cracks.

Speaking before a live audience on June 23 at Aspen Ideas: Health in Colorado, three former governors — one of whom also served as secretary of the Department of Health and Human Services — discussed what it would take to make the nation’s health care system run more smoothly.

The session, moderated by KFF Health News’ Julie Rovner, featured Democrat Kathleen Sebelius, a former governor of Kansas and HHS secretary under President Barack Obama; Republican Chris Sununu, former governor of New Hampshire; and Democrat Roy Cooper, former governor of North Carolina.

Among the takeaways from the discussion:

• States — and the governors who lead them — are major “customers” of the federal health system. For instance, states run research universities with the aid of federal grants from the National Institutes of Health. States also run Medicaid, the joint state-federal program for those with low incomes and disabilities, through which most of the nation’s care for issues such as mental health and substance use disorders is funded. In fact, most federal money sent to states is for Medicaid.
• Cuts to Medicaid outlined in the House and Senate versions of President Donald Trump’s One Big Beautiful Bill Act would leave a huge hole in state budgets — one that the states, already facing budget constraints, would be unable to fill without making difficult choices. Notably, the bill does not make substantive cuts Medicare, a program that has a significant amount of excess spending and is expected to be insolvent within a decade.
• Controlling health care costs is a major concern for the future of the nation’s fragmented health care system, as is maintaining the health care workforce. More people without insurance coverage means higher overall costs. Pandemic burnout, immigration raids, and even the cost of college are putting pressure on a dwindling workforce. The federal government could do more to encourage medical professionals to go into primary care and rural health care.

Video of this episode is available here on YouTube.

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Sarah Kwon

California lawmakers are poised to delay the state’s much-ballyhooed new law mandating in vitro fertilization insurance coverage for millions, set to take effect July 1. Gov. Gavin Newsom has asked lawmakers to push the implementation date to January 2026, leaving patients, insurers, and employers in limbo.

The law, SB 729, requires state-regulated health plans offered by large employers to cover infertility diagnosis and treatment, including IVF. Nine million people will qualify for coverage under the law. Advocates have praised the law as “a major win for Californians,” especially in making same-sex couples and aspiring single parents eligible, though cost concerns limited the mandate’s breadth.

People who had been planning fertility care based on the original timeline are now “left in a holding pattern facing more uncertainty, financial strain, and emotional distress,” Alise Powell, a director at Resolve: The National Infertility Association, said in a statement.

During IVF, a patient’s eggs are retrieved, combined with sperm in a lab, and then transferred to a person’s uterus. A single cycle can total around $25,000, out of reach for many. The California law requires insurers to cover up to three egg retrievals and an unlimited number of embryo transfers.

Not everyone’s coverage would be affected by the delay. Even if the law took effect July 1, it wouldn’t require IVF coverage to start until the month an employer’s contract renews with its insurer. Rachel Arrezola, a spokesperson for the California Department of Managed Health Care, said most of the employers subject to the law renew their contracts in January, so their employees would not be affected by a delay.

She declined to provide data on the percentage of eligible contracts that renew in July or later, which would mean those enrollees wouldn’t get IVF coverage until at least a full year from now, in July 2026 or later.

The proposed new implementation date comes amid heightened national attention on fertility coverage. California is now one of 15 states with an IVF mandate, and in February, President Donald Trump signed an executive order seeking policy recommendations to expand IVF access.

It’s the second time Newsom has asked lawmakers to delay the law. When the Democratic governor signed the bill in September, he asked the legislature to consider delaying implementation by six months. The reason, Newsom said then, was to allow time to reconcile differences between the bill and a broader effort by state regulators to include IVF and other fertility services as an essential health benefit, which would require the marketplace and other individual and small-group plans to provide the coverage.

Newsom spokesperson Elana Ross said the state needs more time to provide guidance to insurers on specific services not addressed in the law to ensure adequate and uniform coverage. Arrezola said embryo storage and donor eggs and sperm were examples of services requiring more guidance.

State Sen. Caroline Menjivar, a Democrat who authored the original IVF mandate, acknowledged a delay could frustrate people yearning to expand their families, but requested patience “a little longer so we can roll this out right.”

Sean Tipton, a lobbyist for the American Society for Reproductive Medicine, contended that the few remaining questions on the mandate did not warrant a long delay.

Lawmakers appear poised to advance the delay to a vote by both houses of the legislature, likely before the end of June. If a delay is approved and signed by the governor, the law would immediately be paused. If this does not happen before July 1, Arrezola said, the Department of Managed Health Care would enforce the mandate as it exists. All plans were required to submit compliance filings to the agency by March. Arrezola was unable to explain what would happen to IVF patients whose coverage had already begun if the delay passes after July 1.

The California Association of Health Plans, which opposed the mandate, declined to comment on where implementation efforts stand, although the group agrees that insurers need more guidance, spokesperson Mary Ellen Grant said.

Kaiser Permanente, the state’s largest insurer, has already sent employers information they can provide to their employees about the new benefit, company spokesperson Kathleen Chambers said. She added that eligible members whose plans renew on or after July 1 would have IVF coverage if implementation of the law is not delayed.

Employers and some fertility care providers appear to be grappling over the uncertainty of the law’s start date. Amy Donovan, a lawyer at insurance brokerage and consulting firm Keenan & Associates, said the firm has fielded many questions from employers about the possibility of delay. Reproductive Science Center and Shady Grove Fertility, major clinics serving different areas of California, posted on their websites that the IVF mandate had been delayed until January 2026, which is not yet the case. They did not respond to requests for comment.

Some infertility patients confused over whether and when they will be covered have run out of patience. Ana Rios and her wife, who live in the Central Valley, had been trying to have a baby for six years, dipping into savings for each failed treatment. Although she was “freaking thrilled” to learn about the new law last fall, Rios could not get clarity from her employer or health plan on whether she was eligible for the coverage and when it would go into effect, she said. The couple decided to go to Mexico to pursue cheaper treatment options.

“You think you finally have a helping hand,” Rios said of learning about the law and then, later, the requested delay. “You reach out, and they take it back.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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GREENVILLE, Miss. — Cedric Sturdevant woke up with “a bit of depression” but made it to church, as he does every Sunday. In a few days, he would drive from Mississippi to Washington, D.C., to join HIV advocates at an April rally against the Trump administration’s actions.

It had clawed back more than $11 billion in federal public health grants to states and abruptly terminated millions of dollars in funds for HIV work in the United States. Testing and outreach for HIV faltered in the South, a region that accounts for more than half of all HIV diagnoses.

Dangerous changes loomed: To compensate for tax cuts for the wealthy, Trump’s “big, beautiful” bill and budget proposal for fiscal year 2026 threaten to curtail Medicaid, which provides health coverage for people with low incomes and disabilities. About 40% of adults with HIV rely on it for their lifesaving treatments.

Further, the budget proposes to eliminate all HIV prevention programs at the Centers for Disease Control and Prevention. This alone could lead to an additional 14,600 HIV-related deaths within the next five years, according to one analysis.

Trump’s budget proposal also would cancel a major grant that provides housing assistance for people with HIV. And it would end a strategic initiative to expand HIV services in minority communities, and another to support the mental health of people of color with HIV or at risk of infection.

“President Trump is committed to eliminating radical gender and racial ideologies that poison the minds of Americans,” a White House addendum to the budget says. Letters terminating HIV grants used similar language, targeting “diversity,” “equity,” and “gender minorities,” words that focus resources where they are needed most. Black and Latino people account for about 70% of new HIV infections in the U.S.

The cuts affect Sturdevant personally. He is a gay, Black man living with HIV and the co-founder of a grassroots group that combats health disparities in the Mississippi Delta, one of the poorest regions of the country.

That morning at church, a close friend, pastor Jerry Shelton of Anointed Oasis of Love Ministry, asked Sturdevant to help him deliver a sermon about resisting the urge to give up when life is hard. “The storm may come, but I shall not be moved!” Shelton preached, directing the congregation to approach adversity with confidence in themselves and in God. “Walk boldly!” he shouted.

After the service, Sturdevant resolved to bring the same energy to Washington. He’d tell his colleagues that they are survivors, he said. He’d tell them, “Let’s get together and make a plan.”

In the past few months, HIV advocates have begun to organize and strategize ways to limit the damage as federal funds are slashed and inflammatory rhetoric rises.

“It is a very scary time to be Black, queer, and living with HIV,” said Marnina Miller, co-executive director of the Positive Women’s Network, a nationwide group for women living with HIV. “But I am grateful that I am part of a community that will not bow down.”

“People are not giving up,” said June Gipson, the CEO of a health care nonprofit, My Brother’s Keeper, in Mississippi. Then she referenced the 1980s cartoon where heroes combine forces to create a super robot to defend the universe:

“We’ve got to form Voltron.”

The Weight of Stigma

Sturdevant often reminds his colleagues of all the HIV movement has overcome. In the 1980s, the government refused to acknowledge HIV as gay men died young. Once powerful treatments were available in the 1990s and early 2000s, the public health establishment largely neglected Black people with HIV, especially in the South. In that period, the demographics of the epidemic shifted away from white, upper- and middle-class gay populations in liberal states. Half of new diagnoses today are in the South and a third are among people with low incomes.

When Sturdevant first tested positive for HIV in 2005, he didn’t seek treatment. He kept his diagnosis hidden from friends and family because he knew how people talked about HIV. They considered it a death sentence, a punishment for irresponsible behavior, or a disease that could infect them through a touch or a shared toilet seat — which it cannot.

“I thought my family was going to disown me,” he said.

A year later, his weight plummeted because he couldn’t hold down food or water. Gaunt and feverish, he went to the hospital and learned he had AIDS. His mother slept at his hospital bedside for two weeks: “She said, ‘God got you.’”

Once he regained his health, Sturdevant resolved to care for others in his position. Scientists had developed powerful HIV drugs that, if taken daily, transform it from a death sentence into a manageable chronic disease in which a person’s virus levels are so suppressed that they cannot spread HIV to others. And policymakers ensured that almost everyone in the U.S. with HIV could get treated regardless of their ability to pay, largely because of Medicaid and the Ryan White HIV/AIDS Program.

But HIV experts had failed to overcome a key problem: Roughly a third of people living with HIV in the U.S. don’t get treated or don’t take the drugs regularly enough to be virally suppressed. Viral suppression rates are better in many African countries than in America.

To seek treatment and stick with it, Sturdevant understood, people had to have basic needs like food and housing met and, as importantly, a sense of belonging and empowerment. At his first job at an HIV organization in Jackson, Mississippi, Sturdevant regularly checked in with clients who didn’t have family members to support them. He hosted gatherings at his apartment and even offered it up as a place to stay. He has taken on the role of dad or uncle to many. “We called ourselves the family of love,” he said.

He saw how care bolstered lives, but the federal government needed data to drive its approach to HIV.

In 2012, the CDC expanded its in-depth surveys to learn more about the lives of people at risk of HIV and of those with HIV who weren’t virally suppressed. The surveys revealed what Sturdevant knew: A disproportionate number of them grappled with unstable housing, food insecurity, depression, and anxiety. Many participants agreed to prompts like, “Having HIV makes me feel that I’m a bad person,” or “Most people think that a person with HIV is disgusting,” or “Most people with HIV are rejected.”

The data showed policymakers that to curb the epidemic, they needed to address underlying problems that people with HIV faced. Federal funds began to flow to grassroots groups embedded in marginalized communities.

Public health researchers folded Black churches into the effort, recognizing them as hubs of volunteerism and as leaders of social movements. Although churches in the U.S. had historically fueled stigma against sexually transmitted diseases, Amy Nunn, a public health researcher at Brown University, said every pastor she talked with was eager to help. It paid off. In Kansas City, for example, researchers found that congregants who went to Black churches involved in HIV education and outreach were more than twice as likely to be tested.

Community-based interventions worked: New HIV infections dropped by 12% from 2018 to 2022.

Now the grassroots groups that have been so effective are in jeopardy and the in-depth surveys have halted as the Trump administration cuts funds and lays off CDC staff. Some health departments have issued stop-work orders to community-based groups that test people for HIV and connect them to treatment because federal HIV grants are unusually delayed. And as the Department of Health and Human Services continues to cancel HIV grants, the directors of grassroots groups anticipate more cuts.

“A lot of them are new and don’t have the resources to survive a year without funding,” said Masen Davis, executive director of Funders Concerned About AIDS.

One such group is Sturdevant’s.

‘Trust the Process’?

In 2017, Sturdevant returned home to the Mississippi Delta to launch a nonprofit, Community Health PIER, in one of the poorest and most medically underserved parts of the country. The average life expectancy in the Delta is 68, a decade shorter than the national average. The disenfranchisement of its majority-Black population stems from the region’s history, in which policies concentrated wealth and power among the minority-white population during the era of cotton sharecropping, Jim Crow laws and segregation, and, recently, due to gerrymandering.

Sturdevant set up shop in Greenville, near a Black church that served as a headquarters for civil rights activists in the 1960s. In a small office, his team organizes health events, tests people for HIV, and connects those who test positive with treatment and housing assistance, funded through federal programs like Ryan White.

“Whites have been getting Ryan White and other programs for years and living healthy,” said Ashley Richardson, administrative assistant of Sturdevant’s group. “Around here, Black people are just now getting to the point where we know there are resources to help.”

Lately the team fields calls from people with HIV who are terrified they will lose their lifesaving drugs and housing if government programs no longer help with the cost.

Sturdevant worries about keeping his staff employed and his community safe. On the drive home from the April event in Washington, he drearily recounted conversations with Republicans in Congress: “They basically all said trust the process.”

The heads of national HIV organizations have stepped up their advocacy, asking Congress to oppose cuts in President Donald Trump’s budget request, said Gregorio Millett, director of public policy at the Foundation for AIDS Research, a nonprofit known as amfAR.

Emily Hilliard, spokesperson for the Department of Health and Human Services, responded to queries from KFF Health News by writing, “Critical HIV/AIDS programs will continue under the Administration for a Healthy America.” Yet the administration’s proposed budget for HIV prevention represents a 78% reduction compared with fiscal year 2025, according to a KFF analysis.

HHS Secretary Robert F. Kennedy Jr. has fostered skepticism  about scientific facts concerning HIV, without citing evidence. “Any questioning of the orthodoxy that HIV is the sole cause of AIDS remains an unforgivable-even dangerous-heresy among our reigning medical cartel,” he wrote in a 2021 book.

Not Bowing to Barriers

Researchers and HIV advocates are hashing out strategies to fill in the vacuum in HIV care that the government is poised to leave. For decades, it has driven priorities, coordinated a constellation of HIV groups, and tracked the epidemic. Leisha McKinley-Beach, CEO of a training institute, Black Public Health Academy, in Atlanta, said people must remember that wasn’t always the case.

“This massive industry we have today was created by committed individuals at the grassroots level, who were going to help people live with HIV or die with dignity, by any means necessary,” she said.

One idea is to have larger, established HIV organizations partner with nascent groups in underserved regions. The bigger ones stand a better chance of garnering significant private donations. And by taking on the fiscal management of grants, large groups could enable small ones to devote time to service rather than fundraising, McKinley-Beach said.

Another strategy, said Kathy Garner, executive director of Mississippi’s AIDS Services Coalition, is to fill gaps by coordinating with churches and nonprofits dedicated to food assistance, housing, or mental health.

“One of the solutions is going to be civil society stepping up,” Garner said. “That’s an old term for people taking care of each other, outside of the government.”

“We’re going to need to ramp up our services in all kinds of ways, and health and HIV will be a part of that,” said Bishop Ronnie Crudup of New Horizon Church International in Jackson, and a member of Mississippi Faith in Action, a coalition of African American churches involved in HIV.

“I have real concerns with what the Trump administration is doing, and how it will play out for the health of people in a poor state,” he said.

National groups, such as AIDS United, have been speaking with corporate funders and philanthropies about building a pooled fund to help sustain HIV organizations across the U.S.

Philanthropy for HIV has never come close to matching federal dollars, however. Non-governmental funders put $284 million toward HIV in the U.S. in 2023, compared with about $16 billion in annual federal funds for HIV in recent years.

“The truth is there is no way for philanthropy to make up for the cuts from the federal government,” Davis said. “I suspect we will see new infections rise within 18 months, which is heartbreaking.”

Sturdevant focuses on survival, not forecasts. “This isn’t going to be easy,” he said, “but we need to keep fighting for those who don’t have the fight in them.”

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Nearly seven months after the fatal shooting of an insurance CEO in New York drew widespread attention to health insurers’ practice of denying or delaying doctor-ordered care, the largest U.S. insurers agreed Monday to streamline their often cumbersome preapproval system.

Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials.

While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement.

“The pledge is not a mandate,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. “This is an opportunity for the industry to show itself.”

Oz said he wants insurers to eliminate preapprovals for knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems. Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care.

The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer.

But health policy analysts say prior authorization — a system that forces some people to delay care or abandon treatment — may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments.

“So much of the prior authorization process is behind the black box,” said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.

Often, she said, patients aren’t even aware that they’re subject to prior authorization requirements until they face a denial.

“I’m not sure how this changes that,” Pestaina said.

The pledge from insurers follows the killing of UnitedHealthcare CEO Brian Thompson, who was shot in midtown Manhattan in early December on the way to an investor meeting, forcing the issue of prior authorization to the forefront.

Oz acknowledged “violence in the streets” prompted Monday’s announcement. Klomp told KFF Health News that insurers were reacting to the shooting because the problem has “reached a fever pitch.” Health insurance CEOs now move with security details wherever they go, Klomp said.

“There’s no question that health insurers have a reputation problem,” said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina.

The pledge shows that insurers are hoping to stave off “more draconian” legislation or regulation in the future, Hartwig said.

But government interventions to improve prior authorization will be used “if we’re forced to use them,” Oz said during the news conference.

“The administration has made it clear we’re not going to tolerate it anymore,” he said. “So either you fix it or we’re going to fix it.”

Here are the key takeaways for consumers:

1. Prior authorization isn’t going anywhere.

Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism that patients and providers level against insurance companies. And it isn’t clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment.

2. Reform efforts aren’t new.

Most states have already passed at least one law imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted “gold card” programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements.

Nationally, rules proposed by the first Trump administration and finalized by the Biden administration are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid.

Beyond that, some insurance companies committed to improvement long before Monday’s announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February.

3. Insurance companies are already supposed to be doing some of these things.

For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage.

But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term “non-approved requests” in Monday’s announcement.

Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is “a standard already in place.” But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds.

4. Health insurers will increasingly rely on artificial intelligence.

Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved.

The use of AI in making prior authorization decisions isn’t new — and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions “in real-time” by 2027.

“Artificial intelligence should help this tremendously,” Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference.

“But remember, artificial intelligence is only as good as what you put into it,” he added.

Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials.

5. Key details remain up in the air.

Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January.

He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn’t clear when that platform will be unveiled. The same holds true for “performance targets” that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them.

While the AMA, which represents doctors, applauded the announcement, “patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions,” the association’s president, Bobby Mukkamala, said in a statement. He noted that health insurers made “past promises” to improve prior authorization in 2018.

Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements.

Patient advocates are in the process of identifying “low-value codes,” Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules.

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MIAMI, Florida. — Josefina Muralles trabaja a tiempo parcial de noche como recepcionista en un condominio de Miami Beach. Así, puede cuidar durante el día de sus tres hijos, su madre mayor y su hermano, que está paralítico.

También ayuda a su madre a alimentar, bañar y dar la medicación a Rodrigo Muralles, el hermano que padece epilepsia y quedó discapacitado luego de desarrollar covid-19 en 2020.

“Vive porque le damos de comer y atendemos sus necesidades personales”, explica Josefina Muralles, de 41 años. “No dice: ‘Necesito esto o aquello’. Lo ha olvidado todo”.

Aunque su marido trabaja a tiempo completo, este arreglo hace que los ingresos familiares estén justo por encima del umbral federal de pobreza: son demasiado altos para aplicar al Medicaid de Florida, pero lo suficientemente bajos como para que Muralles y su marido puedan optar por un seguro médico subvencionado a través del mercado de seguros establecido por la Ley de Cuidado de Salud a Bajo Precio (ACA, también conocida como Obamacare).

Muralles dijo que el año que viene es posible que ella y su marido no puedan permitirse ese seguro médico, que ha pagado por los anticoagulantes que le han recetado, la medicación para el colesterol y dos operaciones, incluida una para tratar un trastorno genético.

A esto se suma que los subsidios adicionales establecidos durante la pandemia, que redujeron las primas que pagaban Muralles y su marido a menos de la mitad, es decir a $30 al mes, solo estarán vigentes hasta el 31 de diciembre.

Sin estos subsidios, las primas de los planes médicos de ACA aumentarían en promedio más del 75%, y en algunos estados las facturas que pagan las personas se duplicarían con creces, según estimaciones de KFF.

Florida y Texas se verían especialmente afectados, ya que tienen más gente inscrita en este mercado que otros estados. Solo algunos de sus distritos electorales, especialmente en el sur de Florida, tienen más personas anotadas en Obamacare que otros estados enteros.

Al igual que muchos de los más de 24 millones de estadounidenses registrados en el mercado de seguros este año, Muralles no sabía que los subsidios mejorados estaban a punto de expirar. Dijo que no puede permitirse un aumento de la prima porque la inflación ya lesionado el presupuesto de su hogar.

“El alquiler está subiendo y la cuenta del agua también”, señaló.

Si se terminan los subsidios ampliados, los inscriptos con bajos ingresos, como el matrimonio Muralles serán los que reciban los mayores aumentos porcentuales en las primas.

En la práctica, los inscriptos de ingresos medios que ganan más de cuatro veces el umbral federal de pobreza ya no serían elegibles para recibir ningún subsidio. Esos afiliados —que en 2025, ganan unos  $62.600 por individuo — son, en su gran mayoría, adultos mayores, trabajadores autónomos y residentes en zonas rurales.

Julio Fuentes, presidente de la Florida Hispanic American Chamber of Commerce dijo que muchos de los miembros de su organización son propietarios de pequeñas empresas que dependen del Obamacare para ofrecer cobertura de salud.

“Es esto o nada”, afirmó.

La Oficina de Presupuesto del Congreso (CBO) calculó que si se dejan de aplicar los subsidios mejorados aumentará en 4,2 millones el número de personas sin seguro médico.

Si se suman los cambios en Medicaid que propone el proyecto de reconciliación presupuestaria de la Cámara de Representantes y las normas propuestas por la administración Trump para el mercado de seguros, que incluyen una verificación de ingresos más estricta y la reducción de los períodos de inscripción, el número total de personas sin cobertura crecerá en 16 millones durante ese período.

Un estudio del Urban Institute reveló que, sin los subsidios adicionales, los hispanos y los afroamericanos sufrirán mayores pérdidas de cobertura que otros grupos.

Fuentes señaló que alrededor de 5 millones de hispanos están inscritos en el mercado de ACA y que Donald Trump ganó el voto hispano en Florida en 2024. Espera que el presidente y los republicanos del Congreso vean la ampliación de los subsidios mejorados como una forma de conservar a esos votantes.

“Probablemente esta sea una buena forma de aumentar aún más esa base”, afirmó. “O un buen comienzo”.

La inscripción en el mercado de seguros ha crecido más rápidamente desde 2020 en los estados donde Trump ganó en 2024.

Una encuesta reciente de KFF reveló que el 45% de los estadounidenses que compran su propio seguro médico se identifican como republicanos o se inclinan por este partido, incluidos 3 de cada 10 que se identifican como partidarios de Make America Great Again (MAGA).

Un porcentaje menor se identifica como demócrata o independiente con tendencia demócrata (35%) o no se inclina por ninguno de los dos partidos (20%).

Kush Desai, vocero de la Casa Blanca, afirmó que las normas propuestas por la administración Trump, junto con las disposiciones del proyecto de ley presupuestaria aprobado por la Cámara de Representantes, “fortalecerán el mercado de ACA”.

El funcionario señaló que la CBO prevé que la legislación reduzca las primas de algunos planes en un promedio del 12% para 2034, pero que los gastos de bolsillo aumentarán o se mantendrán iguales para la mayoría de los consumidores que reciben subsidios.

“Los demócratas saben que los estadounidenses apoyan ampliamente el fin del despilfarro, el fraude y el abuso, tal y como lo hace The One, Big, Beautiful Bill, y por eso están tratando desesperadamente de cambiar el discurso”, afirmó Desai.

Sin embargo, Lauren Aronson, directora ejecutiva de Keep Americans Covered, un grupo con sede en Washington, D.C. que representa a aseguradoras de salud, hospitales, médicos y defensores de los pacientes, afirmó que es fundamental generar conciencia sobre el posible impacto de la pérdida de los subsidios mejorados, también conocidos como créditos fiscales anticipados para el pago de primas.

Aronson se mostró entusiasmada por el hecho de que los demócratas hayan presentado un proyecto de ley para extender la vigencia de estos subsidios, y que algunos senadores republicanos hayan expresado su apoyo.

Lo que más preocupa a Aronson es que el Congreso, controlado por los republicanos, esté más centrado en prorrogar los recortes fiscales que en mejorar los subsidios, afirmó. Según la CBO, el proyecto de ley actual que prorroga los recortes fiscales de 2017 aumentaría el déficit federal en unos $2,4 mil millones durante la próxima década, mientras que hacer que los subsidios mejorados sean permanentes aumentaría el déficit en $358.000 millones durante aproximadamente el mismo período.

“El Congreso está avanzando en un paquete de reconciliación fiscal que pretende beneficiar a las familias trabajadoras”, explicó Aronson. “Pero si los legisladores no se ocupan de los créditos fiscales, las familias trabajadoras terminarán cargando con el problema”.

Brian Blase, presidente del Paragon Health Institute, un centro de estudios conservador en políticas de salud, dijo que se suponía que los subsidios mejorados eran una medida temporal establecida durante la pandemia de covid-19 para ayudar a las personas que corrieran el riesgo de perder la cobertura.

Pero en realidad, afirmó, los subsidios mejorados facilitaron el fraude porque los afiliados no necesitaban verificar su elegibilidad por ingresos para recibir planes sin costo mensual. Alcanzaba con declarar ingresos iguales o cercanos al nivel federal de pobreza.

Los subsidios mejorados también empeoran la inflación en el sector de salud, desalientan a los empleadores a ofrecer cobertura médica y desplazan a modelos alternativos, como los seguros a corto plazo y los planes de la Farm Bureau, dijo Blase.

“Permitir que se acaben estos subsidios sería simplemente volver al Obamacare tal y como estaba redactado”, opinó Blase. “Es un programa más eficiente que el que tenemos ahora”.

Las nuevas normas para el mercado propuestas por la administración Trump en marzo ya están diseñadas para combatir el fraude, dijo Anna Howard, experta en políticas de la American Cancer Society Cancer Action Network, que aboga por una mayor cobertura de seguro médico. Howard señaló que la ampliación de los créditos fiscales mejorados ayudaría a garantizar que las personas que tienen derecho legítimo a la cobertura puedan obtenerla.

“No queremos que más de 5 millones de personas se vean privadas de su cobertura de salud por temor al fraude, cuando las políticas que se proponen no abordan necesariamente este problema”, manifestó.

Sin primas accesibles, muchos consumidores recurrirán a planes de salud de corto plazo, a organizaciones religiosas que ayudan con los costos médicos, y a otras formas de cobertura que no ofrecen las prestaciones ni las protecciones de la ley de salud, afirmó.

“Se trata de planes que no cubren los medicamentos prescriptos o que tienen límites anuales o de por vida”, explicó. “Para un paciente con cáncer, esos planes no sirven”, añadió.

Aunque los subsidios mejorados no expiran hasta finales de año, la Blue Cross Blue Shield Association preferiría que el Congreso actuara antes del otoño para evitar confusiones durante el período de inscripción abierta, señaló David Merritt, vicepresidente senior.

Las aseguradoras están preparando las tarifas para cumplir con los plazos estatales. Hacia octubre, los consumidores recibirán avisos de renovación de sus planes, con 60 días de anticipación. Estos avisos incluirán las primas correspondientes a 2026.

Sin los subsidios mejorados, explicó Merritt, la competencia en el mercado de seguros se reducirá, lo que dará lugar a menos opciones de cobertura y precios más altos, especialmente en los estados que no han ampliado la elegibilidad para Medicaid y donde la inscripción en Obamacare se disparó durante los últimos cuatro años, como Florida y Texas. “Los votantes y los pacientes realmente van a sentir el impacto”, afirmó.

Los representantes republicanos y demócratas de algunos de los distritos electorales de Florida que tienen el mayor número de personas en el mercado no respondieron a las repetidas solicitudes de entrevista.

Muralles, de North Miami, Florida, explicó que quiere que sus representantes se ocupen de defender a las personas que los votan y que, como ella, necesitan cobertura sanitaria para cuidar de sus familias.

“Ahora es el momento de demostrar que están con nosotros”, expresó Muralles. “Cuando todo el mundo está sano, todo el mundo va a trabajar, todo el mundo puede pagar impuestos, todo el mundo puede tener una vida mejor”.

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Bernard J. Wolfson

Republican efforts to restrict taxes on hospitals, health plans, and other providers that states use to help fund their Medicaid programs could strip them of tens of billions of dollars. The move could shrink access to health care for some of the nation’s poorest and most vulnerable people, warn analysts, patient advocates, and Democratic political leaders.

No state has more to lose than California, whose Medicaid program, called Medi-Cal, covers nearly 15 million residents with low incomes and disabilities. That’s twice as many as New York and three times as many as Texas.

A proposed rule by the Centers for Medicare & Medicaid Services, echoed in the Republican House reconciliation bill as well as a more drastic Senate bill, would significantly curtail the federal dollars many states draw in matching funds from what are known as provider taxes. Although it’s unclear how much states could lose, the revenue up for grabs is big. For instance, California has netted an estimated $8.8 billion this fiscal year from its tax on managed care plans and took in about $5.9 billion last year from hospitals.

California Democrats are already facing a $12 billion deficit, and they have drawn political fire for scaling back some key health care policies, including full Medi-Cal coverage for immigrants without permanent legal status. And a loss of provider tax revenue could add billions to the current deficit, forcing state lawmakers to make even more unpopular cuts to Medi-Cal benefits.

“If Republicans move this extreme MAGA proposal forward, millions will lose coverage, hospitals will close, and safety nets could collapse under the weight,” Gov. Gavin Newsom, a Democrat, said in a statement, referring to President Donald Trump’s “Make America Great Again” movement.

The proposals are also a threat to Proposition 35, a ballot initiative California voters approved last November to make permanent the tax on managed care organizations, or MCOs, and dedicate some of its proceeds to raise the pay of doctors and other providers who treat Medi-Cal patients.

All states except Alaska have at least one provider tax on managed care plans, hospitals, nursing homes, emergency ground transportation, or other types of health care businesses. The federal government spends billions of dollars a year matching these taxes, which generally lead to more money for providers, helping them balance lower Medicaid reimbursement rates while allowing states to protect against economic downturns and budget constraints.

New York, Massachusetts, and Michigan would also be among the states hit hard by Republicans’ drive to scale back provider taxes, which allow states to boost their share of Medicaid spending to receive increased federal Medicaid funds.

In a May 12 statement announcing its proposed rule, CMS described a “loophole” as “money laundering,” and said California had financed coverage for over 1.6 million “illegal immigrants” with the proceeds from its MCO tax. CMS said its proposal would save more than $30 billion over five years.

“This proposed rule stops the shell game and ensures federal Medicaid dollars go where they’re needed most — to pay for health care for vulnerable Americans who rely on this program, not to plug state budget holes or bankroll benefits for noncitizens,” Mehmet Oz, the CMS administrator, said in the statement.

Medicaid allows coverage for noncitizens who are legally present and have been in the country for at least five years. And California uses state money to pay for almost all of the Medi-Cal coverage for immigrants who are not in the country legally.

California, New York, Michigan, and Massachusetts together account for more than 95% of the “federal taxpayer losses” from the loophole in provider taxes, CMS said. But nearly every state would feel some impact, especially under the provisions in the reconciliation bill, which are more restrictive than the CMS proposal.

None of it is a done deal. The CMS proposal, published May 15, has not been adopted yet, while the House and Senate bills must be negotiated into one and passed by both chambers of Congress. But the restrictions being contemplated would be far-reaching.

A report by Michigan’s Department of Health and Human Services, ordered by Democratic Gov. Gretchen Whitmer, found that a reduction of revenue from the state’s hospital tax could “destabilize hospital finances, particularly in rural and safety-net facilities, and increase the risk of service cuts or closures.” Losing revenue from the state’s MCO tax “would likely require substantial cuts, tax increases, or reductions in coverage and access to care,” it said.

CMS declined to respond to questions about its proposed rule.

The Republicans’ House-passed reconciliation bill, though not the CMS proposal, also prohibits any new provider taxes or increases to existing ones. The Senate version, released June 16, would gradually reduce the allowable amount of many provider taxes.

The American Hospital Association, which represents nearly 5,000 hospitals and health systems nationwide, said the proposed moratorium on new or increased provider taxes could force states “to make significant cuts to Medicaid to balance their budgets, including reducing eligibility, eliminating or limiting benefits, and reducing already low payment rates for providers.”

Because provider taxes draw matching federal dollars, Washington has a say in how they are implemented. And the Republicans who run the federal government are looking to spend far fewer of those dollars.

In California, the insurers that pay the MCO tax are reimbursed for the portion levied on their Medi-Cal enrollment. That helps explain why the tax rate on Medi-Cal enrollment is sharply higher than on commercial enrollment. Over 99% of the tax money the insurers pay comes from their Medi-Cal business, which means most of the state’s insurers get back almost all the tax they pay.

That imbalance, which CMS describes as a loophole, is one of the main things Republicans are trying to change. If either the CMS rule or the corresponding provisions in the House reconciliation bill were enacted, states would be required to levy provider taxes equally on Medicaid and commercial business to draw federal dollars.

California would likely be unable to raise the commercial rates to the level of the Medi-Cal ones, because state law constrains the legislature’s ability to do so. The only way to comply with the rule would be to lower the tax rate on Medi-Cal enrollment, which would sharply reduce revenue.

CMS has warned California and other states for years, including under the Biden administration, that it was considering significant changes to MCO and other provider taxes. Those warnings were never realized. But the risk may be greater this time, some observers say, because the effort to shrink provider taxes is embedded in both Republican reconciliation bills and intertwined with a broader Republican strategy — and set of proposals — to cut Medicaid spending by $800 billion or more.

“All of these proposals move in the same direction: fewer people enrolled, less generous Medicaid programs over time,” said Edwin Park, a research professor at Georgetown University’s McCourt School of Public Policy.

California’s MCO tax is expected to net California $13.9 billion over the next two fiscal years, according to January estimates. The state’s hospital tax is expected to bring in an estimated $9 billion this year, up sharply from last year, according to the Department of Health Care Services, which runs Medi-Cal.

Losing a significant slice of that revenue on top of other Medicaid cuts in the House reconciliation bill “all adds up to be potentially a super serious impact on Medi-Cal and the California state budget overall,” said Kayla Kitson, a senior policy fellow at the California Budget & Policy Center.

And it’s not only California that will feel the pain.

“All states are going to be hurt by this,” Park said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Supreme Court this week ruled in favor of Tennessee’s law banning most gender-affirming care for minors — a law similar to those in two dozen other states.

Meanwhile, the Senate is still hoping to complete work on its version of President Donald Trump’s huge budget reconciliation bill before the July Fourth break. But deeper cuts to the Medicaid program than those included in the House-passed bill could prove difficult to swallow for moderate senators.

This week’s panelists are Julie Rovner of KFF Health News, Victoria Knight of Axios, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

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Sandhya Raman
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Among the takeaways from this week’s episode:

• The Supreme Court’s ruling on gender-affirming care for transgender minors was relatively limited in its scope. The majority did not address the broader question about whether transgender individuals are protected under federal anti-discrimination laws and, as with the court’s decision overturning the constitutional right to an abortion, left states the power to determine what care trans youths may receive.
• The Senate GOP unveiled its version of the budget reconciliation bill this week. Defying expectations that senators would soften the bill’s impact on health care, the proposal would make deeper cuts to Medicaid, largely at the expense of hospitals and other providers. Republican senators say those cuts would allow them more flexibility to renew and extend many of Trump’s tax cuts.
• The Medicare trustees are out this week with a new forecast for the program that covers primarily those over age 65, predicting insolvency by 2033 — even sooner than expected. There was bipartisan support for including a crackdown on a provider practice known as upcoding in the reconciliation bill, a move that could have saved a bundle in government spending. But no substantive cuts to Medicare spending ultimately made it into the legislation.
• With the third anniversary of the Supreme Court decision overturning Roe v. Wade approaching, the movement to end abortion has largely coalesced around one goal: stopping people from accessing the abortion pill mifepristone.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: The New York Times’ “The Bureaucrat and the Billionaire: Inside DOGE’s Chaotic Takeover of Social Security,” by Alexandra Berzon, Nicholas Nehamas, and Tara Siegel Bernard.  

Victoria Knight: The New York Times’ “They Asked an A.I. Chatbot Questions. The Answers Sent Them Spiraling,” by Kashmir Hill.  

Alice Miranda Ollstein: Wired’s “What Tear Gas and Rubber Bullets Do to the Human Body,” by Emily Mullin.  

Sandhya Raman: North Carolina Health News and The Charlotte Ledger’s “Ambulance Companies Collect Millions by Seizing Wages, State Tax Refunds,” by Michelle Crouch.  

Also mentioned in this week’s podcast:

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While the Senate budget bill released this week proposes deep funding cuts and work requirements for Medicaid — proposals likely to increase the number of people without health insurance — another big health care issue looms that could affect millions unless Congress acts. 

Enrollment in the Affordable Care Act’s health insurance marketplace has soared over the past four years, especially in states that went for President Donald Trump in 2024. But next year, things might be very different. 

That record enrollment has been driven by a Biden-era enhancement for subsidies that lower the out-of-pocket cost of premiums for eligible people. Those enhanced subsidies are due to expire at the end of the year unless Congress extends them. 

If they don’t, ACA enrollees’ health insurance premiums would rise by more than 75% on average, with bills for people in some states more than doubling, according to estimates from KFF, a health information nonprofit that includes KFF Health News. 

Of the more than 24 million Americans who signed up for insurance through the marketplace this year, 9 in 10 receive a subsidy. Many are unaware that the enhanced subsidies are in place only through Dec. 31. 

Fabiola Auguste, a Florida insurance agent who lives in Miami-Dade County, said the enhanced subsidy reduced the premiums she pays by more than half, to $20 a month. If she can’t afford her premiums next year, Auguste said, she would most likely end up uninsured. 

“That would be, like, scary,” she said. “Just like before, everybody would stay without insurance until something happens, then you go to the hospital and ask for emergency Medicaid.” 

Low-income enrollees such as Auguste would experience the biggest bump in premiums if enhanced subsidies expire. Middle-income enrollees who earn more than four times federal poverty ($62,600 for a single person or $84,600 for a couple in 2025) would be ineligible for subsidies. 

Those middle-income enrollees are disproportionately older (ages 50 to 64), self-employed, and living in rural areas, according to a KFF analysis. A study by the Urban Institute, a nonprofit think tank, found that Hispanic and Black people would see greater coverage losses than other groups if the extra subsidies lapse. 

The Congressional Budget Office estimates ACA enrollment would drop from 22.8 million in 2025 to 18.9 million in 2026 and 15.4 million by 2030. While some people might be able to find other sources of coverage, others would become uninsured. 

Brian Blase, president of Paragon Health Institute, a conservative health policy think tank, said the enhanced subsidies were supposed to be a temporary measure during the covid pandemic to help people at risk of losing coverage. 

Allowing the subsidies to expire, he said, “is really going back to what the Obamacare structure was like,” he said.

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When Alyne Diamond fell off a horse in August 2023 and broke her back, her employer-based health plan through UnitedHealthcare covered her emergency care in Aspen, Colorado. It also covered related pain management and physical therapy after she returned home to New York City. The bills totaled more than $100,000.

The real estate lawyer, now 67, was eligible for Medicare at the time but hadn’t enrolled. Since she was still working, she thought her employer health insurance plan would cover her.

That misunderstanding has had financial repercussions that she continues to deal with today.

More than a year after her riding accident, Diamond was back at the emergency room after she tripped on a step while entering a New York restaurant. Her face covered in blood, Diamond was examined by staff, who did multiple CT scans. The bill for that care: $12,000.

This time, though, the insurance coverage wasn’t routine. Nearly all her claims were denied.

Diamond was caught in a fairly common coverage snag: People who have group health insurance when they become eligible for Medicare sometimes find themselves on the hook for their medical bills because their group plan stops paying.

Diamond contacted several people at UnitedHealthcare before she found out why the insurer refused to pay her claims.

When Diamond turned 65 in 2022, Medicare — unbeknownst to her — became the “primary payer” for her claims, meaning the federal health program for older or disabled people was supposed to take the lead in covering her medical bills, before other insurers paid anything. (As secondary payer, Diamond’s employer policy picked up 20% of what Medicare would have paid.)

Had she signed up for the government insurance plan when she turned 65, Diamond could have avoided a financially perilous situation that left her unexpectedly responsible for the medical costs she incurred during that time.

She began to understand what had happened as she made inquiries about the denied claims.

Diamond said she was told that UnitedHealthcare audited her claims last year and determined it had been improperly paying for her care, perhaps because her pricey medical claims after her fall from the horse raised a red flag.

The insurer not only stopped paying current claims but also moved to claw back tens of thousands of dollars it had paid to providers in the two years since she turned 65. Some of those providers are now seeking payment from her.

“It’s horrifying,” she said. “For about two months I was devastated. I thought, ‘Where am I going to get the money to pay all these people? There goes my retirement.’”

The mistake has already cost her $25,000 and may cost her much more if providers continue to bill her for amounts that UnitedHealthcare has clawed back for care she received before signing up for Medicare in February.

A UnitedHealthcare spokesperson declined to provide an on-the-record statement, citing safety concerns.

Patient advocates say they frequently hear from people who, like Diamond, thought they didn’t need to sign up for Medicare upon turning 65 because they had group health coverage.

That assumption is generally correct if they or their spouse is working at a company with at least 20 employees. In that case, employer coverage is considered primary and they can delay signing up for Medicare as long as they or their spouse continues to be employed there.

But if someone has employer coverage through a company with fewer than 20 workers, Medicare generally becomes the primary payer when they turn 65. The real estate law firm at which Diamond is a partner has a handful of employees.

Similarly, if someone is older than 65 and has retiree health coverage or has left their job and opted to continue their employer coverage under the Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, Medicare pays first. The issue can also arise for people who are younger than 65 if they are eligible for Medicare because of a disability. In those instances, Medicare pays first if they or their family member works at a company with fewer than 100 employees.

If people in these groups don’t sign up for Medicare when they become eligible, they can find themselves responsible for all their medical bills for years. (They may also owe a penalty for late enrollment in the Medicare program.)

“It’s very alarming and there’s no current fix to the situation,” said Fred Riccardi, president of the New York-based Medicare Rights Center, a national patient advocacy organization.

The Centers for Medicare & Medicaid Services did not respond to a request for comment.

Mark Scherzer, a lawyer in Germantown, New York, who helps people with insurance problems, and who advised Diamond, said he gets calls a couple of times a month from people who face this issue.

“What I see constantly now is that insurers go back and they claw back the money from the doctor and the doctor then claws the money back from the patient,” he said.

Costly claims may trigger an insurer to examine someone’s coverage.

Those big claims “seem to get on the insurer’s radar,” said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center.

UnitedHealthcare has recouped over $50,000 in medical bills from some of the providers who treated Diamond in New York after her riding accident. She’s paid them about $25,000 so far. Some have agreed to let her pay the amount Medicare would have paid.

But there may be more bills to come. Under New York law, health plans have two years after claims are paid to claw back payments from providers, and providers have three years to sue patients for medical debt. So, while there is still time for Diamond to be billed, the clock will eventually run out.

Diamond plans to sue the broker who manages her company’s health plan and other benefits for negligence.

“The Medicare secondary payment rules basically say that if you didn’t sign up because you didn’t know Medicare was supposed to be primary, that’s on you,” said Melanie Lambert, senior Medicare advocate at the Center for Medicare Advocacy in Connecticut.

Lambert said she has seen the issue “many, many times.” In some instances, if a beneficiary can demonstrate they were misled by an employer or a federal employee, they may qualify for relief or a special enrollment period, she said.

In a 2023 letter to the acting secretary of the Department of Labor, the National Association of Insurance Commissioners advocated applying a “commonsense rule to COBRA plans, individual health insurance, and other coverage sources: those entitled to Medicare Part B but not enrolled in it should not lose benefits they pay for from a non-Medicare coverage source.”

The Department of Labor didn’t respond to a request for comment.

In earlier times, people started collecting Social Security benefits then automatically got Medicare when they turned 65.

Now, enrolling in Medicare is more complicated for many people, said Tricia Neuman, a senior vice president and the executive director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

“As more people are delaying going on Social Security and delaying going on Medicare, there’s more opportunities for people to make mistakes, and those mistakes are costly,” Neuman said.

Coverage experts say there are no clear requirements for insurers, employers, or the federal government to notify people about how the payment rules governing coordination of benefits between health plans may change when they become eligible for Medicare.

The information appears in a chart in the government’s “Medicare & You” handbook, if someone knows to look for it. But it is not easy to find.

A straightforward fix could solve many of the problems people face in this area, Scherzer said. Since every health plan knows its enrollees’ ages, why not require them to notify people approaching 65 of possible benefit coordination issues with Medicare? “It’s so simple and such a no-brainer.”

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