Among the biggest-grossing films in America in February 2002 were a war drama about American troops in Somalia (“Black Hawk Down”), an Arnold Schwarzenegger action movie (“Collateral Damage”), and a future Oscar winner about a brilliant mathematician struggling with schizophrenia (“A Beautiful Mind”).

But none of these films topped the box office that month. That title went to “John Q.,” a movie about health insurance.

Or, more precisely, a story about a desperate father — played by Denzel Washington — who takes a hospital emergency room hostage at gunpoint when his HMO refuses to cover a heart transplant for his young son.

John Q.’s violent quest for justice was, of course, fictional. And even in the film, no one ends up dead.

Tragically, that wasn’t the case on the streets of New York City on Dec. 4 when a gunman fatally shot Brian Thompson, CEO of health insurance giant UnitedHealthcare.

But there was nothing new about the anger at health insurers that Thompson’s shooting unleashed online — and which suspect Luigi Mangione expressed in a document he allegedly wrote.

In fact, eruptions of public rage have shadowed the American health care system for decades.

In the late 1990s and early 2000s, as “John Q.” was hitting movie screens, Americans were revolting against HMOs, whose practice of denying care to plan members to pad their bottom lines made them public enemy No. 1.

Just a few years later, health insurers stoked new ire for rescinding coverage after people were diagnosed with expensive illnesses like cancer. More recently, insurers’ widening use of cumbersome prior authorization procedures that slow patients’ access to care has provoked yet another round of fury.

The cycle of outrage periodically turns on others in the health care industry as well. Exorbitant bills and aggressive collection tactics, such as garnishing patients’ wages, are sapping public trust in hospitals and other medical providers.

And drug companies — perennial poster children for greed and profiteering — have enraged Americans since at least the 1950s, when new “wonder drugs” like steroids were fueling a growing industry.

When Sen. Estes Kefauver, a Tennessee Democrat who had led an investigation of the Mafia, convened hearings in 1959 to probe high prescription prices, his committee received mountains of mail from Americans who reported being fleeced by drugmakers. One retired rail worker told of having to spend more than a third of his retirement income on medicines for himself and his wife.

All this public outcry has occasionally sparked change. President Barack Obama and congressional Democrats leveraged anger at spiking insurance premiums in California to get the Affordable Care Act over the finish line in 2010, a landmark achievement that expanded health coverage to millions of Americans.

But more often, cycles of rage have been so much sound and fury, producing only modest reforms. In some cases, public anger has yielded more headaches for patients.

The HMO backlash in the late 1990s and early 2000s, for example, prompted employers — from whom about half of Americans get their health coverage — to embrace high-deductible health plans. Many employers saw these plans as a way to hold down costs if they couldn’t limit patients’ choice of medical providers through HMOs. These deductibles, which can reach thousands of dollars a year, are driving tens of millions of Americans into debt.

To many on the left who have long argued for a single-payer, government-run health system, the obstacle to more meaningful relief has been the political power of the same industries — health insurers, drug companies, hospitals — that fuel patient anger.

These industries have indeed proven adept at resisting change that threatened their bottom lines. They’ve also benefited from a paradox in how Americans think about their health care.

Patients may get angry. They may even lose faith in the system. This year, public views of health care quality fell to the lowest point since Gallup began asking about it in 2001, with 44% of Americans rating quality as excellent or good, down from a high of 62%.

Yet more than 70% said their own health care is excellent or good.

There is much debate about what accounts for this paradox. Are Americans just grateful to have the health protections they do? Are they satisfied because most don’t have to use the health care system on a regular basis? Do they simply like their doctor, in the way that voters routinely say they like their own member of Congress but hate Washington politicians? Or do they worry that no matter how frustrating the current system can be, any change risks making the situation worse?

The answer is probably a bit of all of this. Together, such sentiments represent a major challenge for those who hope the current wave of anger at health insurers will drive big improvements.

Could that change? Maybe. These are volatile and unpredictable political times. And the pressure of big medical bills is real. Medical debt, in particular, is exacting a fearsome toll on millions of Americans, KFF Health News’ reporting has shown.

But to drive change, advocates looking to harness public anger at the health care industry probably need to rethink their favored solutions. Old ideas like “Medicare for All,” long cherished on the left, or a deregulated health care market, long championed by the right, haven’t swayed Americans so far, no matter how angry they’ve been.

I don’t know when we’ll see meaningful alternatives. One thing that’s almost certainly on the way: Hollywood’s spin on the death of a health insurance executive gunned down in Midtown Manhattan.

LOS ANGELES — President-elect Donald Trump’s promise of mass deportations and tougher immigration restrictions is deepening mistrust of the health care system among California’s immigrants and clouding the future for providers serving the state’s most impoverished residents.

At the same time, immigrants living illegally in Southern California told KFF Health News they thought the economy would improve and their incomes might increase under Trump, and for some that outweighed concerns about health care.

Community health workers say fear of deportation is already affecting participation in Medi-Cal, the state’s Medicaid program for low-income residents, which was expanded in phases to all immigrants regardless of residency status over the past several years. That could undercut the state’s progress in reducing the uninsured rate, which reached a record low of 6.4% last year.

Immigrants lacking legal residency have long worried that participation in government programs could make them targets, and Trump’s election has compounded those concerns, community advocates say.

The incoming Trump administration is also expected to target Medicaid with funding cuts and enrollment restrictions, which activists worry could threaten the Medi-Cal expansion and kneecap efforts to extend health insurance subsidies under Covered California to all immigrants.

“The fear alone has so many consequences to the health of our communities,” said Mar Velez, director of policy with the Latino Coalition for a Healthy California. “This is, as they say, not their first rodeo. They understand how the system works. I think this machine is going to be, unfortunately, a lot more harmful to our communities.”

Alongside such worries, though, is a strain of optimism that Trump might be a boon to the economy, according to interviews with immigrants in Los Angeles whom health care workers were soliciting to sign up for Medi-Cal.

Selvin, 39, who, like others interviewed for this article, asked to be identified by only his first name because he’s living here without legal permission, said that even though he believes Trump dislikes people like him, he thinks the new administration could help boost his hours at the food processing facility where he works packing noodles. “I do see how he could improve the economy. From that perspective, I think it’s good that he won.”

He became eligible for Medi-Cal this year but decided not to enroll, worrying it could jeopardize his chances of changing his immigration status.

“I’ve thought about it,” Selvin said, but “I feel like it could end up hurting me. I won’t deny that, obviously, I’d like to benefit — get my teeth fixed, a physical checkup.” But fear holds him back, he said, and he hasn’t seen a doctor in nine years.

It’s not Trump’s mass deportation plan in particular that’s scaring him off, though. “If I’m not committing any crimes or getting a DUI, I think I won’t get deported,” Selvin said.

Petrona, 55, came from El Salvador seeking asylum and enrolled in Medi-Cal last year.

She said that if her health insurance benefits were cut, she wouldn’t be able to afford her visits to the dentist.

A street food vendor, she hears often about Trump’s deportation plan, but she said it will be the criminals the new president pushes out. “I’ve heard people say he’s going to get rid of everyone who’s stealing.”

Although she’s afraid she could be deported, she’s also hopeful about Trump. “He says he’s going to give a lot of work to Hispanics because Latinos are the ones who work the hardest,” she said. “That’s good, more work for us, the ones who came here to work.”

Newly elected Republican Assembly member Jeff Gonzalez, who flipped a seat long held by Democrats in the Latino-heavy desert region in the southeastern part of the state, said his constituents were anxious to see a new economic direction.

“They’re just really kind of fed up with the status quo in California,” Gonzalez said. “People on the ground are saying, ‘I’m hopeful,’ because now we have a different perspective. We have a businessperson who is looking at the very things that we are looking at, which is the price of eggs, the price of gas, the safety.”

Gonzalez said he’s not going to comment about potential Medicaid cuts, because Trump has not made any official announcement. Unlike most in his party, Gonzalez said he supports the extension of health care services to all residents regardless of immigration status.

Health care providers said they are facing a twin challenge of hesitancy among those they are supposed to serve and the threat of major cuts to Medicaid, the federal program that provides over 60% of the funding for Medi-Cal.

Health providers and policy researchers say a loss in federal contributions could lead the state to roll back or downsize some programs, including the expansion to cover those without legal authorization.

California and Oregon are the only states that offer comprehensive health insurance to all income-eligible immigrants regardless of status. About 1.5 million people without authorization have enrolled in California, at a cost of over $6 billion a year to state taxpayers.

“Everyone wants to put these types of services on the chopping block, which is really unfair,” said state Sen. Lena Gonzalez, a Democrat and chair of the California Latino Legislative Caucus. “We will do everything we can to ensure that we prioritize this.”

Sen. Gonzalez said it will be challenging to expand programs such as Covered California, the state’s health insurance marketplace, for which immigrants lacking permanent legal status are not eligible. A big concern for immigrants and their advocates is that Trump could reinstate changes to the public charge policy, which can deny green cards or visas based on the use of government benefits.

“President Trump’s mass deportation plan will end the financial drain posed by illegal immigrants on our healthcare system, and ensure that our country can care for American citizens who rely on Medicaid, Medicare, and Social Security,” Trump spokesperson Karoline Leavitt said in a statement to KFF Health News.

During his first term, in 2019, Trump broadened the policy to include the use of Medicaid, as well as housing and nutrition subsidies. The Biden administration rescinded the change in 2021.

KFF, a health information nonprofit that includes KFF Health News, found immigrants use less health care than people born in the United States. And about 1 in 4 likely undocumented immigrant adults said they have avoided applying for assistance with health care, food, and housing because of immigration-related fears, according to a 2023 survey.

Another uncertainty is the fate of the Affordable Care Act, which was opened in November to immigrants who were brought to the U.S. as children and are protected by the Deferred Action Childhood Arrivals program. If DACA eligibility for the act’s plans, or even the act itself, were to be reversed under Trump, that would leave roughly 40,000 California DACA recipients, and about 100,000 nationwide, without access to subsidized health insurance.

On Dec. 9, a federal court in North Dakota issued an order blocking DACA recipients from accessing Affordable Care Act health plans in 19 states that had challenged the Biden administration’s rule.

Clinics and community health workers are encouraging people to continue enrolling in health benefits. But amid the push to spread the message, the chilling effects are already apparent up and down the state.

“¿Ya tiene Medi-Cal?” community health worker Yanet Martinez said, asking residents whether they had Medi-Cal as she walked down Pico Boulevard recently in a Los Angeles neighborhood with many Salvadorans.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!” she shouted, offering help to sign up, free of charge.

“Gracias, pero no,” said one young woman, responding with a no thanks. She shrugged her shoulders and averted her eyes under a cap that covered her from the late-morning sun.

Since Election Day, Martinez said, people have been more reluctant to hear her pitch for subsidized health insurance or cancer prevention screenings.

“They think I’m going to share their information to deport them,” she said. “They don’t want anything to do with it.”

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

LOS ÁNGELES, California.— La promesa del presidente electo Donald Trump de deportaciones masivas y restricciones migratorias más severas está aumentando la desconfianza en el sistema de salud entre los inmigrantes en California, y nublando el futuro de los proveedores que atienden a los residentes más empobrecidos del estado.

Al mismo tiempo, inmigrantes que viven en el sur de California sin papeles dijeron a KFF Health News que pensaban que la economía mejoraría y que sus ingresos podrían aumentar bajo Trump. Para algunos, esa esperanza supera a sus preocupaciones sobre la atención de salud.

Trabajadores comunitarios de salud dicen que el miedo a la deportación ya está afectando la participación en Medi-Cal, el programa de Medicaid del estado para residentes de bajos ingresos, que en los últimos años se ha estado expandiendo gradualmente a todos los inmigrantes, independientemente de su estatus migratorio. Esto podría socavar el progreso del estado en la reducción de la tasa de personas sin seguro, que alcanzó un mínimo histórico del 6.4% en 2023.

Los inmigrantes sin papeles han temido durante mucho tiempo que participar en programas gubernamentales los convierta en blanco fácil de las autoridades migratorias, y la elección de Trump ha exacerbado estas preocupaciones, según defensores comunitarios.

Se espera que Medicaid esté en la mira de la nueva administración Trump, con recortes de fondos y restricciones de inscripción, lo que preocupa a activistas, ya que podría amenazar la expansión de Medi-Cal y obstaculizar los esfuerzos para extender los subsidios que ayudan a pagar por los seguros de salud bajo Covered California a todos los inmigrantes.

“El miedo por sí solo tiene tantas consecuencias para la salud de nuestras comunidades”, dijo Mar Vélez, directora de políticas de la Latino Coalition for a Healthy California. “Como ellos dicen, esta no es su primera batalla. Entienden cómo funciona el sistema. Creo que esta maquinaria será, desafortunadamente, mucho más dañina para nuestras comunidades”.

A pesar de estas preocupaciones, también hay una corriente de optimismo de que Trump podría beneficiar a la economía, según entrevistas con inmigrantes en Los Ángeles mientras trabajadores de salud estaban invitándolos a inscribirse en Medi-Cal.

Selvin, de 39 años, quien, como otros entrevistados para este artículo, pidió ser identificado solo por su primer nombre porque no tiene papeles, dijo que aunque cree que a Trump no le gustan las personas como él, piensa que la nueva administración podría ayudar a aumentar sus horas en la planta procesadora de alimentos donde trabaja empacando fideos. “Sí veo cómo podría mejorar la economía. Desde esa perspectiva, creo que es bueno que haya ganado”.

Este año, Selvin se convirtió en elegible para Medi-Cal, pero decidió no inscribirse, preocupado de que pudiera poner en peligro sus posibilidades de cambiar su estatus migratorio.

“Lo he pensado”, dijo Selvin, pero “siento que podría terminar perjudicándome. No negaré que, obviamente, me gustaría beneficiarme: arreglarme los dientes, un chequeo físico”. Pero dijo que el miedo lo frena, y no ha visto a un médico en nueve años.

No es el plan de deportación masiva de Trump en particular lo que lo asusta, sin embargo. “Si no estoy cometiendo ningún crimen o manejando ebrio, creo que no me deportarán”, dijo Selvin.

Petrona, de 55 años, vino de El Salvador buscando asilo y se inscribió en Medi-Cal el año pasado.

Dijo que si se recortan sus beneficios de salud, no podría costear sus visitas al dentista.

Vendedora ambulante de comida, escucha a menudo sobre el plan de deportación de Trump, pero dijo que el nuevo presidente expulsará a los criminales. “He oído decir que va a deshacerse de todos los que están robando”.

Aunque teme que pudiera ser deportada, también tiene esperanza en Trump. “Dice que va a dar mucho trabajo a los hispanos porque los latinos son los que trabajan más duro”, dijo. “Eso es bueno, más trabajo para nosotros, los que vinimos aquí a trabajar”.

El recién electo asambleísta republicano Jeff Gonzalez, quien ganó un escaño históricamente demócrata en la región desértica del sureste del estado, con una gran población latina, dijo que sus electores estaban ansiosos por ver un nuevo rumbo económico.

“Están realmente cansados del statu quo en California”, dijo Gonzalez. “La gente en las calles está diciendo: ‘Tengo esperanza’, porque ahora tenemos una perspectiva diferente. Tenemos a un empresario que está viendo las mismas cosas que nosotros estamos viendo, como el precio de los huevos, el precio de la gasolina, la seguridad”.

Gonzalez dijo que no comentará sobre posibles recortes a Medicaid porque Trump no ha hecho ningún anuncio oficial. A diferencia de la mayoría en su partido, Gonzalez aseguró que apoya la extensión de servicios de salud a todos los residentes, independientemente de su estatus migratorio.

Los proveedores de salud dijeron que enfrentan un doble desafío: la reticencia de las personas a las que deben atender y la amenaza de recortes importantes a Medicaid, el programa federal que proporciona más del 60% del financiamiento para Medi-Cal.

Proveedores de salud e investigadores de políticas dicen que una pérdida en las contribuciones federales podría llevar al estado a reducir o eliminar algunos programas, incluida la expansión para cubrir a quienes no tienen documentos.

California y Oregon son los únicos estados que ofrecen un seguro de salud integral a todos los inmigrantes elegibles, independientemente de su estatus. En California, se han inscrito cerca de 1.5 millones de personas sin papeles, a un costo de más de $6.000 millones al año para los contribuyentes del estado.

“Todo el mundo quiere poner este tipo de servicios en la lista de recortes, lo cual es realmente injusto”, dijo la senadora estatal Lena Gonzalez, demócrata y presidenta del Caucus Legislativo Latino de California. “Haremos todo lo posible para asegurarnos de que esto se priorice”.

La senadora Gonzalez dijo que será un desafío expandir programas como Covered California, el mercado de seguros de salud del estado, para el cual los inmigrantes sin estatus legal no son elegibles. Una gran preocupación para los inmigrantes y sus defensores es que Trump podría restablecer los cambios a la política de carga pública, que habilita para negar tarjetas de residencia o visas basándose en el uso de ciertos beneficios gubernamentales.

“El plan de deportación masiva del presidente Trump pondrá fin al drenaje financiero que representan los inmigrantes ilegales para nuestro sistema de salud y garantizará que nuestro país pueda cuidar a los ciudadanos estadounidenses que dependen de Medicaid, Medicare y el Seguro Social”, dijo Karoline Leavitt, vocera de Trump, en un comunicado para KFF Health News.

Durante su primer mandato, en 2019, Trump amplió la política de carga pública para incluir el uso de Medicaid, así como subsidios de vivienda y para comprar alimentos. La administración Biden rescindió el cambio en 2021.

KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News, encontró que los inmigrantes usan menos servicios de salud que las personas nacidas en los Estados Unidos. Y aproximadamente 1 de cada 4 inmigrantes adultos probablemente indocumentados dijo que ha evitado solicitar asistencia para la atención de salud, alimentos y vivienda debido a temores relacionados con la inmigración, según una encuesta de 2023.

Otra incertidumbre es el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), que se expandió en noviembre a los inmigrantes traídos al país de niños y que están protegidos bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA). Si la elegibilidad de DACA, y la misma ley, fuera revertida bajo Trump, eso dejaría a aproximadamente 40.000 beneficiarios de DACA en California, y alrededor de 100.000 en todo el país, sin acceso a seguros de salud subsidiados.

El 9 de diciembre, un tribunal federal en Dakota del Norte emitió una orden bloqueando el acceso de los beneficiarios de DACA a estos planes de salud en 19 estados que habían impugnado la regla de la administración Biden.

Clínicas y trabajadores comunitarios de salud están alentando a las personas a seguir inscribiéndose para obtener beneficios de salud. Pero en medio del esfuerzo por difundir el mensaje, los efectos disuasorios ya son evidentes a lo largo y ancho del estado.

“¿Ya tiene Medi-Cal?”, preguntaba la trabajadora comunitaria Yanet Martínez a los residentes mientras caminaba por Pico Boulevard recientemente, en un vecindario de Los Ángeles con muchos salvadoreños.

“¡Nosotros podemos ayudarle a solicitar Medi-Cal! ¡Todo gratuito!”, gritaba, ofreciendo ayuda para inscribirse sin costo.

“Gracias, pero no”, respondió una joven, encogiéndose de hombros y evitando el contacto visual bajo una gorra que la cubría del sol dela  media mañana.

Martínez dijo que desde el día de las elecciones, la gente ha estado más reacia a escuchar lo que dice sobre seguros de salud subsidiados o exámenes preventivos de cáncer.

“Creen que voy a compartir su información para deportarlos”, dijo. “No quieren tener nada que ver con esto”.

When George Lai of Portland, Oregon, took his toddler son to a pediatrician last summer for a checkup, the doctor noticed a little splinter in the child’s palm. “He must have gotten it between the front door and the car,” Lai later recalled, and the child wasn’t complaining. The doctor grabbed a pair of forceps — aka tweezers — and pulled out the splinter in “a second,” Lai said. That brief tug was transformed into a surgical billing code: Current Procedural Terminology (CPT) code 10120, “incision and removal of a foreign body, subcutaneous” — at a cost of $414.

“This was ridiculous,” Lai said. “There was no scalpel.” He was so angry that he went back to the office to speak with the manager, who told him the coding was correct because tweezers could make an incision to open the skin.

When Helene Schilders of Seattle went to her dermatologist for her annual skin check this year, she mentioned her clothing was irritating a skin tag she had. The doctor froze the tag with liquid nitrogen. “It was squirt, squirt. That’s it,” Schilders told me. She was “floored” by an explanation of benefits that said the simple treatment had been billed as $469 for surgery.

Assuming the bill was a mistake, she called the doctor’s office and was told that surgery had indeed occurred — because the skin was broken in the process. Hence surgical CPT code 17110, “destruction of 1-14 benign lesions.”

Schilders complained to her insurer, who provided a document informing her that “surgery is classified as something entering the body, such as a Q-tip entering the ear canal or a scalpel during surgery.”

Huh? “I have had surgery, and this is not it,” Schilders said.

In common vernacular, “surgery” evokes images of physicians and nurses leaning over an operating table, gowned and masked, as they address a problem deep in the body. Removing an appendix or a tumor. Replacing a knee. Clipping a leaking aneurysm in the brain. It most probably involves a scalpel or specialized instruments and surgical skill.

More and more minor interventions, however, have been rebranded and billed as surgery, for profit. These tiny interventions don’t yield huge bills — in the hundreds rather than the thousands of dollars — but, cumulatively, they likely add up to tens if not hundreds of millions of dollars for doctors and hospitals annually. The surprise bills often catch patients off guard. And they must pay up if they haven’t met their insurance deductible. Even if they have, “surgery” generally requires a coinsurance payment, while an office visit doesn’t.

“There’s more pressure to make money, and the idea is you can charge more if it’s a surgical procedure,” said Sabrina Corlette, founder and co-director of Georgetown University’s Center on Health Insurance Reforms. “The payer should be reviewing this and saying this is run-of-the-mill. But there’s not a lot of incentive to do that.”

Corlette surmised that the codes employed in the instances mentioned above were intended for rare, complicated cases in which the removal of a splinter or a skin lesion — or 14 of them — required special skills or time. But the codes’ use has ballooned, covering the complicated and the commonplace. The use of code 17110 billed from doctors’ offices has gone up 62% from 2013 (1,739,708) to 2022 (2,817,190).

The blizzard of surgeries-in-name-only is a symptom of a system that has long valued procedures far more than intellectual work in its payments to medical providers. That merits rethinking, and there are some hints that the incoming presidential administration might be interested in doing so.

The current payment calculation system has its origins in the late 1980s, when a team led by an economist at Harvard University’s public health school, William Hsiao, created what’s called the Resource Based Relative Value Scale, or RBRVS, to rationalize Medicare’s payments to doctors. It allocated reimbursement using a formula that included physician work, practice expenses, and malpractice expenses. It concluded “that the work per unit time (a measure of intensity) for invasive services is about three times that of evaluation/management.”

In other words, it enshrined the notion that “invasive services” — procedures or surgery — were by far the most valuable.

An American Medical Association committee that includes physicians from an array of specialties periodically suggests updates to those codes (and federal regulators accept them, in many years, over 90% of the time). Since surgeons are overrepresented on the committee, the valuation of anything defined as an operation has only increased, giving billers the incentive to classify even the most mundane interventions as surgery.

Experts of all political stripes have spent years critiquing the process — it’s common sense that the fox (physicians) should not be guarding the henhouse (payments). President-elect Donald Trump’s pick for Health and Human Services secretary, Robert F. Kennedy Jr., has signaled that he might rethink that approach, according to the health-industry publication Stat. Kennedy has not outlined an actual plan to replace the current process, but he is reportedly exploring if the Centers for Medicare & Medicaid Services, a government agency, could do it instead.

Absent reform, on it goes.

Anthony Norton of Puyallup, Washington, took his 3-year-old daughter to a doctor this year because she had a bothersome plantar wart on her foot. The doctor applied a chemical ointment to the wart in the office every two weeks and covered it with a Band-Aid. When the child arrived for a third visit, Norton was informed he had an outstanding balance of $465 (in addition to the $25 office visit copay already paid) because the application was “surgery.” CPT code 17110 again.

“It made no sense,” Norton later recalled. The billing office assured him it was surgery, he said, “because the ointment penetrates the skin.”

Norton wondered: “When you extrapolate that, is putting on Neosporin or calamine surgery, too?”

We are now in an era in which a neurologist spending 40 minutes with a patient to tease out a diagnosis can be paid less for that time than a dermatologist spending a few seconds squirting a dollop of liquid nitrogen onto the skin.

Lai was so angry at being charged more than $400 to pull that splinter out of his child’s hand that he went on a crusade, returning to the dermatologist’s office when his calls were ignored, accusing it of fraud and threatening to complain to his insurer. Only then, he said, did the doctor’s office waive the surgical charge — and kick him and his family out of the practice.

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 Host

The shooting death of UnitedHealthcare CEO Brian Thompson on the streets of New York City prompted a surprising wave of sympathy for the perpetrator, rather than the victim, from Americans who say they have been wronged by their health insurers. It remains to be seen whether backlash from the killing will result in a more serious conversation about what ails the health care system.

Meanwhile, in some of his first extended interviews since the election, President-elect Donald Trump continued to be noncommittal about his plans for health care in general and the Affordable Care Act in particular.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Among the takeaways from this week’s episode:

• The killing of UnitedHealthcare’s chief executive has amplified simmering anger and distrust over the nation’s health care system. Many people are upset about the cost of care, limitations of coverage, gaps in access — and much more. While Democratic policymakers have pushed in recent years to insure as many Americans as possible, insurance coverage is only part of the equation in resolving the system’s ills.
• There’s not much time left for this Congress. Still on the agenda is passing funding for some health priorities. Extending telehealth access, for instance, is a small but key issue for which lawmakers will need to find money to offset the cost of an expensive program. And cultural issues continue to play a role, with the House passing a defense spending package this week that would cut coverage for gender-affirming care for minor dependents of those in the armed forces.
• And Trump’s recent interviews with NBC News’ “Meet the Press” and Time magazine offered little clarity on his health care plans. He referred to making changes to the ACA and not making changes to abortion pill availability — but it is clear that such issues are not among his top concerns and that policies will depend largely on the personnel within the health agencies.

Also this week, Rovner interviews Francis Collins, who was the director of the National Institutes of Health and a science adviser to President Joe Biden.

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

Julie Rovner: KFF’s “Medicare Spending was 27% More for People Who Disenrolled From Medicare Advantage Than for Similar People in Traditional Medicare,” by Jeannie Fuglesten Biniek, Alex Cottrill, Nolan Sroczynski, and Tricia Neuman. 

Alice Miranda Ollstein: CNN’s “Most Women in the US Aren’t Accessing Family Planning Services, Even as Abortion Restrictions Grow,” by Deidre McPhillips. 

Sandhya Raman: Stat’s “Spending Less, Living Longer: What the U.S. Can Learn From Portugal’s Innovative Health System,” by Usha Lee McFarling. 

Rachel Cohrs Zhang: ProPublica’s “‘Eat What You Kill,’” by J. David McSwane.

Also mentioned in this week’s podcast:

To hear all our podcasts, click here.

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Con el regreso de Donald Trump a la Casa Blanca, y el control total del Congreso por parte de los republicanos en 2025, la expansión de Medicaid promovida por la Ley de Cuidado de Salud a Bajo Precio (ACA) vuelve a estar en peligro.

Más de 3 millones de adultos en nueve estados estarían en riesgo inmediato de perder su cobertura de salud si el Partido Republicano reduce la financiación federal adicional para Medicaid que ha permitido a los estados ampliar la elegibilidad, según KFF y el Center for Children and Families de la Universidad de Georgetown. Esto se debe a que esos estados tienen leyes activadas que pondrían fin rápidamente a sus expansiones de Medicaid si disminuyen los fondos federales.

Los estados son Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, Carolina del Norte, Utah y Virginia.

Promulgada en 2010, ACA incentivó a los estados a ampliar los programas de Medicaid para cubrir a más estadounidenses de bajos ingresos que no recibían seguro médico a través de sus empleos. Cuarenta estados y el Distrito de Columbia pusieron en marcha la expansión, sumando desde 2014 a un estimado de 21 millones de personas y ayudando a reducir la tasa de personas sin seguro en el país a niveles récord.

A cambio, el gobierno federal cubre el 90% del costo para asegurar a la población ampliada. Esto es significativamente más alto que el porcentaje promedio de financiamiento federal para otros beneficiarios de Medicaid, que es de aproximadamente 57% a nivel nacional.

Los grupos de políticas conservadoras, que generalmente se han opuesto a ACA, afirman que el programa cuesta demasiado y cubre a demasiadas personas. Los demócratas, por su parte, sostienen que la expansión de Medicaid ha salvado vidas y beneficiado a las comunidades al ampliar la cobertura para personas que no podían pagar un seguro privado.

Si el Congreso reduce la financiación federal, la expansión de Medicaid estaría en riesgo en todos los estados que se han sumado al programa, incluso aquellos sin leyes de activación, ya que las legislaturas estatales tendrían que compensar la diferencia, dijo Renuka Tipirneni, profesora asociada en la Escuela de Salud Pública de la Universidad de Michigan.

Las decisiones de mantener o revertir la expansión “dependerían de la política a nivel estatal”, señaló Tipirneni.

Por ejemplo, Michigan aprobó una ley de activación como parte de su expansión de Medicaid en 2013, cuando el estado estaba bajo el control de un gobernador y una legislatura republicanas. El año pasado, con el gobierno controlado por los demócratas, el estado eliminó esa cláusula.

Seis de los nueve estados con leyes de activación —Arizona, Arkansas, Indiana, Montana, Carolina del Norte y Utah— apoyaron a Trump en las elecciones de 2024.

La mayoría de las leyes de activación de estos nueve estados se aplican si la financiación federal cae por debajo del umbral del 90%. La ley de activación de Arizona eliminaría la expansión si los fondos caen por debajo del 80%.

La ley de Montana revierte la expansión si la financiación federal cae por debajo del 90%, pero permite que continúe si los legisladores identifican fondos adicionales. Según la legislación estatal, los legisladores de Montana deben volver a autorizar la expansión de Medicaid en 2025 o esta finalizará.

En los estados con leyes de activación, entre 3.1 millones y 3.7 millones de personas perderían su cobertura rápidamente, según estimaciones de investigadores de KFF y el centro de Georgetown. La diferencia depende de cómo los estados traten a las personas que sumaron a Medicaid antes de la expansión de ACA; podrían seguir siendo elegibles incluso si la expansión termina.

Otros tres estados —Iowa, Idaho y Nuevo México— tienen leyes que exigen a sus gobiernos mitigar el impacto financiero de perder los fondos federales de expansión de Medicaid, pero no terminarían automáticamente las expansiones. Incluyendo esos tres estados, alrededor de 4.3 millones de inscritos bajo la expansión de Medicaid estarían en riesgo de perder su cobertura, según KFF.

ACA permitió la expansión de Medicaid para adultos con ingresos de hasta el 138% del nivel federal de pobreza, o aproximadamente $20,783 para un individuo en 2024.

Casi una cuarta parte de las 81 millones de personas inscritas en Medicaid a nivel nacional están en el programa gracias a las expansiones.

“Con una reducción en la tasa de financiamiento para la expansión, es probable que todos los estados necesiten evaluar si continúan con la cobertura ampliada, ya que requeriría un aumento significativo en el gasto estatal”, dijo Robin Rudowitz, vicepresidenta y directora del Program on Medicaid and the Uninsured en KFF. “Si los estados eliminan la cobertura, es probable que haya un aumento en el número de personas sin seguro, lo que limitaría el acceso a la atención en estados rojos y azules que han adoptado la expansión”.

Los estados rara vez reducen la elegibilidad para programas sociales como Medicaid una vez que se ha otorgado.

Las leyes de activación facilitan políticamente que los legisladores estatales terminen con la expansión de Medicaid porque no tendrían que tomar ninguna acción nueva para reducir la cobertura, dijo Edwin Park, profesor de investigación en el Center for Children and Families de la Universidad de Georgetown.

Para ver el impacto de las leyes de activación, hay que considerar lo que sucedió después que, en 2022, la Corte Suprema, anulara Roe vs. Wade y, con ello, el derecho constitucional al aborto. Los legisladores conservadores en 13 estados habían redactado leyes de activación que implementarían automáticamente prohibiciones si se eliminaba el derecho nacional al aborto. Esas leyes estatales resultaron en restricciones que entraron en vigencia inmediatamente después del fallo judicial o poco después.

Los estados adoptaron leyes de activación como parte de la expansión de Medicaid para convencer a los legisladores escépticos de comprometer fondos estatales para un programa federal que no es popular entre la mayoría de los republicanos.

No está claro qué harán Trump y los republicanos en el Congreso con Medicaid después que asuma el cargo en enero, pero un indicador podría ser una recomendación reciente del Paragon Health Institute, una destacada organización de políticas conservadoras liderada por Brian Blase, ex asesor de salud de Trump.

Paragon ha propuesto que, a partir de 2026, el gobierno federal reduzca gradualmente el financiamiento del 90% para la expansión hasta 2034, cuando alcanzaría la paridad con la tasa de financiamiento federal para los beneficiarios tradicionales de Medicaid en cada estado.

Bajo ese plan, los estados aún podrían recibir financiamiento para la expansión de Medicaid bajo ACA, pero restringirían la cobertura a inscritos con ingresos de hasta el nivel federal de pobreza. Actualmente, para recibir financiamiento de expansión, los estados deben ofrecer cobertura a todos con ingresos de hasta el 138% del nivel de pobreza.

Daniel Derksen, director del Center for Rural Health de la Universidad de Arizona, dijo que es poco probable que Arizona elimine su cláusula de activación y compense los fondos federales perdidos. “Sería difícil justificarlo en este momento, ya que supondría una gran presión para el presupuesto”, señaló.

Medicaid ha estado en la mira de los republicanos en Washington antes. En 2017, los líderes republicanos en el Congreso propusieron una legislación para recortar la financiación federal de la expansión, lo que habría trasladado miles de millones en costos a los estados. Ese plan, parte de una estrategia para derogar el Obamacare, finalmente fracasó.

A federal judge in North Dakota has ruled in favor of 19 states that challenged a Biden administration rule allowing — for the first time — enrollment in Affordable Care Act coverage by people brought to the U.S. as children without immigration paperwork, known as “Dreamers.”

The move effectively bars those who have qualified for the Deferred Action for Childhood Arrivals program in those 19 states from enrolling in or getting subsidies for ACA plans. It does not appear to affect enrollment or coverage in other states, lawyers following the case said Tuesday.

The Biden administration is likely to appeal, although a Centers for Medicare & Medicaid Services representative said in an email that the agency would not comment on the litigation.

While an appeal may be filed quickly, a final decision may not occur before the incoming Trump administration takes office. “They could take a different position on the litigation,” said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

In the meantime, it is not clear what will happen to Dreamer enrollees in the 19 states whose coverage has already started or begins early next year, although the judge’s ruling does not say it is retroactive, Baron noted.

The case was filed in August in U.S. District Court for the District of North Dakota.

Previously, the federal government estimated that about 100,000 uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, the sign-up season start date in all states except Idaho.

The Biden administration rule, finalized in May, clarified that those who qualify for DACA would be considered “lawfully present” for the purposes of enrolling in plans under the ACA, which are open to American citizens and what are called “lawfully present” immigrants.

In granting a preliminary injunction and stay, U.S District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, noted in his Monday ruling that the plaintiffs were likely to win on the merits of their argument.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. In addition to Kansas and North Dakota, the states that joined the lawsuit are Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia.

“Judge Traynor’s ruling is both disappointing and wrong on the law,” said Nicholas Espíritu, a deputy legal director of the National Immigration Law Center, in an emailed statement. “While we study the court’s ruling to evaluate the next steps in this case, we will continue to fight on behalf of our clients and hundreds of thousands of DACA recipients who have been waiting over a decade to access life-sustaining care under the Affordable Care Act.”

DACA was established through executive action in June 2012 by President Barack Obama, protecting from deportation and providing work authorization to some unauthorized residents brought to the U.S. as children by their families. It had certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were serving in the military.

Before the injunction, 19 other states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many in the East and West, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

Un juez federal en Dakota del Norte falló a favor de 19 estados que impugnaron una regla de la administración Biden que permite —por primera vez— que las personas traídas a Estados Unidos de niños, sin papeles, conocidas como Dreamers, se inscribieran para obtener cobertura de salud a través de los mercados establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

La decisión prohíbe a los beneficiarios del programa de Acción Diferida para los Llegados en la Infancia (DACA) en esos 19 estados inscribirse o recibir subsidios para pagar los planes de ACA.

Abogados que siguen el caso dijeron que este fallo no parece afectar la inscripción ni la cobertura en otros estados.

La administración Biden probablemente apelará, aunque un representante de los Centros de Servicios de Medicare y Medicaid (CMS,) la entidad federal que coordina estos mercados, dijo por correo electrónico que la agencia no comentará sobre el litigio.

Aunque se podría presentar una apelación rápidamente, una decisión final podría no ocurrir antes de que comience la próxima administración Trump. “Podrían tomar una posición diferente sobre el litigio”, dijo Zachary Baron, experto legal de Georgetown Law, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Mientras tanto, no está claro qué sucederá con los Dreamers inscritos en los 19 estados cuya cobertura ya comenzó o comienza a principios del próximo año, aunque la decisión del juez no menciona que sea retroactiva, señaló Baron.

El caso fue presentado en agosto en el Tribunal de Distrito de los EE.UU. para el Distrito de Dakota del Norte.

Anteriormente, el gobierno federal estimó que alrededor de 100.000 personas sin seguro, de medio millón de beneficiarios de DACA, podrían inscribirse a partir del 1 de noviembre, la fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

La regla de la administración Biden, finalizada en mayo, aclaró que quienes califican para DACA serían considerados como “presentes legalmente” en el país a los propósitos de inscripción en planes de salud de ACA, que están disponibles para ciudadanos estadounidenses e inmigrantes denominados “presentes legalmente”.

Al otorgar una orden judicial preliminar y una suspensión, el juez federal Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, señaló en su fallo del lunes 9 de diciembre que es probable que los demandantes ganaran gracias a los méritos de su argumento.

Los estados que impugnan la regla de ACA argumentan que causará cargas administrativas y de recursos al aumentar el número de inscritos y que alentará a más personas a permanecer en el país sin documentos legales.

Además de Kansas y Dakota del Norte, los estados que se unieron a la demanda son Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, Carolina del Sur, Dakota del Sur, Tennessee, Texas y Virginia.

“El fallo del juez Traynor es tanto decepcionante como erróneo en cuanto a la ley”, dijo Nicholas Espíritu, subdirector legal del Centro Nacional de Leyes de Inmigración, en un comunicado por correo electrónico.

“Mientras estudiamos la decisión del tribunal para evaluar los próximos pasos en este caso, continuaremos luchando en nombre de nuestros clientes y cientos de miles de beneficiarios de DACA que han esperado más de una década para acceder a atención vital bajo la Ley de Cuidado de Salud a Bajo Precio”.

DACA fue establecido mediante acción ejecutiva en junio de 2012 por el presidente Barack Obama, protegiendo de la deportación y proporcionando permiso de trabajo a algunos residentes no autorizados traídos al país de niños. Debían cumplir con ciertos requisites para calificar: haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o servir en el ejército.

Antes de la orden judicial, otros 19 estados y el Distrito de Columbia presentaron un informe en apoyo de la regla de la administración Biden. Liderados por Nueva Jersey, esos estados incluyen muchos en el Este y Oeste del país, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

ATLANTA — Deegant Adhvaryu completed his parents’ applications for Medicaid and food benefits in June. Then the waiting and frustration began.

In July, his parents, Haresh and Nina Adhvaryu, received a letter saying their applications would be delayed, he said. In August, the Adhvaryus started calling a Georgia helpline, he said, but couldn’t leave a message. It wasn’t until September, when they visited state offices, that they were informed their applications were incomplete.

The couple were mystified. They had Medicaid coverage when they lived in Virginia, before their recent move to metro Atlanta.

While they waited, Adhvaryu’s parents — ages 71 and 76 — delayed care, fearing they couldn’t afford it. They have Medicare, and, in Georgia, Medicaid pays for its premiums, copayments, and deductibles. The lack of extra coverage strained their fixed incomes.

“It was concerning,” Deegant Adhvaryu said, because his family lost a critical financial “lifeline.”

It took Adhvaryu’s parents until late October — more than 120 days after applying — to finally get their Medicaid cards in the mail. Federal rules require states to process most Medicaid applications within 45 days.

For years, Georgia’s public benefits system has been plagued by problems like the Adhvaryus’ — a glitchy website that’s often down for maintenance, a shortage of staff to process applications, and technology that malfunctions, according to consumer advocacy organizations, former state employees, and researchers.

But a KFF Health News analysis shows processing times have worsened since July 2023, when Georgia launched the nation’s only active Medicaid work requirement program, “Georgia Pathways to Coverage.” The program began three months after the state began redetermining the eligibility of all Medicaid enrollees following a covid-19 pandemic pause.

The percentage of Medicaid applicants waiting more than a month and a half to have their applications processed has nearly tripled in the first year of Pathways, the analysis of state and federal records found. Georgia had the slowest processing time in the country as of June, for income-based applications. Preliminary data from July puts the state as the second-slowest. The percentage of applications for financial and food assistance that take more than 30 days to process has also risen by at least 8 percentage points.

Pathways “is really bogging down” a system that was “already functioning relatively poorly,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute, a nonprofit research organization that supports full Medicaid expansion.

Georgia’s effort to run Pathways reveals the challenges that loom for states looking to launch Medicaid work requirements under a second Donald Trump presidency. His first administration approved them in more than a dozen states. On Nov. 5, South Dakota voters gave lawmakers the green light to seek a work requirement for its existing Medicaid expansion population.

Conservative lawmakers around the country would like to add work requirements to Medicaid, the state-federal insurance program for people with disabilities or low incomes, said Joan Alker, who leads Georgetown University’s Center for Children and Families. “If Georgia fails, that’s a big black eye for the Republican Party.”

Pathways is one of Republican Gov. Brian Kemp’s signature health policy initiatives and his alternative to fully expanding Medicaid eligibility under the Affordable Care Act. Applicants must document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage.

Consumer advocacy organizations, former state employees, and researchers say the initiative adds inefficiencies and bureaucracy that slow down other public programs, like the Supplemental Nutrition Assistance Program, or SNAP, and the Temporary Assistance for Needy Families program, or TANF.

As of Nov. 1, just 5,542 residents were participating in the work requirement program. Under a full Medicaid expansion program, nearly 300,000 Georgians would gain health coverage, according to the Robert Wood Johnson Foundation.

Georgia’s work requirement hasn’t been cheap to implement. An analysis by Chan’s think tank found about $13,360 in state and federal spending for each enrollee from January 2021 through June 2024, largely on administrative costs, not health benefits. That doesn’t account for the cost to prepare and submit the application for Pathways to the feds or the fees associated with legal fights over the program.

Officials in Georgia told KFF Health News that, as of June 30, Pathways had cost $40.6 million in state and federal funds.

Pathways also has increased the workload for state staffers who must manually verify complex eligibility requirements and monitor enrollees’ continued eligibility, according to consumer advocacy organizations, former state employees, and researchers.

The Kemp administration blames the processing slowdown of state benefits, in part, on what’s known as the Medicaid “unwinding,” which began in April 2023 as states had to redetermine the eligibility of all enrollees in the wake of the coronavirus pandemic.

“Georgia Pathways is an innovative, Georgia-specific program that has provided coverage to thousands of Georgians who otherwise would be without care,” said Garrison Douglas, a Kemp spokesperson.

Critics say the Pathways rollout stressed a system that’s had snags for years. In contrast, Chan pointed to North Carolina, which fully expanded Medicaid during the unwinding, covering more people for less than the cost per person of Pathways and without creating additional backlogs for other public benefits programs.

Waiting for benefits approval can have concrete consequences for people’s health and well-being, say doctors, researchers, and patient advocates.

Flavia Rossi, a pediatrician in Tifton, about 180 miles south of Atlanta, said some parents skip their kids’ checkups because they fear expensive out-of-pocket costs while waiting for Medicaid coverage for their children.

In October 2023, Ellenwood, Georgia, residents Gloria and William Felder, who have custody of a granddaughter, were told by the state that her Medicaid coverage had lapsed. William Felder said they reapplied three times but waited 11 months for her coverage to be restored, during which they spent over $1,500 on her care. “We wanted to make sure she had coverage,” he said.

After a health insurance navigator queried the state, Felder said, the state finally informed them in September that she had Medicaid again.

Georgia officials haven’t invested enough in the state agency that processes public benefits applications, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit policy advocacy organization. The problem is exacerbated by staffing shortages, high staff turnover, and outdated technology, she said.

In November 2023, the U.S. Department of Agriculture notified state officials that Georgia was “severely out of compliance” with timeliness standards for processing SNAP applications. A recent progress report details the scope of the issues: a system that incorrectly prioritizes applications, not enough staff to handle a backlog of nearly 52,000 new applications, and no system to promptly reassign applications when staff are off.

“These delays create real hardship, forcing families to make choices between paying for medicine, food, or rent while they wait for the support they’re entitled to,” Colbert said.

The state checked the eligibility of about 2.7 million residents when the pandemic-era Medicaid continuous coverage requirement ended. Nearly half a million Georgians lost coverage — including nearly 300,000 children, according to an analysis by Alker’s nonprofit.

Instead of investing more to ensure that people who were wrongly removed could reenroll, the state continues to pour money into the Pathways program, Alker said. She cited a recently launched $10.7 million ad campaign aimed at boosting Pathways enrollment with money from federal pandemic recovery funds.

The contract for that work was awarded to the consulting firm Deloitte, which has already received millions from Georgia to build and implement Pathways. It’s also responsible for the state’s Gateway technology system, which people use to access public benefits and Georgia officials have described as having ongoing problems, according to KFF Health News’ reporting.

Deloitte did not respond to a request for comment for this article. It previously told KFF Health News that it does not comment on state-specific issues.

In a November letter to KFF Health News, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand that large system implementations are challenging due to the complexity of the programs they support, and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Deegant Adhvaryu had to help keep his parents afloat as they waited months to get approved for Medicaid and SNAP. He bought them groceries and helped cover their rent. Not every applicant is that lucky.

“There are people in the state of Georgia with far less financial resources, far less family connections to be able to help them that need these services,” he said.

In 2017, the Republicans who controlled Congress tried mightily to slash federal spending on Medicaid, the government-funded health program covering low-income families and individuals.

California, like other states, depends heavily on federal dollars to provide care for its poorest residents. Analyses at the time showed the GOP’s proposals would cut Medicaid funds flowing from Washington by tens of billions of dollars, perhaps even more, forcing state officials to rethink the scope of Medi-Cal.

But the GOP efforts ended in failure — iconically crystallized by Arizona Republican Sen. John McCain, sick with terminal brain cancer, issuing his decisive early-morning thumbs-down.

More than seven years later, here we go again.

With Donald Trump preparing to reenter the White House, bolstered once more by Republican majorities in both houses of Congress, expectations are high that the GOP will quickly resurrect its long-desired goal of cutting Medicaid.

Republicans want to finance large tax cuts, and the GOP platform under Trump pledges not to touch Social Security or Medicare. To be sure, that’s not set in stone. But for now, as my KFF colleagues have noted, Medicaid looks an awful lot like low-hanging fruit. (KFF is a health information nonprofit that includes KFF Health News.)

Health officials in California and across the nation are on edge about the possibility of large-scale Medicaid cuts being enacted as soon as next year. Such cuts would have an outsize impact in the Golden State, whose 14.7 million Medi-Cal enrollees exceed the entire populations of all but three other U.S. states. Medi-Cal provides health coverage for over 40% of the state’s children and pays for nearly 40% of births. It is a crucial source of funding for safety net hospitals and community clinics.

And over 60% of its $161 billion budget this year comes by way of Washington.

The potential for big federal cuts to Medicaid may have been a factor in Democratic Gov. Gavin Newsom’s decision to call a special session of the state legislature this week.

California could seek to offset a sharp drop in federal dollars with higher taxes or cuts to other state programs. But both those options could be politically untenable. That’s why many health experts think leaders in Sacramento would almost certainly have to consider shrinking Medi-Cal.

That could mean cutting any number of optional benefits, such as dental services, optometry, and physical therapy. It might also mean rolling back some of the ambitious expansion Medi-Cal has undertaken in recent years. That could include some aspects of California Advancing and Innovating Medi-Cal, a $12 billion program of services that address patients’ social and economic needs in addition to their medical ones.

Some observers fear federal cuts could affect the approximately 1.5 million immigrants living in the U.S. without authorization who are enrolled in Medi-Cal at an annual cost of over $6 billion, nearly all of it funded by the state. But others say a more likely route would be to reduce payments across the board to the managed care plans that cover 94% of Medi-Cal enrollees, rather than target any specific groups of people.

“Medicaid is on the chopping block, and I don’t think that’s speculation,” says Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research. “It is widely viewed by potential members of Trump’s administration as a program that is too broad and needs to be brought under control.”

Whether they can succeed this time remains to be seen. But more on that later.

People who have followed previous GOP efforts to downsize Medicaid say a variety of previously attempted methods might be back on the table this time. They could include outright caps on federal Medicaid dollars; elimination of the core Affordable Care Act policy under which the feds pay 90% of the cost of expanding coverage to a wider swath of low-income adults; a work requirement, which could depress enrollment; and rule changes intended to make it harder for states to draw federal Medicaid dollars through the use of taxes on health care insurers known as MCOs.

The first Trump administration proposed but later dropped changes to the rules governing such taxes. If similar changes were adopted this time around, they could cause financial headaches in California, which has frequently used MCO taxes to offset Medi-Cal spending from state coffers.

Proposition 35, recently passed by California voters, could also be at risk. The initiative calls for the MCO tax to become a permanent fixture in 2027, pending federal approval, with the goal of financing billions of dollars in new Medi-Cal spending, primarily to increase funding for doctors and other providers. A federal rule change could upend those intentions.

Termination of the federal government’s 90% coverage of the ACA Medicaid expansion would put a gaping hole in the Medi-Cal budget. Medi-Cal spent over $34 billion in fiscal year 2023 covering the roughly 5 million people who enrolled as a result of the expansion, and nearly $31 billion of that amount was paid by the federal government.

If the feds’ share dropped back to its regular Medi-Cal rate of 50%, California would have to pony up nearly $14 billion more to keep the expansion enrollees covered — and that’s just for a year.

A more ambitious GOP push, including both spending caps and a rollback of federal support for the Medicaid expansion, could really send California officials scrambling.

In 2017, the state’s Department of Health Care Services issued an analysis showing that a legislative proposal filed by a group of Republican U.S. senators to cap Medicaid spending and end enhanced funding for the ACA expansion, along with some other cuts, would result in nearly $139 billion of lost federal funding to California from 2020 to 2027.

“There are almost limitless changes state leaders could make to Medi-Cal if they are forced to do that,” says David Kane, a senior attorney at the Western Center on Law & Poverty. “And we fear that burden will almost certainly hurt poor people and immigrants the most.”

But big Medicaid cuts are not a foregone conclusion. After all, when Trump was in the White House in 2017, Republicans also had House and Senate majorities and still did not achieve their goal. The political stars could be aligning differently this time, but the GOP has only a razor-thin majority in the House.

A decade into the ACA’s Medicaid expansion, some 21 million people across the country have coverage through it, embedding the program more deeply in the nation’s health care landscape. According to a 2023 study from Georgetown University, Medicaid and the related Children’s Health Insurance Program cover a higher proportion of the population in rural counties than in urban ones. And as we know, rural America leans strongly Republican.

Will GOP members of Congress, faced with a vote on cutting Medicaid, buck their own constituents?

Edwin Park, one of the authors of that Georgetown study, thinks there’s a chance big cuts can be averted. “Large numbers of Americans are either on Medicaid, have family members on Medicaid, or know somebody on Medicaid,” says Park, a research professor at Georgetown’s McCourt School of Public Policy. “Hopefully its popularity and its importance will win the day.”

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

With Donald Trump’s return to the White House and Republicans taking full control of Congress in 2025, the Affordable Care Act’s Medicaid expansion is back on the chopping block.

More than 3 million adults in nine states would be at immediate risk of losing their health coverage should the GOP reduce the extra federal Medicaid funding that’s enabled states to widen eligibility, according to KFF, a health information nonprofit that includes KFF Health News, and the Georgetown University Center for Children and Families. That’s because the states have trigger laws that would swiftly end their Medicaid expansions if federal funding falls.

The states are Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia.

The 2010 Affordable Care Act encouraged states to expand Medicaid programs to cover more low-income Americans who didn’t get health insurance through their jobs. Forty states and the District of Columbia agreed, extending health insurance since 2014 to an estimated 21 million people and helping drive the U.S. uninsured rate to record lows.

In exchange, the federal government pays 90% of the cost to cover the expanded population. That’s far higher than the federal match for other Medicaid beneficiaries, which averages about 57% nationwide.

Conservative policy groups, which generally have opposed the ACA, say the program costs too much and covers too many people. Democrats say the Medicaid expansion has saved lives and helped communities by widening coverage to people who could not afford private insurance.

If Congress cuts federal funding, Medicaid expansion would be at risk in all states that have opted into it — even those without trigger laws — because state legislatures would be forced to make up the difference, said Renuka Tipirneni, an associate professor at the University of Michigan’s School of Public Health.

Decisions to keep or roll back the expansion “would depend on the politics at the state level,” Tipirneni said.

For instance, Michigan approved a trigger as part of its Medicaid expansion in 2013, when it was controlled by a Republican governor and legislature. Last year, with the government controlled by Democrats, the state eliminated its funding trigger.

Six of the nine states with trigger laws — Arizona, Arkansas, Indiana, Montana, North Carolina, and Utah — went for Trump in the 2024 election.

Most of the nine states’ triggers kick in if federal funding falls below the 90% threshold. Arizona’s trigger would eliminate its expansion if funding falls below 80%.

Montana’s law rolls back expansion below 90% funding but allows it to continue if lawmakers identify additional funding. Under state law, Montana lawmakers must reauthorize its Medicaid expansion in 2025 or the expansion will end.

Across the states with triggers, between 3.1 million and 3.7 million people would swiftly lose their coverage, researchers at KFF and the Georgetown center estimate. The difference depends on how states treat people who were added to Medicaid before the ACA expansion; they may continue to qualify even if the expansion ends.

Three other states — Iowa, Idaho, and New Mexico— have laws that require their governments to mitigate the financial impact of losing federal Medicaid expansion funding but would not automatically end expansions. With those three states included, about 4.3 million Medicaid expansion enrollees would be at risk of losing coverage, according to KFF.

The ACA allowed Medicaid expansions to adults with incomes up to 138% of the federal poverty level, or about $20,783 for an individual in 2024.

Nearly a quarter of the 81 million people enrolled in Medicaid nationally are in the program due to expansions.

“With a reduction in the expansion match rate, it is likely that all states would need to evaluate whether to continue expansion coverage because it would require a significant increase in state spending,” said Robin Rudowitz, vice president and director of the Program on Medicaid and the Uninsured at KFF. “If states drop coverage, it is likely that there would be an increase in the number of uninsured, and that would limit access to care across red and blue states that have adopted expansion.”

States rarely cut eligibility for social programs such as Medicaid once it’s been granted.

The triggers make it politically easier for state lawmakers to end Medicaid expansion because they would not have to take any new action to cut coverage, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

To see the impact of trigger laws, consider what happened after the Supreme Court in 2022 struck down Roe v. Wade and, with it, the constitutional right to an abortion. Conservative lawmakers in 13 states had crafted trigger laws that would automatically implement bans in the event a national right to abortion were struck down. Those state laws resulted in restrictions taking effect immediately after the court ruling, or shortly thereafter.

States adopted triggers as part of Medicaid expansion to win over lawmakers skeptical of putting state dollars on the hook for a federal program unpopular with most Republicans.

It’s unclear what Trump and congressional Republicans will do with Medicaid after he takes office in January, but one indicator could be a recent recommendation from the Paragon Health Institute, a leading conservative policy organization led by former Trump health adviser Brian Blase.

Paragon has proposed that starting in 2026 the federal government would phase down the 90% federal match for expansion until 2034, when it would reach parity with each state’s federal match for its traditional enrollees. Under that plan, states could still get ACA Medicaid expansion funding but restrict coverage to enrollees with incomes up to the federal poverty level. Currently, to receive expansion funding, states must offer coverage to everyone up to 138% of the poverty level.

Daniel Derksen, director of the Center for Rural Health at the University of Arizona, said it’s unlikely Arizona would move to eliminate its trigger and make up for lost federal funds. “It would be a tough sell right now as it would put a big strain on the budget,” he said.

Medicaid has been in the crosshairs of Republicans in Washington before. Republican congressional leaders in 2017 proposed legislation to cut federal expansion funding, a move that would have shifted billions in costs to states. That plan, part of a strategy to repeal Obamacare, ultimately failed.

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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Ryan Wettstein Nauman was inconsolable one evening last December. After being put down for bed, the 3-year-old from Peoria, Illinois, just kept crying and crying and crying, and nothing would calm her down.

Her mother, Maggi Wettstein, remembered fearing it could be a yeast or urinary tract infection, something they had been dealing with during potty training. The urgent care centers around them were closed for the night, so around 10:30 p.m. she decided to take Ryan to the emergency room at Carle Health.

The Medical Procedure

The ER wasn’t very busy when they arrived at 10:48 p.m., Wettstein recalled. Medical records indicate they checked in and she explained Ryan’s symptoms, including an intermittent fever. The toddler was triaged and given a nasal swab test to check for covid-19 and influenza A and B.

Wettstein said they sat down and waited to be called. And they waited.

As Wettstein watched Ryan in the waiting room’s play area, she noticed her daughter had stopped crying.

In fact, she seemed fine.

So Wettstein decided to drive them home. Ryan had preschool the next day, and she figured there was no point keeping her awake for who knew how much longer and getting stuck with a big ER bill.

There was no one at the check-in desk to inform that they were leaving, Wettstein said, so they just headed home to go to bed.

Ryan went to her preschool the next day, and Wettstein said they forgot all about the ER trip for eight months.

Then the bill came.

The Final Bill

$445 for the combined covid and flu test — from an ER visit in which the patient never made it beyond the waiting room.

The Billing Problem: A Healthy Hospital Markup and Standard Insurance Rules

Even though Ryan and her mother left without seeing a doctor, the family ended up owing $298.15 after an insurance discount.

At first, Wettstein said, she couldn’t recall Ryan being tested at all. It wasn’t until she received the bill and requested her daughter’s medical records that she learned the results. (Ryan tested negative for covid and both types of flu.)

While Wettstein said the bill isn’t going to break the bank, it seemed high to her, considering Walgreens sells an at-home covid and flu combination test for $30 and can do higher-quality PCR testing for $145.

Under the public health emergency declared in 2020 for the covid pandemic, insurance companies were required to pay for covid tests without copayments or cost sharing for patients.

That requirement ended when the emergency declaration expired in May 2023. Now, it is often patients who foot the bill — and ER bills are notoriously high.

“That’s a pretty healthy markup the hospital is making on it,” Loren Adler, associate director of the Brookings Institution Center on Health Policy, told KFF Health News when contacted about Ryan’s case.

The rates the insurance companies negotiate with hospitals for various procedures are often based on multipliers of what Medicare pays, Adler said.

Lab tests are one of the few areas in which insurance companies can often pay less than Medicare, he said — the exception being when the test is performed by the hospital laboratory, which is often what happens during ER visits.

Medicare pays $142.63 for the joint test that Ryan received, but the family is on the hook for more than twice that amount, and the initial hospital charge was over three times as much.

The hospital is “utilizing their market power to make as much money as possible, and the insurance companies are not all that good at pushing back,” Adler said. A markup of a few hundred dollars is a drop in the bucket for big insurers. But for the patients who get unexpected bills, it can be a big burden.

Brittany Simon, a public relations manager for Carle Health, did not respond to specific questions but said in a statement, “We follow policies that support the safety and wellbeing of our patients, which includes the initial triage of symptomatic patients to the Emergency Department.”

While Ryan’s family would not have had to pay for a covid test during the public health emergency, it was the family’s insurer, Cigna, that did not have to pay this time, since the family had not yet met a $3,000 yearly deductible.

A Cigna representative did not respond to requests for comment.

The Resolution

Wettstein said she knew she could just pay the bill and be done with it, “but the fact that I never saw a provider, and the fact that it was just for a covid test, is mind-blowing to me.”

She contacted the hospital’s billing department to make sure the bill was correct. She explained what happened and said the hospital representative was also surprised by the size of the bill and sent it up for further review.

“‘Don’t pay this until you hear from me,’” Wettstein remembered being told.

Soon, though, she received a letter from the hospital explaining that the charge was correct and supported by documentation.

Wettstein thought she was avoiding any charges by taking Ryan home without being seen. Instead, she got a bill “that they have verified that I have to pay.”

“Like I said, it’s mind-blowing to me.”

The Takeaway

ERs are among the most expensive options for care in the nation’s health system, and the meter can start running as soon as you check in — even if you check out before receiving care.

If your issue isn’t life-threatening, consider an urgent care facility, which is often cheaper (and look for posted notices to confirm whether it’s actually an urgent care clinic). The urgent care centers near Ryan’s home were closed that evening, but some facilities stay open late or around the clock.

In some ways, Wettstein was lucky. KFF Health News’ “Bill of the Month” has received tips from other patients who left an ER after a long wait without seeing a doctor — and got slapped with a facility fee of over $1,000.

Making the decision about where to go is tough, especially in a stressful situation — such as when the patient is too young to communicate what’s wrong. Trying to figure out what’s going on physically with a 3-year-old can feel impossible.

If you decide to leave an ER without treatment, don’t just walk out. Tell the triage nurse you’re leaving. You might get lucky and avoid some charges.

Wettstein won’t think twice about taking Ryan to the pediatrician or an urgent care center the next time she’s ailing. But, Wettstein said, after getting this bill, “I’m not going to create a habit out of going to the emergency room.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

In mid-May, Mandi Rokx had a 3-month-old baby and a letter from a Florida agency warning that they both would be cut from Medicaid, the health insurance program for people with low incomes or disabilities.

Under a Florida law passed in 2021, Rokx was supposed to receive 12 months of continuous coverage after giving birth. But the letter from Florida’s Department of Children and Families said their coverage would end May 31.

The explanation: “You failed to complete or follow through with your Medicaid renewal.”

Rokx said she didn’t understand why the state was cutting coverage. She had provided everything it asked for, she said.

She worried about what losing Medicaid would mean for her daughter, Vernita. Initially after the coverage ended, Rokx said, she paid out-of-pocket for the infant’s checkups. She then turned to a free health fair put on once a month by a local nonprofit near her home in Melrose, Florida.

“I just hope she doesn’t get sick,” she said.

An unknown number of mothers in Florida have abruptly lost Medicaid coverage after giving birth, despite being eligible, according to an ongoing federal lawsuit filed against the state in August 2023. The issue is linked to the state’s computer eligibility system, run by Deloitte Consulting, according to trial testimony from state and Deloitte employees. It is yet one more example of problems states and beneficiaries have encountered with Medicaid management systems operated by Deloitte, a giant consulting firm.

As of July, Florida had awarded the global firm contracts valued at more than $100 million to modernize, operate, and maintain the state’s integrated eligibility system for Medicaid and other benefits.

Deloitte did not respond to requests for comment about its work in Florida.

In total, 25 states have awarded Deloitte eligibility system contracts, making the company the dominant player in this crucial slice of government business. These agreements, in which Deloitte commits to design, develop, or operate state-owned systems, are worth at least $6 billion, according to a KFF Health News analysis of state contracts.

The KFF investigation found that errors in Deloitte-run eligibility systems can cost millions and take years to fix while denying benefits like health insurance to eligible people.

In response to the investigation, Deloitte spokesperson Karen Walsh said the firm’s clients — state governments — “understand large system implementations are challenging due to the complexity of the programs they support and that all IT systems require ongoing maintenance, periodic enhancements and upgrades to software and hardware, and database management.”

Senate Democrat John Fetterman of Pennsylvania, which is one of Deloitte’s state clients, sees it much differently. “Let’s call this what it is: a racket,” he said. “This isn’t an occasional glitch. It’s a pattern of systemic failure. And the worst part? We’re paying them billions to do it.”

In July, Kimber Taylor of Jacksonville and Lily Mezquita of Orlando testified in a federal courtroom in Florida that state officials removed them from Medicaid even though their pregnancies made them eligible. The class-action lawsuit alleges that Florida did not adequately explain to people with Medicaid the reason for cutting their health insurance, or explain to them that they could appeal the decision before losing coverage.

Florida has denied the allegations in court filings. But the trial revealed problems with the computer system the state uses to determine Medicaid eligibility and inform people that they are no longer eligible. Deloitte did not respond to questions about the trial, in which a judge’s decision is pending.

Although Deloitte is not a named defendant in the lawsuit, an employee was called to testify about the firm’s role in operating Florida’s eligibility system. Harikumar Kallumkal, a Deloitte managing director who is responsible for Florida’s system, said that a “defect” may have led to coverage losses for new mothers.

William Roberts, a state worker who reviews Medicaid eligibility decisions, also testified that the agency learned about a “glitch” that cut postpartum coverage for eligible new mothers in April 2023 — the same month Florida launched a Medicaid eligibility review process known as “unwinding,” which all states undertook after pandemic-era coverage protections ended in March of that year. Kallumkal testified that Deloitte fixed the problem by April or May 2024.

And yet Rokx’s coverage was cut May 31.

During the unwinding, Florida disenrolled nearly 2 million people, including kids, from Medicaid, according to the Centers for Medicare & Medicaid Services.

Patient advocates say flaws in Florida’s Deloitte-operated computer system prevented some of the state’s most vulnerable residents from getting care they were entitled to receive.

“Florida’s Medicaid officials knew from the start of the unwinding period that their system was not handling pregnancy and postpartum Medicaid correctly, and proceeded full steam ahead anyway,” said Lynn Hearn, an attorney with the Florida Health Justice Project, a nonprofit legal aid and advocacy group that together with the National Health Law Program represents the class-action plaintiffs. “To this day, we don’t know that the problems have been fully corrected. The mothers of this state deserve better from their government.”

Medicaid is the largest insurance payer for childbirths in Florida, covering nearly 98,000, or 44%, of all deliveries in 2022, according to the state health department. But it’s unclear how many mothers have been cut from the Medicaid coverage they were entitled to receive. Florida’s Department of Children and Families on Sept. 9 cashed a check from KFF Health News to cover the processing fee for records it requested about eligible mothers who were disenrolled. As of Nov. 22, the state had not released the records.

The state did provide an estimate during the trial, but that number was not made available by the state to KFF Health News. In a court filing, the plaintiffs cited the state’s estimate as showing that 19,802 women were removed from pregnancy coverage as of March 2024, one year after Florida began unwinding. It’s unclear how many of these women lost coverage incorrectly. The figure is probably a conservative estimate — it excludes anyone who was removed from coverage because of paperwork issues.

Mallory McManus, deputy chief of staff for the Department of Children and Families, told KFF Health News that after identifying the problem, agency workers “manually corrected cases until necessary system updates were in place.” She added that the department also reviewed the system to “ensure there were no gaps in coverage.”

McManus said that Floridians who were disenrolled from Medicaid “were properly noticed and provided with information on requesting an appeal.”

Rokx, Taylor, and Mezquita ultimately regained their Medicaid coverage after seeking help from the Florida Health Justice Project. Attorneys there have said they are often able to get coverage restored for eligible people by reaching out directly to the state agency’s general counsel — an avenue not known to most Floridians.

While the class-action lawsuit awaits a judgment, the problems revealed at trial echo those encountered in other states with Deloitte-run Medicaid eligibility systems, such as Arkansas, Colorado, Florida, Georgia, Kentucky, Michigan, Pennsylvania, Rhode Island, Tennessee, and Texas.

In Texas, according to a July report by the U.S. Government Accountability Office, “about 100,000 eligible individuals had been disenrolled due to eligibility system errors,” including denial of postpartum coverage for some eligible women.

The error-plagued systems and widespread denials of Medicaid for eligible people have caught the attention of lawmakers on congressional committees that oversee social programs. They blame state leaders who they say aren’t holding vendors like Deloitte accountable.

“As the errors compound, contractors are rewarded with more billing hours and higher payouts,” said Rep. Lloyd Doggett (D-Texas). “This is an alarming and unacceptable waste of taxpayer dollars.”

Sen. Ron Wyden (D-Ore.), chairman of the Senate Finance Committee, which oversees Medicaid, said that too many people “can’t even get in through the front door due to outdated and inaccurate eligibility systems.”

And Rep. Kathy Castor (D-Fla.) said that “there’s such a pattern of trying to discourage and inappropriately cutting families off of Medicaid in Florida.”

“It appears to be intentional,” she said, “and I think it clearly is.”

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 current Affordable Care Act open enrollment season is the first big test of new federal guardrails against fraud.

The rules aim to head off unauthorized ACA plan enrollments or switches by rogue agents and entities looking to make money via enrollment commissions. Such sign-ups triggered more than 274,000 consumer complaints through August this year.

But some health insurance experts fear the new rules could slow consumer sign-ups and reduce the number who sign up for 2025 coverage. In most states, ACA open enrollment started Nov. 1 and extends through Jan. 15.

Regulators “really have this tightrope to walk,” said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University.

The Centers for Medicare and Medicaid Services, for example, now requires that certain policy adjustments — those in which the agent is not “affiliated” with the existing plan — have more restrictions, such as mandating a three-way call between the agent or broker, the consumer and healthcare.gov.

In August, CMS also barred two of about a dozen private sector online enrollment platforms from connecting with healthcare.gov. And it suspended 850 agents suspected of possibly being involved in these activities, although some were reinstated.

Federal regulators said in mid-October that casework associated with consumer complaints had fallen by almost a third in recent weeks.

Still, CMS’s actions inadvertently could slow the enrollment process.

Given that phone lines for healthcare.gov already get busy — especially in mid-December — Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers, said consumers should “hit the ground running.”

Meanwhile, reports are emerging that fraudsters are already figuring out workarounds for CMS’s antifraud protections, Nolan said.

For its part, CMS said it has “ramped up support operations” at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight. CMS officials expect “minimal wait times,” Wu added.

The problem of unauthorized switches is not new but took off during last year’s open enrollment.

Brokers generally blamed much of the problem on the ease with which agents could access ACA information in the federal marketplace. Though federal regulators have worked to tighten that access, they stopped short of instituting what Nolan and some other agents say is needed: two-factor authentication.

For consumers, unauthorized switches can cause a host of problems, from higher deductibles to new networks that do not include their physicians or hospitals, or even tax bills if those unauthorized policies came with premium credits for which they did not qualify.

But they also posed a political liability for the Biden administration, a blemish amid two years of record ACA enrollment. Democrats want more oversight and punishment of rogue agents, while Republicans say fraud was fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire at the end of 2025, will be decided by Congress next year.

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Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators. The Centers for Medicare & Medicaid Services, which oversees the ACA, credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.

Now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?

“They really have this tightrope to walk,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “The more you tighten it up to prevent fraud, the more barriers there are that could inhibit enrollment among those who need the coverage.”

CMS said in July that some types of policy changes — those in which the agent is not “affiliated” with the existing plan — will face more requirements, such as a three-way call with the consumer, broker, and a healthcare.gov call center representative.

In August, the agency barred two of about a dozen private sector online-enrollment platforms from connecting with healthcare.gov over concerns related to improper switching.

And CMS has suspended 850 agents suspected of being involved in unauthorized plan-switching from accessing the ACA marketplace.

Still, the clampdown could add complexity to enrollment and slow the process. For example, a consumer might have to wait in a queue for a three-way call, or scramble to find a new agent because the one they previously worked with had been suspended.

Given that phone lines with healthcare.gov staff already get busy — especially during mid-December — agents and policy analysts advise consumers not to dally this year.

“Hit the ground running,” said Ronnell Nolan, president and CEO of Health Agents for America, a professional organization for brokers.

Meanwhile, reports are emerging that some rogue entities are already figuring out workarounds that could undermine some of the anti-fraud protections CMS put in place, Nolan said.

“Bottom line is: Fraud and abuse is still happening,” Nolan said.

Brokers assist the majority of people actively enrolling in ACA plans and are paid a monthly commission by insurers for their efforts. Consumers can compare plans or enroll themselves online through federal or state marketplace websites. They can also seek help from people called assisters or navigators — certified helpers who are not paid commissions. Under a “find local help” button on the federal and state ACA websites, consumers can search for nearby brokers or navigators.

CMS says it has “ramped up support operations” at its healthcare.gov marketplace call centers, which are open 24/7, in anticipation of increased demand for three-way calls, and it expects “minimal wait times,” said Jeff Wu, deputy director for policy of the CMS Center for Consumer Information and Insurance Oversight.

Wu said those three-way calls are necessary only when an agent or a broker not already associated with a consumer’s enrollment wants to change that consumer’s enrollment or end that consumer’s coverage. It does not apply to people seeking coverage for the first time.

Organizations paid by the government to offer navigator services have a dedicated phone line to the federal marketplace, and callers are not currently experiencing long waits, said Xonjenese Jacobs, director of Florida Covering Kids & Families, a program based at the University of South Florida that coordinates enrollment across the state through its Covering Florida navigator program.

Navigators can assist with the three-way calls if a consumer’s situation requires it.

“Because we have our quick line in, there’s no increased wait time,” Jacobs said.

The problem of unauthorized switches has been around for a while but took off during last year’s open enrollment season.

Brokers generally blamed much of the problem on the ease with which rogue agents can access ACA information in the federal marketplace, needing only a person’s name, date of birth, and state of residence. Though federal regulators have worked to tighten that access with the three-way call requirement, they stopped short of instituting what some agent groups say is needed: two-factor authentication, which could involve a code accessed by a consumer through a smartphone.

Unauthorized switches can lead to a host of problems for consumers, from higher deductibles to landing in new networks that do not include their preferred physicians or hospitals. Some people have received tax bills when unauthorized policies came with premium credits for which they did not qualify.

Unauthorized switches posed a political liability for the Biden administration, a blemish on two years of record ACA enrollment. The practice drew criticism from lawmakers on both sides of the aisle; Democrats demanded more oversight and punishment of rogue agents, while Republicans said fraud attempts were fueled by Biden administration moves that allowed for more generous premium subsidies and special enrollment periods. The fate of those enhanced subsidies, which are set to expire, will be decided by Congress next year as the Trump administration takes power. But the premiums and subsidies that come with 2025 plans that people are enrolling in now will remain in effect for the entire year.

The actions taken this year to thwart the unauthorized enrollments apply to the federal marketplace, used by 31 states. The remaining states and the District of Columbia run their own websites, with many having in place additional layers of security.

For its part, CMS says its efforts are working, pointing to the 30% drop in complaint casework. The agency also noted a 90% drop in the number of times an agent’s name was replaced by another’s, which it says indicates that it is tougher for rival agents to steal clients to gain the monthly commissions that insurers pay.

Still, the move to suspend 850 agents has drawn pushback from agent groups that initially brought the problem to federal regulators’ attention. They say some of those accused were suspended before getting a chance to respond to the allegations.

“There will be a certain number of agents and brokers who are going to be suspended without due process,” said Nolan, with the health agents’ group. She said that it has called for increased protections against unauthorized switching and that two-factor authentication, like that used in some state marketplaces or in the financial sector, would be more effective than what’s been done.

“We now have to jump through so many hoops that I’m not sure we’re going to survive,” she said of agents in general. “They are just throwing things against the wall to see what sticks when they could just do two-factor.”

The agency did not respond to questions asking for details about how the 850 agents suspended since July were selected, the states where they were located, or how many had their suspensions reversed after supplying additional information.

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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Los cambios no autorizados en los planes médicos de la Ley de Cuidado de Salud a Bajo Precio (ACA) parecen haberse reducido en las últimas semanas: reguladores federales informaron que hay menos quejas de los consumidores.

Los Centros de Servicios de Medicare y Medicaid (CMS), que supervisan ACA, atribuyen esta reducción a las medidas adoptadas para prevenir problemas de inscripción y cambios de planes, que ya habían generado más de 274,000 quejas hasta agosto.

Ahora, el período anual de inscripción abierta de ACA, que comenzó el 1 de noviembre, plantea una prueba en el mundo real: ¿lograrán estos cambios frenar el fraude perpretado por agentes o corredores deshonestos sin ralentizar demasiado el proceso de inscripción o reducir el número total de inscripciones para la cobertura de 2025?

“Realmente tienen que caminar por una cuerda floja”, dijo Sabrina Corlette, codirectora del Centro de Reformas de Seguros de Salud de la Universidad de Georgetown. “Cuanto más se endurecen las medidas para prevenir el fraude, más barreras podrían existir que inhiban la inscripción de quienes necesitan la cobertura”.

En julio, los CMS anunciaron que ciertos tipos de cambios de póliza, particularmente aquellos en los que el agente no está “afiliado” al plan existente, enfrentarán requisitos adicionales, como una llamada tripartita con el consumidor, el corredor y un representante del centro de llamadas de cuidadodesalud.gov.

En agosto, la agencia prohibió a dos de unas doce plataformas privadas de inscripción en línea conectarse con cuidadodesalud.gov debido a preocupaciones relacionadas con cambios indebidos de planes. Además, los CMS suspendieron a 850 agentes sospechosos de participar en cambios no autorizados de planes dentro de los mercados de seguros de salud de ACA.

Sin embargo, estas medidas podrían agregar complejidad al proceso de inscripción y hacerlos más lento. Por ejemplo, un consumidor podría tener que esperar en “fila” para realizar una llamada tripartita o buscar un nuevo agente porque el anterior fue suspendido.

“Empiecen rápido”, recomendó Ronnell Nolan, presidenta y directora ejecutiva de Health Agents for America, una organización profesional de corredores de seguros.

Mientras tanto, algunos reportes sugieren que entidades deshonestas ya están encontrando formas de eludir las protecciones contra el fraude implementadas por CMS.

“La realidad es que el fraude y el abuso aún están ocurriendo”, dijo Nolan.

Los corredores ayudan a la mayoría de las personas que se inscriben activamente en planes de ACA y reciben una comisión mensual de las aseguradoras por sus esfuerzos.

Los consumidores pueden comparar planes o inscribirse ellos mismos en línea a través de los sitios web del mercado federal o estatal. También pueden buscar ayuda de asistentes, a veces llamadas navegadores, quienes están certificados pero no reciben comisiones.

Bajo “encuentren ayuda local” en el sitio federal y en los de los mercados estatales, los consumidores prueben encontrar a corredores o navegadores locales.

Los CMS afirman que han “ampliado las operaciones de apoyo” en sus centros de llamadas del mercado federal cuidadodesalud.gov, los cuales están abiertos las 24 horas del día, anticipando una mayor demanda de llamadas tripartitas.

Según Jeff Wu, subdirector de políticas del Centro de Información y Supervisión de Seguros para Consumidores de los CMS, se esperan “tiempos de espera mínimos”.

Wu aclaró que estas llamadas tripartitas solo son necesarias cuando un agente o corredor que no está asociado con la inscripción de un consumidor desea modificarla o finalizar su cobertura. No aplican para personas que buscan cobertura por primera vez.

Los navegadores, que cuentan con una línea telefónica directa al mercado federal, pueden asistir en estas llamadas tripartitas si es necesario.

El problema de los cambios no autorizados no es nuevo, pero se intensificó durante la temporada de inscripción abierta del año pasado.

Los corredores culpan en gran parte de este problema a la facilidad con la que agentes deshonestos pueden acceder a la información de ACA en el mercado federal, necesitando solo el nombre, la fecha de nacimiento y el estado en donde vive la persona. Aunque los reguladores han trabajado para limitar este acceso, no han implementado lo que algunos grupos de agentes consideran necesario: la autenticación en dos pasos, que podría requerir un código que los consumidores recibirían en su teléfono móvil.

Estos cambios no autorizados pueden causar una serie de problemas para los consumidores, desde deducibles más altos hasta la inclusión en redes que no incluyen a sus médicos o hospitales preferidos. Algunas personas han recibido facturas de impuestos cuando pólizas no autorizadas venían con créditos para pagar las primas para los cuales no calificaban.

Los cambios no autorizados plantearon una responsabilidad política para la administración Biden, una mancha en dos años de inscripciones récord en ACA.

La práctica generó críticas de legisladores de ambos partidos; los demócratas exigieron más supervisión y castigo a los agentes deshonestos, mientras que los republicanos dijeron que los intentos de fraude fueron alimentados por las medidas de la administración Biden que permitieron subsidios de primas más generosos y períodos de inscripción especiales.

El destino de esos subsidios mejorados, que expirarán, lo decidirá el Congreso el próximo año cuando la administración Trump tome el poder. Pero las primas y los subsidios que vienen con los planes 2025 en los que las personas se están inscribiendo ahora permanecerán vigentes durante todo el año.

Las medidas adoptadas este año para frustrar las inscripciones no autorizadas se aplican al mercado federal, utilizado por 31 estados. Los estados restantes y el Distrito de Columbia tienen sus propios sitios web, y muchos de ellos cuentan con capas de seguridad adicionales.

A pesar de la controversia, los CMS dicen que sus esfuerzos están funcionando, destacando una disminución del 30% en las quejas.

La agencia también informó una reducción del 90% en el número de veces que el nombre de un agente fue reemplazado por otro, lo que indica que ahora es más difícil para los agentes rivales robar clientes para obtener las comisiones mensuales.

No obstante, algunos grupos de agentes critican que algunos de los 850 agentes suspendidos no tuvieron oportunidad de responder a las acusaciones antes de ser sancionados. “Habrá agentes y corredores suspendidos sin un debido proceso”, dijo Nolan. Según estos grupos, implementar la autenticación en dos pasos sería más efectivo que las medidas actuales. “Estamos saltando tantos obstáculos que no estoy segura de que vayamos a sobrevivir”, concluyó Nolan.

Medicare officials are pushing back against a federal watchdog’s call to crack down on home visits by Medicare Advantage health plans — a practice the watchdog says may waste billions of tax dollars every year.

In late October, a Health and Human Services inspector general audit found that the insurers pocketed $7.5 billion in 2023 from diagnosing health conditions that prompted no medical services — about $4.2 billion of it through the health assessments done in patients’ homes.

Assistant Inspector General Erin Bliss told me the plans are raking in billions of dollars without providing any treatment for medical conditions the plans flagged during the visits, including serious diseases such as diabetes and major depression.

But the power to curb billing tied to home visits rests with regulators at the Centers for Medicare and Medicaid Services, who appear unmoved by the OIG’s criticism.

In a statement to KFF Health News by spokesperson Alexx Pons, CMS said it “appreciates the OIG’s review in this area” and will keep studying the issue.

In a formal response published in the audit report, CMS said it disagreed with the watchdog’s call to restrict use of home health assessments in computing how much to pay health plans. People on Medicare “should have access to care that is appropriately provided in the home setting,” CMS wrote.

That’s just fine with the insurance industry. The OIG drew “inaccurate conclusions,” said Heather Soule, a spokesperson for UnitedHealthcare. The insurer is the largest Medicare Advantage contractor and accounted for about two-thirds of the payments tied to home visits and related data mining of patient files cited in the audit.

The home visits are “among the most comprehensive and thorough assessments of a patient’s health and physical environment available in the health-care system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage,” Soule said in the statement.

Medicare Advantage plans serve more than 33 million Americans, more than half of the people eligible for Medicare.

Government spending on the program, which is dominated by a handful of private health insurance companies, is expected to hit $462 billion this year. The industry argues that most Medicare Advantage enrollees are satisfied with the care they receive and typically pay less out-of-pocket than those enrolled in original Medicare.

But critics of the program point to years and years of federal audits, whistleblower lawsuits and other investigations revealing that many health plans exaggerate how sick patients are to boost their payments.

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President-elect Donald Trump’s choice to run the sprawling government agency that administers Medicare, Medicaid, and the Affordable Care Act marketplace — celebrity doctor Mehmet Oz — recently held broad investments in health care, tech, and food companies that would pose significant conflicts of interest.

Oz’s holdings, some shared with family, included a stake in UnitedHealth Group worth as much as $600,000, as well as shares of pharmaceutical firms and tech companies with business in the health care sector, such as Amazon. Collectively, Oz’s investments total tens of millions of dollars, according to financial disclosures he filed during his failed 2022 run for a Pennsylvania U.S. Senate seat.

Trump said Tuesday he would nominate Oz as administrator of the Centers for Medicare & Medicaid Services. The agency’s scope is huge: CMS oversees coverage for more than 160 million Americans, nearly half the population. Medicare alone accounts for approximately $1 trillion in annual spending, with over 67 million enrollees.

UnitedHealth Group is one of the largest health care companies in the nation and arguably the most important business partner of CMS, through which it is the leading provider of commercial health plans available to Medicare beneficiaries.

UnitedHealth also offers managed-care plans under Medicaid, the joint state-federal program for low-income people, and sells plans on government-run marketplaces set up via the Affordable Care Act. Oz also had smaller stakes in CVS Health, which now includes the insurer Aetna, and in the insurer Cigna.

It’s not clear if Oz, a heart surgeon by training, still holds investments in health care companies, or if he would divest his shares or otherwise seek to mitigate conflicts of interest should he be confirmed by the Senate. Reached by phone on Wednesday, he said he was in a Zoom meeting and declined to comment. An assistant did not reply to an email message with detailed questions.

“It’s obvious that over the years he’s cultivated an interest in the pharmaceutical industry and the insurance industry,” said Peter Lurie, president of the Center for Science in the Public Interest, a watchdog group. “That raises a question of whether he can be trusted to act on behalf of the American people.” (The publisher of KFF Health News, David Rousseau, is on the CSPI board.)

Oz used his TikTok page on multiple occasions in November to praise Trump and Robert F. Kennedy Jr., including their efforts to take on the “illness-industrial complex,” and he slammed “so-called experts like the big medical societies” for dishing out what he called bad nutritional advice. Oz’s positions on health policy have been chameleonic; in 2010, he cut an ad urging Californians to sign up for insurance under President Barack Obama’s Affordable Care Act, telling viewers they had a “historic opportunity.”

Oz’s 2022 financial disclosures show that the television star invested a substantial part of his wealth in health care and food firms. Were he confirmed to run CMS, his job would involve interacting with giants of the industry that have contributed to his wealth.

Given the breadth of his investments, it would be difficult for Oz to recuse himself from matters affecting his assets, if he still holds them. “He could spend his time in a rocking chair” if that happened, Lurie said.

In the past, nominees for government positions with similar potential conflicts of interest have chosen to sell the assets or otherwise divest themselves. For instance, Treasury Secretary Janet Yellen and Attorney General Merrick Garland agreed to divest their holdings in relevant, publicly traded companies when they joined the Biden administration.

Trump, however, declined in his first term to relinquish control of his own companies and other assets while in office, and he isn’t expected to do so in his second term. He has not publicly indicated concern about his subordinates’ financial holdings.

CMS’ main job is to administer Medicare. About half of new enrollees now choose Medicare Advantage, in which commercial insurers provide their health coverage, instead of the traditional, government-run program, according to an analysis from KFF, a health information nonprofit that includes KFF Health News.

Proponents of Medicare Advantage say the private plans offer more compelling services than the government and better manage the costs of care. Critics note that Medicare Advantage plans have a long history of costing taxpayers more than the traditional program.

UnitedHealth, CVS, and Cigna are all substantial players in the Medicare Advantage market. It’s not always a good relationship with the government. The Department of Justice filed a 2017 complaint against UnitedHealth alleging the company used false information to inflate charges to the government. The case is ongoing.

Oz is an enthusiastic proponent of Medicare Advantage. In 2020, he proposed offering Medicare Advantage to all; during his Senate run, he offered a more general pledge to expand those plans. After Trump announced Oz’s nomination for CMS, Jeffrey Singer, a senior fellow at the libertarian-leaning Cato Institute, said he was “uncertain about Dr. Oz’s familiarity with health care financing and economics.”

Singer said Oz’s Medicare Advantage proposal could require large new taxes — perhaps a 20% payroll tax — to implement.

Oz has gotten a mixed reception from elsewhere in Washington. Pennsylvania Sen. John Fetterman, the Democrat who defeated Oz in 2022, signaled he’d potentially support his appointment to CMS. “If Dr. Oz is about protecting and preserving Medicare and Medicaid, I’m voting for the dude,” he said on the social platform X.

Oz’s investments in companies doing business with the federal government don’t end with big insurers. He and his family also hold hospital stocks, according to his 2022 disclosure, as well as a stake in Amazon worth as much as nearly $2.4 million. (Candidates for federal office are required to disclose a broad range of values for their holdings, not a specific figure.)

Amazon operates an internet pharmacy, and the company announced in June that its subscription service is available to Medicare enrollees. It also owns a primary care service, One Medical, that accepts Medicare and “select” Medicare Advantage plans.

Oz was also directly invested in several large pharmaceutical companies and, through investments in venture capital funds, indirectly invested in other biotech and vaccine firms. Big Pharma has been a frequent target of criticism and sometimes conspiracy theories from Trump and his allies. Kennedy, whom Trump has said he’ll nominate to be Health and Human Services secretary, is a longtime anti-vaccine activist.

During the Biden administration, Congress gave Medicare authority to negotiate with drug companies over their prices. CMS initially selected 10 drugs. Those drugs collectively accounted for $50.5 billion in spending between June 1, 2022, and May 31, 2023, under Medicare’s Part D prescription drug benefit.

At least four of those 10 medications are manufactured by companies in which Oz held stock, worth as much as about $50,000.

Oz may gain or lose financially from other Trump administration proposals.

For example, as of 2022, Oz held investments worth as much as $6 million in fertility treatment providers. To counter fears that politicians who oppose abortion would ban in vitro fertilization, Trump floated during his campaign making in vitro fertilization treatment free. It’s unclear whether the government would pay for the services.

In his TikTok videos from earlier in November, Oz echoed attacks on the food industry by Kennedy and other figures in his “Make America Healthy Again” movement. They blame processed foods and underregulation of the industry for the poor health of many Americans, concerns shared by many Democrats and more mainstream experts.

But in 2022, Oz owned stakes worth as much as $80,000 in Domino’s Pizza, Pepsi, and US Foods, as well as more substantial investments in other parts of the food chain, including cattle; Oz reported investments worth as much as $5.5 million in a farm and livestock, as well as a stake in a dairy-free milk startup. He was also indirectly invested in the restaurant chain Epic Burger.

One of his largest investments was in the Pennsylvania-based convenience store chain Wawa, which sells fast food and all manner of ultra-processed snacks. Oz and his wife reported a stake in the company, beloved by many Pennsylvanians, worth as much as $30 million.

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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In April, just 12 weeks into her pregnancy, Kathleen Clark was standing at the receptionist window of her OB-GYN’s office when she was asked to pay $960, the total the office estimated she would owe after she delivered.

Clark, 39, was shocked that she was asked to pay that amount during this second prenatal visit. Normally, patients receive the bill after insurance has paid its part, and for pregnant women that’s usually only when the pregnancy ends. It would be months before the office filed the claim with her health insurer.

Clark said she felt stuck. The Cleveland, Tennessee, obstetrics practice was affiliated with a birthing center where she wanted to deliver. Plus, she and her husband had been wanting to have a baby for a long time. And Clark was emotional, because just weeks earlier her mother had died.

“You’re standing there at the window, and there’s people all around, and you’re trying to be really nice,” recalled Clark, through tears. “So, I paid it.”

On online baby message boards and other social media forums, pregnant women say they are being asked by their providers to pay out-of-pocket fees earlier than expected. The practice is legal, but patient advocacy groups call it unethical. Medical providers argue that asking for payment up front ensures they get compensated for their services.

How frequently this happens is hard to track because it is considered a private transaction between the provider and the patient. Therefore, the payments are not recorded in insurance claims data and are not studied by researchers.

Patients, medical billing experts, and patient advocates say the billing practice causes unexpected anxiety at a time of already heightened stress and financial pressure. Estimates can sometimes be higher than what a patient might ultimately owe and force people to fight for refunds if they miscarry or the amount paid was higher than the final bill.

Up-front payments also create hurdles for women who may want to switch providers if they are unhappy with their care. In some cases, they may cause women to forgo prenatal care altogether, especially in places where few other maternity care options exist.

It’s “holding their treatment hostage,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation.

Medical billing and women’s health experts believe OB-GYN offices adopted the practice to manage the high cost of maternity care and the way it is billed for in the U.S.

When a pregnancy ends, OB-GYNs typically file a single insurance claim for routine prenatal care, labor, delivery, and, often, postpartum care. That practice of bundling all maternity care into one billing code began three decades ago, said Lisa Satterfield, senior director of health and payment policy at the American College of Obstetricians and Gynecologists. But such bundled billing has become outdated, she said.

Previously, pregnant patients had been subject to copayments for each prenatal visit, which might lead them to skip crucial appointments to save money. But the Affordable Care Act now requires all commercial insurers to fully cover certain prenatal services. Plus, it’s become more common for pregnant women to switch providers, or have different providers handle prenatal care, labor, and delivery — especially in rural areas where patient transfers are common.

Some providers say prepayments allow them to spread out one-time payments over the course of the pregnancy to ensure that they are compensated for the care they do provide, even if they don’t ultimately deliver the baby.

“You have people who, unfortunately, are not getting paid for the work that they do,” said Pamela Boatner, who works as a midwife in a Georgia hospital.

While she believes women should receive pregnancy care regardless of their ability to pay, she also understands that some providers want to make sure their bill isn’t ignored after the baby is delivered. New parents might be overloaded with hospital bills and the costs of caring for a new child, and they may lack income if a parent isn’t working, Boatner said.

In the U.S., having a baby can be expensive. People who obtain health insurance through large employers pay an average of nearly $3,000 out-of-pocket for pregnancy, childbirth, and postpartum care, according to the Peterson-KFF Health System Tracker. In addition, many people are opting for high-deductible health insurance plans, leaving them to shoulder a larger share of the costs. Of the 100 million U.S. people with health care debt, 12% attribute at least some of it to maternity care, according to a 2022 KFF poll.

Families need time to save money for the high costs of pregnancy, childbirth, and child care, especially if they lack paid maternity leave, said Joy Burkhard, CEO of the Policy Center for Maternal Mental Health, a Los Angeles-based policy think tank. Asking them to prepay “is another gut punch,” she said. “What if you don’t have the money? Do you put it on credit cards and hope your credit card goes through?”

Calculating the final costs of childbirth depends on multiple factors, such as the timing of the pregnancy, plan benefits, and health complications, said Erin Duffy, a health policy researcher at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The final bill for the patient is unclear until a health plan decides how much of the claim it will cover, she said.

But sometimes the option to wait for the insurer is taken away.

During Jamie Daw’s first pregnancy in 2020, her OB-GYN accepted her refusal to pay in advance because Daw wanted to see the final bill. But in 2023, during her second pregnancy, a private midwifery practice in New York told her that since she had a high-deductible plan, it was mandatory to pay $2,000 spread out with monthly payments.

Daw, a health policy researcher at Columbia University, delivered in September 2023 and got a refund check that November for $640 to cover the difference between the estimate and the final bill.

“I study health insurance,” she said. “But, as most of us know, it’s so complicated when you’re really living it.”

While the Affordable Care Act requires insurers to cover some prenatal services, it doesn’t prohibit providers from sending their final bill to patients early. It would be a challenge politically and practically for state and federal governments to attempt to regulate the timing of the payment request, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University. Medical lobbying groups are powerful and contracts between insurers and medical providers are proprietary.

Because of the legal gray area, Lacy Marshall, an insurance broker at Rapha Health and Life in Texas, advises clients to ask their insurer if they can refuse to prepay their deductible. Some insurance plans prohibit providers in their network from requiring payment up front.

If the insurer says they can refuse to pay up front, Marshall said, she tells clients to get established with a practice before declining to pay, so that the provider can’t refuse treatment.

Clark said she met her insurance deductible after paying for genetic testing, extra ultrasounds, and other services out of her health care flexible spending account. Then she called her OB-GYN’s office and asked for a refund.

“I got my spine back,” said Clark, who had previously worked at a health insurer and a medical office. She got an initial check for about half the $960 she originally paid.

In August, Clark was sent to the hospital after her blood pressure spiked. A high-risk pregnancy specialist — not her original OB-GYN practice — delivered her son, Peter, prematurely via emergency cesarean section at 30 weeks.

It was only after she resolved most of the bills from the delivery that she received the rest of her refund from the other OB-GYN practice.

This final check came in October, just days after Clark brought Peter home from the hospital, and after multiple calls to the office. She said it all added stress to an already stressful period.

“Why am I having to pay the price as a patient?” she said. “I’m just trying to have a baby.”

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Julie Rovner
KFF Health News

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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.

Come January, Republicans will control the House of Representatives, Senate, and White House, regaining full power for the first time since 2018. That will give them significant clout to dramatically change health policy. But slim margins in Congress will leave little room for dissent.

Meanwhile, President-elect Donald Trump has vowed not to touch Medicare, though there are Medicare-related issues — including drug price negotiations and physician pay — that will soon demand attention.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachel Roubein of The Washington Post, and Lauren Weber of The Washington Post.

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Anna Edney
Bloomberg

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Rachel Roubein
The Washington Post

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Lauren Weber
The Washington Post

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Read Lauren’s stories.

Among the takeaways from this week’s episode:

• Republicans will control the House and the Senate beginning next year, potentially offering Trump crucial votes in support of his nominees and agenda. However, the party will govern with only a narrow majority in both chambers, which could hamper its ability to make sweeping or controversial changes. Regardless, the GOP will steer legislative efforts, such as setting government spending levels and limits, and control committees that decide what to prioritize and oversee.
• Trump this week named several people he intends to nominate to his Cabinet. Yet many of his picks lack relevant experience or have staked out controversial policy positions — or both — raising the question: Can they clear the Senate confirmation process? Trump has suggested using recess appointments to get around that, a method that would largely bypass the Senate and limit his Cabinet secretaries’ authority.
• Meanwhile, among the issues on Robert F. Kennedy Jr.’s health agenda are some that resonate with Democrats, such as cracking down on ultra-processed foods and food dyes. Notably, those sorts of initiatives — which could tighten rules for businesses, for instance — have not been part of the traditional conservative playbook.
• And, looking ahead, there’s a lot the Trump administration could do to further erode abortion rights, and the GOP is likely to see this as a moment for trying things.

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’ “In Vermont, Where Almost Everyone Has Insurance, Many Can’t Find or Afford Care,” by Phil Galewitz.

Anna Edney: The Atlantic’s “Throw Out Your Black Plastic Spatula,” by Zoë Schlanger.

Rachel Roubein: Politico’s “‘Been a Long Time Since I Felt That Way’: Sexually Transmitted Infection Numbers Provide New Hope,” by Alice Miranda Ollstein.

Lauren Weber: JAMA Network Open’s “Medical Board Discipline of Physicians for Spreading Medical Misinformation,” by Richard S. Saver.

Also mentioned in this week’s podcast:

Credits

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Lonnie Ro
Audio producer

Emmarie Huetteman
Editor

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KFF Health News has sued the U.S. Department of Health and Human Services Office of Inspector General to compel it to release a range of Medicare Advantage health plan audits and other financial records.

The suit, filed Nov. 12 in U.S. District Court in San Francisco under the Freedom of Information Act, or FOIA, seeks documents from the HHS inspector general’s office, which acts as a watchdog over federal health insurance programs run by the Centers for Medicare & Medicaid Services.

The suit asks for correspondence and other records of contact between HHS officials or their representatives and Medicare Advantage organizations concerning overpayment audit findings and potential financial penalties.

It also seeks records reflecting communication between HHS and CMS officials regarding the government’s policies for recovering overpayments discovered during Medicare Advantage audits, including a controversial decision in January 2023 to limit dollar recoveries for audits dating back a decade or more.

Additionally, the suit seeks copies of government contracts awarded to outside firms that have conducted Medicare Advantage audits, including budgets and performance evaluations, dating to 2020. In these audits, reviewers take a sample of 200 patients from a health plan and determine whether medical records support the diagnoses the government paid health plans to treat.

KFF Health News requested the records in August, but, more than two months later, “no documents, responsive or otherwise, have been produced,” the suit says.

Sam Cate-Gumpert, an attorney with Davis Wright Tremaine, which is representing KFF Health News pro bono in the case, said the information is “critically important to public oversight of government misspending.”

According to the suit, the inspector general’s office has audited the Medicare Advantage program more than three dozen times since 2019, revealing billions of dollars in overpayments.

But government officials have not recouped the overcharges, according to the suit.

The HHS Office of Inspector General “has left taxpayers footing the bill for billions of dollars in overpayments — even though HHS OIG’s primary purpose is to combat fraud and waste in Medicare and other federally funded health programs,” the suit alleges.

“In fact, taxpayers have been forced to pay for the Medicare Advantage program’s wasteful spending twice — first, because of the program itself, and second, because of the costs of the audits, which the government spends millions of dollars to conduct,” according to the suit.

Medicare Advantage, mostly run by private insurance companies, has enrolled more than 33 million seniors and people with disabilities, more than half of people on Medicare.

But the program has faced criticism that it costs billions of dollars more than it should with research showing that many health plans exaggerate how sick patients are to boost payments.

A FOIA lawsuit filed by KFF Health News in September 2019 prompted CMS to release summaries of 90 Medicare Advantage audits revealing millions of dollars in overpayments. As part of a settlement, CMS paid $63,000 in KFF Health News’ legal fees, though it did not admit to wrongfully withholding the records.

The HHS Office of Inspector General had no immediate comment on the suit.

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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Este año, California ha dado el último paso para abrir el Medi-Cal, su programa de Medicaid, a todos los residentes que reúnan los requisitos, independientemente de su estatus migratorio.

Es una expansión significativa para un programa de protección social que ya de por sí es masivo.

El gasto anual de Medi-Cal asciende actualmente a  $157.000 millones, con los que atiende a unos 15 millones de residentes de bajos ingresos, más de un tercio de los californianos.

De ellos, aproximadamente 1.5 millones son inmigrantes que viven en Estados Unidos sin papeles, y su acceso a servicios de atención médica representa un costo estimado de $6.4 mil millones, según el Departamento de Servicios de Atención Médica.

Estos inmigrantes se han ido sumando al programa poco a poco, a medida que el estado fue eliminando el requisito de residencia legal. Primero, en 2016, se incluyó a los niños. En 2020, a los jóvenes de 19 a 25 años. En 2022, a las personas de 50 años o más. Finalmente, desde enero, a todos los adultos restantes.

Los defensores de los inmigrantes aplauden el aumento de personas inscriptas en el seguro público de California y elogian al estado por haber ampliado Medi-Cal y logrado que la tasa de personas sin cobertura médica bajara a un mínimo histórico de 6.4%.

Sin embargo, los proveedores de servicios de salud y los hospitales advierten que el estado no ha ampliado adecuadamente el número de profesionales ni ha aumentado lo suficiente los pagos de Medi-Cal. Por esta situación, algunos afiliados tienen problemas para encontrar prestadores de salud que los atiendan en plazos adecuados o directamente se quedan sin ninguna atención médica.

“La cobertura no significa necesariamente acceso”, afirmó Isabel Becerra, consejera delegada y presidenta de la Coalición de Centros de Salud Comunitarios del Condado de Orange, durante una cumbre sobre política sanitaria, el 2 de octubre en Los Ángeles. “Existe una escasez de profesionales de salud. Todos estamos luchando por recibir atención médica. Estamos compitiendo entre nosotros para conseguir que los médicos nos atiendan”.

Aunque el estado ha aumentado un 87,5% los pagos de Medi-Cal para la atención primaria, de maternidad y servicios de salud mental respecto de lo que paga Medicare, el seguro privado todavía tiende a pagar más, según la California Legislative Analyst’s Office.

Una iniciativa electoral presentada hace poco podría garantizar que los ingresos procedentes de un impuesto sobre los planes de salud gestionados se destinen a aumentar el pago a los proveedores de asistencia sanitaria que tratan a los pacientes de Medi-Cal.

Pero algunos creen que el próximo capítulo para dar cobertura a los inmigrantes requerirá algo más que Medi-Cal.

En 2022, Joaquín Arámbula, miembro de la Asamblea estatal por el Partido Demócrata, presentó un proyecto de ley en este sentido. Proponía que los aproximadamente 520.000 residentes indocumentados sin seguro que ganaran más del 138% del nivel federal de pobreza pudieran solicitar cobertura sanitaria subvencionada por el estado a través de Covered California, el mercado de seguros de salud estatal. Sin embargo, el proyecto de ley no avanzó en el comité este año.

La nueva entrega de la serie “Faces de Medi-Cal” muestra cómo Medi-Cal ha impactado en la vida de sus nuevos afiliados.

Entre ellos, Vanessa López Zamora, que por fin está recibiendo tratamiento para su hepatitis y cirrosis, pero tiene problemas para ver a un gastroenterólogo cerca de su casa; Douglas López, un trabajador de un parque de atracciones que atribuye la cobertura dental a la mejora de su bienestar; y Daniel García, que sufre de gota, pero ha renunciado a la búsqueda de un proveedor de atención primaria.

Todos ellos hablaron con KFF Health News luego de comenzar a ser beneficiarios de Medi-Cal.

“Empecé a sentirme mal hace mucho tiempo”

En marzo, el estómago de Vanessa López Zamora se había hinchado tanto que parecía que estaba embarazada. Había estado dolorida y vomitando durante días.

López Zamora contó que fue al servicio de urgencias de su localidad, el Kaweah Health Medical Center, pero no había ningún especialista disponible. Así que la mujer, de 31 años, fue trasladada en ambulancia a Adventist Health Bakersfield, a unas 80 millas de su casa en Visalia.

Contó que allí, los médicos le diagnosticaron hepatitis A y C y cirrosis, y le explicaron que eso le había causado lesiones internas en el hígado y el esófago.

Vanessa pasó cuatro días en el hospital y, para recibir tratamiento adicional, la remitieron a un gastroenterólogo, al que puede ir como nueva beneficiaria de Medi-Cal. Esta es una opción que no podía permitirse en el pasado, cuando tenía dolores de estómago y náuseas.

“Ha sido un proceso muy largo porque empecé a sentirme mal hace mucho tiempo”, dijo López Zamora, que trabaja como contable en una emisora de radio local de Visalia, en el valle de San Joaquín. “Mis hijas son muy pequeñas, y si no consigo el tratamiento necesario, no sabré cuánto tiempo me queda”, se lamentó.

López Zamora, que llegó a California desde Ciudad de México cuando tenía 8 años, está agradecida por la atención que recibió inicialmente.

Pero también está frustrada.

El gastroenterólogo al que la derivó el hospital está en Bakersfield y para Zamora es difícil ir: no conduce, y no puede viajar a otra ciudad.

El acceso limitado a especialistas —desde gastroenterólogos hasta cardiólogos— ha sido durante mucho tiempo un desafío para muchos pacientes de Medi-Cal, especialmente los que viven en zonas rurales o en regiones donde hay escasez de proveedores de salud.

El Valle de San Joaquín, donde vive López Zamora, tiene la menor oferta de especialistas del estado, según la California Health Care Foundation.

Michael Bowman, vocero Anthem Blue Cross, el plan de Medi-Cal de López Zamora, dijo en un correo electrónico que Anthem tiene una amplia red de especialistas que atienden a los beneficiarios de Medi-Cal, incluyendo más de 100 gastroenterólogos en un radio de 20 millas alrededor de Visalia.

López Zamora está tratando su cirrosis con medicamentos y dieta, pero en agosto su gastroenterólogo de Bakerfield descubrió signos de una condición precancerosa en el estómago.

Ella dijo que está buscando un especialista que atienda más cerca de su casa. Por ahora, su madre debe tomarse el día en el trabajo para llevarla a las citas médicas. Si no, toma el autobús.

López Zamora intentó utilizar el transporte proporcionado por Medi-Cal, pero se quedó varada en el hospital. Y ha tenido que cambiar dos veces de cita.

“Me llevaron, pero no me pudieron traer de vuelta porque no encontraban un Uber”, explicó.

Un proceso muy sencillo

Medi-Cal proporcionó a Douglas López el tratamiento dental que no podía costear.

En 2022, este hombre de 33 años ganaba el salario mínimo como trabajador de limpieza en un parque de atracciones. El plan de emergencia de Medi-Cal en el que se había anotado sólo cubría extracciones de urgencia.

Ese año, López experimentó un dolor agudo en las muelas de atrás cuando comía sus queridas bolitas de caramelo de coco y tamarindo de su Guatemala natal.

Un dentista le dijo que necesitaba varias obturaciones y tres endodoncias. Empezó el tratamiento, pero las facturas se fueron encareciendo: $150 la primera sesión, luego $200 y después $300.

“No podía permitírmelo”, recordó López, que vive en Fullerton. “Tenía que pagar el alquiler y la comida”.

Preocupado por perder los dientes, dejó de comer cualquier cosa que le causara dolor.

En enero, cuando el estado amplió la elegibilidad para el seguro a los residentes sin papeles de entre 26 y 49 años, el condado de Orange inscribió automáticamente a López en el plan Medi-Cal de Molina Healthcare. La cobertura transformó su atención, dijo.

Desde entonces, ya vio a un dentista seis veces. Le hicieron una limpieza, tres endodoncias, dos obturaciones y radiografías. Y Medi-Cal ha pagado la factura.

La experiencia de López contrasta con la de muchos otros beneficiarios, que luchan por obtener la atención que necesitan. El Centro de Investigación de Políticas de Salud de UCLA descubrió que el 21% de los dentistas de California vieron pacientes de Medi-Cal de todas las edades, según datos de 2019 a 2021.

Sin embargo, a menudo esos dentistas limitan el número de pacientes de Medi-Cal que reciben; entonces, solo el 15% de los adultos inscritos podrían recibir atención dental en un año determinado.

A López Medi-Cal lo ha ayudado. “Fue un proceso muy sencillo. Estaba muy emocionado porque podía buscar un dentista”, dijo. “Y mi miedo a perder los dientes por no recibir tratamiento desapareció”.

“Algo que ni siquiera puedes usar”

El año pasado, el dolor punzante en el brazo y en el pie que sufría Daniel García se agravó tanto que el hombre de 39 años fue una sala de emergencias.

García padece gota, un tipo de artritis inflamatoria que puede causarle un intenso dolor e hinchazón en las articulaciones. Cuando este año pudo tener la cobertura de Medi-Cal, pensó que por fin podría ir al médico para recibir tratamiento.

Pero el residente del condado de Los Ángeles dijo que no ha sido capaz de encontrar un proveedor de atención primaria que acepte tomar su seguro de Molina Healthcare.

“Es frustrante porque tienes algo que ni siquiera puedes usar”, dijo García, quien tampoco ha podido hacerse un examen físico anual. “He llamado y me dicen que no aceptan mi seguro”.

Molina declinó hacer comentarios sobre el caso de García y no respondió a preguntas sobre su red de atención primaria.

En California, casi 6 millones de personas viven en un total de 611 áreas donde escasea la atención primaria, según un análisis de KFF, que descubrió que el estado necesitaría sumar 881 profesionales para cerrar esta brecha.

García, trabajador de la construcción, dijo que leyó que podía controlar su artritis cambiando sus hábitos alimentarios. Ahora come más sano y ha reducido el consumo de azúcar y de Coca-Cola. En cuanto al dolor, lo alivia con ibuprofeno. Ha renunciado a buscar un proveedor de salud.

Mantener a los pacientes fuera de las salas de emergencias, que pueden ser hasta 12 veces más costosas que la atención primaria, es uno de los argumentos a favor de la expansión de Medi-Cal.

Estudios han demostrado que ampliar la cobertura de salud no solo reduce la cantidad de visitas a emergencias, sino que también aumenta el uso de atención preventiva por parte de los pacientes, según Drishti Pillai, directora de políticas de salud para inmigrantes en KFF.

 “Esto puede ayudar a ahorrar costos de salud, porque no se deja las enfermedades sin atención durante mucho tiempo, lo que podría hacer que su tratamiento se vuelva más complejo y costoso”, explicó Pillai.

Esta historia fue producida por Kaiser Health News, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

California this year took the final step in opening Medi-Cal, its Medicaid program, to every eligible resident regardless of immigration status. It’s a significant expansion for an already massive safety net program.

Medi-Cal’s annual spending now stands at $157 billion, serving about 15 million low-income residents, more than a third of Californians. Of those, about 1.5 million are immigrants living in the U.S. without authorization, costing an estimated $6.4 billion, according to the Department of Health Care Services. They have been gradually added to the program as the state lifted legal residency as an eligibility requirement for children in 2016, young adults ages 19-25 in 2020, people 50 and older in 2022, and all remaining adults in January.

As California’s public insurance roll swells, advocates for immigrants praise the Golden State for an expansion that has helped reduce the uninsured rate to a record low 6.4%. Providers and hospitals, however, caution that the state hasn’t expanded its workforce adequately or increased Medi-Cal payments sufficiently, leaving some enrollees unable to find providers to see them in a timely manner — if at all.

“Coverage does not necessarily mean access,” said Isabel Becerra, CEO and president of the Coalition of Orange County Community Health Centers, during an Oct. 2 health policy summit in Los Angeles. “There’s a workforce shortage. We’re all fighting for those doctors. We’re fighting with each other for those doctors.”

Though the state has raised Medi-Cal payments for primary care, maternity care, and mental health services to 87.5% of what Medicare pays, private insurance still tends to pay more, according to the California Legislative Analyst’s Office.

A ballot initiative approved this month guarantees that revenue from a tax on managed-care plans goes toward raising the pay of health care providers who serve Medi-Cal patients.

Some believe the next chapter for covering immigrants will require more than Medi-Cal.

Democratic state Assembly member Joaquin Arambula in 2022 proposed legislation to allow the approximately 520,000 uninsured unauthorized residents who earn more than 138% of the federal poverty level to apply for state-subsidized health coverage through Covered California, the state’s health exchange. The bill, however, died in committee this year.

The final installment of the “Faces of Medi-Cal” series looks at how Medi-Cal has affected its newest enrollees. They include Vanessa López Zamora, who is finally getting treated for hepatitis and cirrhosis but has trouble seeing a gastroenterologist close to home; Douglas Lopez, an entertainment park worker who credits dental coverage for boosting his well-being; and Daniel Garcia, who suffers from gout but has given up his search for a primary care provider. All spoke to KFF Health News in Spanish after recently becoming eligible for Medi-Cal.

‘Started Feeling Sick a Long Time Ago’

In March, Vanessa López Zamora’s stomach had swollen so much it looked like she was pregnant. She had been vomiting and in pain for days.

She went to her local emergency room, at Kaweah Health Medical Center, but it didn’t have a specialist available, she said. So, the 31-year-old was transferred by ambulance to Adventist Health Bakersfield, about 80 miles from her home in Visalia.

Doctors diagnosed her with hepatitis A and C and cirrhosis, which had caused internal injuries to her liver and esophagus, she said. She spent four days in the hospital and for further treatment got a referral to a gastroenterologist, whom she can see as a new Medi-Cal enrollee — an option she couldn’t afford in the past when she had stomach pains and nausea.

“It’s been a very long process because I started feeling sick a long time ago.” said López Zamora, an accountant at a local radio station in Visalia in the San Joaquin Valley. “My girls are very little, and if I can’t get the necessary treatment, I won’t know how much time I have left.”

López Zamora, who came to California from Mexico City when she was 8 years old, is grateful for the care she initially received.

But she’s also frustrated.

The gastroenterologist the hospital referred her to is in Bakersfield — a tough journey for López Zamora, who doesn’t drive and can’t afford to travel to another city.

Limited access to specialists — from gastroenterologists to cardiologists — has been a long-standing challenge for many Medi-Cal patients, especially those in rural areas or regions facing staff shortages. The San Joaquin Valley, where López Zamora lives, has the lowest supply of specialists in the state, according to the California Health Care Foundation.

Michael Bowman, a spokesperson for Anthem Blue Cross, her Medi-Cal plan, said in an email that Anthem has a broad network of specialists that serve Medi-Cal beneficiaries, including more than 100 gastroenterologists within 20 miles of Visalia.

She is treating her cirrhosis with medication and diet, but in August her gastroenterologist in Bakerfield discovered signs of a precancerous condition in the stomach.

López Zamora said she is searching for a specialist closer to home. For now, she relies on her mother, who must take the day off work, to get to appointments or she takes the bus. She tried using transportation provided by Medi-Cal but was left stranded at the hospital. And she has rescheduled her appointments twice.

“They drove me up but didn’t take me back because they couldn’t find an Uber,” she said.

‘A Very Simple Process’

Medi-Cal gave Douglas Lopez the dental treatment he couldn’t afford.

The 33-year-old earned minimum wage as a cleaner in an entertainment park in 2022, and the emergency Medi-Cal plan he signed up for covered only emergency extractions.

That year, Lopez experienced a sharp pain in his back teeth when he ate his beloved coconut-and-tamarind candy balls from his native Guatemala.

A dentist told him that he needed several filings and three root canals. He began treatment, but the bills became more expensive: $150 the first session, then $200, then $300.

“I couldn’t afford it,” recalled Lopez, who lives in Fullerton. “I had to pay rent and food.”

Worried he would lose teeth, he stopped eating anything that would cause him pain.

In January, Orange County automatically enrolled Lopez in Molina Healthcare’s Medi-Cal plan when the state expanded insurance eligibility for unauthorized residents ages 26-49. The coverage has transformed his care, he said.

So far, Lopez has seen a dentist six times, for a cleaning, three root canals, two filings, and X-rays. And Medi-Cal has footed the bill.

Lopez’s experience contrasts with that of many other Medi-Cal enrollees, who struggle to get the care they need. The UCLA Center for Health Policy Research found that 21% of California dentists saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see; only 15% of adult enrollees might get dental care in a given year.

Lopez said Medi-Cal has come through for him.

“It was a very simple process. I was so excited to search for a dentist,” Lopez said. “The fear of losing my teeth because I wasn’t getting treatment disappeared.”

‘Something That You Can’t Even Use’

Last year, the stabbing pain in Daniel Garcia’s arm and foot got so bad that the 39-year-old went to the ER.

Garcia has gout, a type of inflammatory arthritis that can cause intense pain and swelling in his joints. When he became eligible for Medi-Cal coverage this year, he thought he could finally see a doctor for treatment.

But the Los Angeles County resident said he hasn’t been able to find a primary care provider willing to take his Molina Healthcare insurance.

“It’s frustrating because you have something that you can’t even use,” said Garcia, who has been unable to get an annual physical. “I’ve called, and they say they don’t take my insurance.”

Molina declined to comment on Garcia’s case and didn’t respond to questions about its primary care network.

Nearly 6 million people in California live in a total of 611 primary care shortage areas, according to a KFF analysis, which found the state would need to add 881 practitioners to close this gap.

Garcia, a construction worker, said he read that he could manage his arthritis by changing his eating habits. He now eats healthier and has cut back on sugar and Coke. As for the pain, he eases it with ibuprofen. He has given up looking for a provider.

Keeping patients out of the ER, which can be 12 times as expensive as primary care, is one of the arguments for expanding Medi-Cal. Studies have shown that not only does expanding health coverage lead to lower rates of ER visits, but expanding coverage also leads to patients using preventive care more, said Drishti Pillai, immigrant health policy director at KFF, a health information nonprofit that includes KFF Health News.

“It can help save health care costs because conditions are no longer going untreated for a long time, in which case they may become more complex and expensive to treat,” Pillai said.

This article is part of “Faces of Medi-Cal,” a series exploring the impact of the state’s safety-net health program on enrollees.

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

A new federal watchdog audit is ratcheting up pressure on government officials to crack down on billions of dollars in overcharges linked to Medicare Advantage home visits.

But so far, the Centers for Medicare & Medicaid Services has rejected a recommendation from the Health and Human Services Inspector General to limit payments stemming from house visits that don’t result in any medical treatment — a potential red flag that may signal overcharges.

In late October, the HHS watchdog found that the health plans pocketed $7.5 billion in 2023 from diagnosing health conditions that prompted no medical services — about $4.2 billion of it through health assessments done in patients’ homes. And court records show that for a decade or more, CMS officials have failed to act on their concerns that the home visits waste tax dollars and should be limited.

UnitedHealthcare, the largest Medicare Advantage contractor, accounted for about two-thirds of the payments tied to home visits and chart reviews, in which health plans mine patient medical files to add new diagnoses that can bring in additional revenue, according to the audit.

Assistant Inspector General Erin Bliss said the health plans are making billions without offering any treatment for medical conditions they flag during the visits, such as diabetes and major depression.

“Frankly, it needs to stop,” Bliss said.

CMS, which runs the Medicare program, disagrees.

In a statement to KFF Health News by spokesperson Alexx Pons, the agency said it “appreciates the OIG’s review in this area” and will continue to study the issue.

However, CMS disagreed with the OIG’s call to restrict use of home health assessments in computing how much to pay health plans. People on Medicare “should have access to care that is appropriately provided in the home setting,” CMS wrote in a written response included in the audit report.

“One would think that CMS would kick its regulatory oversight up a notch or two,” said Richard Lieberman, a Colorado health data analytics expert.

“In contrast, CMS appears to be unconcerned and is telling OIG to stay out of their lane,” he said.

UnitedHealthcare spokesperson Heather Soule said in a statement that the OIG had drawn “inaccurate conclusions” in the audit.

The home visits are “among the most comprehensive and thorough assessments of a patient’s health and physical environment available in the healthcare system, helping to identify and drive needed follow-on care for the vast majority of the patients with whom we engage,” according to the company.

No Care Provided

Government spending on Medicare Advantage, which is dominated by UnitedHealthcare and a handful of other health insurance companies, is expected to hit $462 billion this year.

The industry, whose more than 33 million members make up over half of people eligible for Medicare, argues that most enrollees are satisfied with the care they receive and typically pay less out-of-pocket than those on original Medicare.

Whether Medicare Advantage is a good deal for taxpayers is another matter, largely because many health plans exaggerate how sick patients are to boost their payments, multiple federal audits and other investigations have shown. Medicare pays the health plans higher rates for sicker patients.

For fiscal year 2023, CMS identified $12.7 billion in overpayments linked to diagnoses not supported by patients’ medical records.

The OIG audit tied $7.5 billion in payments to health conditions that prompted no treatment, including serious diseases such as diabetes, congestive heart failure, and major depression. That suggests that the medical condition either didn’t exist or that the health plan failed to treat it adequately, auditors said.

“These are serious conditions. You would think you would see additional care during that year,” said Jacqualine Reid, who led the OIG audit team. “We are asking CMS to step up its oversight.”

Homegrown

The in-home visits have sparked controversy for more than a decade. A June 2014 media investigation found that a sharp rise in home visits had inflated Medicare’s costs by billions of dollars. The visits, which typically last less than an hour, are often conducted by nurse practitioners, who do not treat the patient, but go over a checklist of possible health conditions.

Sabrina Skeldon, a Texas lawyer who advises physicians on billing issues, said problems arise when health plans fail to order necessary medical tests to confirm a diagnosis made during a home visit — and treat it.

Skeldon noted that The Cigna Group in 2023 paid $172 million to settle a whistleblower lawsuit that alleged its Medicare Advantage plan illegally collected payments for medical diagnoses that were based solely on in-home assessments.

The OIG audit comes as the Justice Department presses a civil fraud case that accuses UnitedHealth Group of cheating Medicare out of more than $2 billion by mining patient records to churn up diagnoses that boosted revenue, while ignoring evidence of overpayments. The company denies the allegations.

Court filings from the case show CMS officials were concerned years ago that home visits and chart reviews could needlessly drive up costs.

In April 2014, CMS backed off a proposal to restrict their use amid complaints from the industry that it would lose billions of dollars as a result. Similarly, CMS officials scrapped a proposal to tighten scrutiny on the chart reviews after what one official called an “uproar” from the industry.

CMS officials also had concerns that unchecked home visits might affect efforts to recover overpayments through billing reviews known as “RADV” audits.

Former CMS official Thomas Hutchinson, who ran the agency’s Medicare Plan Payment Group from September 2006 through June 2010, testified in a deposition that officials had “heard about various folks that figured out how they could RADV-proof things by doing in-home visits.”

In a confidential April 2015 slide presentation, CMS officials observed that health plans were “now conducting health risk assessments in beneficiaries’ homes. One purpose of the assessments is to identify conditions and create medical records documentation that substantiates diagnoses.”

And an October 2015 CMS memo circulated among senior agency staff cites “limitations around home visits” among the possible ways to “strengthen” the RADV audits.

In its statement to KFF Health News, CMS said it was “committed” to ensuring that diagnoses health plans submitted for payment were accurate. But the agency declined to answer written questions about the impact of home visits on its audit program, which has yet to complete reviews of payments dating back as far as 2011.

UnitedHealthcare had the lowest rates of unconfirmed diagnoses among five large Medicare Advantage organizations audited in 2011, according to court records.

Overall, the company ended up with underpayments of more than $261 million for 15 of its plans audited for 2011-2013, court records show. The audit findings for other Medicare Advantage firms are blacked out in court filings.

CMS audits payments to just 30 out of more than 700 contracts a year. That’s not enough to protect tax dollars, said Matthew Fiedler, a health policy researcher at The Brookings Institution.

“They should be auditing 10 times as many contracts,” he said. “Where we are now you are not likely to get caught.”

RICHMOND, Vt. — On a warm autumn morning, Roger Brown walked through a grove of towering trees whose sap fuels his maple syrup business. He was checking for damage after recent flooding. But these days, his workers’ health worries him more than his trees’.

The cost of Slopeside Syrup’s employee health insurance premiums spiked 24% this year. Next year it will rise 14%.

The jumps mean less money to pay workers, and expensive insurance coverage that doesn’t ensure employees can get care, Brown said. “Vermont is seen as the most progressive state, so how is health care here so screwed up?”

Vermont consistently ranks among the healthiest states, and its unemployment and uninsured rates are among the lowest. Yet Vermonters pay the highest prices nationwide for individual health coverage, and state reports show its providers and insurers are in financial trouble. Nine of the state’s 14 hospitals are losing money, and the state’s largest insurer is struggling to remain solvent. Long waits for care have become increasingly common, according to state reports and interviews with residents and industry officials.

Rising health costs are a problem across the country, but Vermont’s situation surprises health experts because virtually all its residents have insurance and the state regulates care and coverage prices.

For more than 15 years, federal and state policymakers have focused on increasing the number of people insured, which they expected would shore up hospital finances and make care more available and affordable.

“Vermont’s struggles are a wake-up call that insurance is only one piece of the puzzle to ensuring access to care,” said Keith Mueller, a rural health expert at the University of Iowa.

Regulators and consultants say the state’s small, aging population of about 650,000 makes spreading insurance risk difficult. That demographic challenge is compounded by geography, as many Vermonters live in rural areas, where it’s difficult to attract more health workers to address shortages.

At least part of the cost spike can be attributed to patients crossing state lines for quicker care in New York and Massachusetts. Those visits can be more expensive for both insurers and patients because of long ambulance rides and charges from out-of-network providers.

Patients who stay, like Lynne Drevik, face long waits. Drevik said her doctor told her in April that she needed knee replacement surgeries — but the earliest appointment would be in January for one knee and the following April for the other.

Drevik, 59, said it hurts to climb the stairs in the 19th-century farmhouse in Montgomery Center she and her husband operate as an inn and a spa. “My life is on hold here, and it’s hard to make any plans,” she said. “It’s terrible.”

Health experts say some of the state’s health system troubles are self-inflicted.

Unlike most states, Vermont regulates hospital and insurance prices through an independent agency, the Green Mountain Care Board. Until recently, the board typically approved whatever price changes companies wanted, said Julie Wasserman, a health consultant in Vermont.

The board allowed one health system — the University of Vermont Health Network — to control about two-thirds of the state’s hospital market and allowed its main facility, the University of Vermont Medical Center in Burlington, to raise its prices until it ranked among the nation’s most expensive, she said, citing data the board presented in September.

Hospital officials contend their prices are no higher than industry averages.

But for 2025, the board required the University of Vermont Medical Center to cut the prices it bills private insurers by 1%.

The nonprofit system says it is navigating its own challenges. Top officials say a severe lack of housing makes it hard to recruit workers, while too few mental health providers, nursing homes, and long-term care services often create delays in discharging patients, adding to costs.

Two-thirds of the system’s patients are covered by Medicare or Medicaid, said CEO Sunny Eappen. Both government programs pay providers lower rates than private insurance, which Eappen said makes it difficult to afford rising prices for drugs, medical devices, and labor.

Officials at the University of Vermont Medical Center point to several ways they are trying to adapt. They cited, for example, $9 million the hospital system has contributed to the construction of two large apartment buildings to house new workers, at a subsidized price for lower-income employees.

The hospital also has worked with community partners to open a mental health urgent care center, providing an alternative to the emergency room.

In the ER, curtains separate areas in the hallway where patients can lie on beds or gurneys for hours waiting for a room. The hospital also uses what was a storage closet as an overflow room to provide care.

“It’s good to get patients into a hallway, as it’s better than a chair,” said Mariah McNamara, an ER doctor and associate chief medical officer with the hospital.

For the about 250 days a year when the hospital is full, doctors face pressure to discharge patients without the ideal home or community care setup, she said. “We have to go in the direction of letting you go home without patient services and giving that a try, because otherwise the hospital is going to be full of people, and that includes people that don’t need to be here,” McNamara said.

Searching for solutions, the Green Mountain Care Board hired a consultant who recommended a number of changes, including converting four rural hospitals into outpatient facilities, in a worst-case scenario, and consolidating specialty services at several others.

The consultant, Bruce Hamory, said in a call with reporters that his report provides a road map for Vermont, where “the health care system is no match for demographic, workforce, and housing challenges.”

But he cautioned that any fix would require sacrifice from everyone, including patients, employers, and health providers. “There is no simple single policy solution,” he said.

One place Hamory recommended converting to an outpatient center only was North Country Hospital in Newport, a village in Vermont’s least populated region, known as the Northeast Kingdom.

The 25-bed hospital has lost money for years, partly because of an electronic health record system that has made it difficult to bill patients. But the hospital also has struggled to attract providers and make enough money to pay them.

Officials said they would fight any plans to close the hospital, which recently dropped several specialty services, including pulmonology, neurology, urology, and orthopedics. It doesn’t have the cash to upgrade patient rooms to include bathroom doors wide enough for wheelchairs.

On a recent morning, CEO Tom Frank walked the halls of his hospital. The facility was quiet, with just 14 admitted patients and only a couple of people in the ER. “This place used to be bustling,” he said of the former pulmonology clinic.

Frank said the hospital breaks even treating Medicare patients, loses money treating Medicaid patients, and makes money from a dwindling number of privately insured patients.

The state’s strict regulations have earned it an antihousing, antibusiness reputation, he said. “The cost of health care is a symptom of a larger problem.”

About 30 miles south of Newport, Andy Kehler often worries about the cost of providing health insurance to the 85 workers at Jasper Hill Farm, the cheesemaking business he co-owns.

“It’s an issue every year for us, and it looks like there is no end in sight,” he said.

Jasper Hill pays half the cost of its workers’ health insurance premiums because that’s all it can afford, Kehler said. Employees pay $1,700 a month for a family, with a $5,000 deductible.

“The coverage we provide is inadequate for what you pay,” he said.

On the campaign trail, both former President Donald Trump and Vice President Kamala Harris are eager to portray themselves as guardians of Medicare. Each presidential candidate accuses the other of backing spending cuts and other policies that would damage the health insurance program for older Americans.

But the election’s outcome could alter the very nature of the nearly 60-year-old federal program. More than half of Medicare beneficiaries are already enrolled in plans, called Medicare Advantage, run by commercial insurers, and if Trump wins, that proportion is expected to grow — perhaps dramatically.

Trump and many congressional Republicans have already taken steps to aggressively promote Medicare Advantage. And Project 2025, a political wish list produced by the conservative Heritage Foundation for the next presidency, calls for making insurer-run plans the default enrollment option for Medicare.

Such a change would effectively privatize the program, because people tend to stick with the plans they’re initially enrolled in, health analysts say. Trump has repeatedly tried to distance himself from Project 2025, though the document’s authors include numerous people who worked in his first administration.

Conservatives say Medicare beneficiaries are better off in the popular Advantage plans, which offer more benefits than the traditional, government-run program. Critics say increasing insurers’ control of the program would trap consumers in health plans that are costlier to taxpayers and that can restrict their care, including by imposing onerous prior authorization requirements for some procedures.

“Traditional Medicare will wither on the vine,” said Robert Berenson, a former official in the Jimmy Carter and Bill Clinton administrations who’s now a senior fellow at the Urban Institute, a left-leaning research group.

While the fate of Medicare has gotten scant attention so far in the campaign, the different visions under Trump versus Harris indicate the high stakes.

A candidate’s position on protecting Medicare and Social Security is the most important health care issue, or among the most important, in determining 63% of Americans’ vote in the presidential election, according to a September poll by Gallup and West Health, a family of nonprofit and nonpartisan organizations focused on health care and aging.

Medicare, which covers about 66 million people, is funded largely by payroll taxes. At age 65, most Americans are automatically enrolled in Medicare coverage for hospitalization and doctor visits, known as Part A and Part B, though others must sign up. Consumers must also sign up for other aspects of Medicare, specifically drug coverage (Part D) and supplemental plans from insurers that pay for costs that aren’t covered by traditional Medicare, such as extended stays in skilled nursing facilities and cost sharing.

People on Medicare pay premiums plus as much as 20% of the cost of their care.

Medicare Advantage plans typically combine coverage for hospital and outpatient care and prescriptions, while eliminating the 20% coinsurance requirement and capping customers’ annual out-of-pocket costs. Many of the plans don’t charge an extra monthly premium, though some carry a deductible — an amount patients must pay each year before coverage kicks in.

Sometimes the plans throw in extras like coverage for eye exams and glasses or gym memberships.

However, they control costs by limiting patients to networks of approved doctors and hospitals, with whom the plans negotiate payment rates. Some hospitals and doctors refuse to do business with some or all Medicare Advantage plans, making those networks narrow or limited. Traditional Medicare, in comparison, is accepted by nearly every hospital and doctor.

Medicare’s popularity is one reason both candidates are pledging to enhance it. Last month, Harris released a plan that would add benefits including care for hearing and vision, and long-term in-home health care. The costs would be covered by savings from expanding Medicare’s negotiations with drugmakers, reducing fraud, and increasing discounts drugmakers pay for certain brand-name drugs in the program, according to Harris’ campaign.

Trump’s campaign said he would prioritize home care benefits and support unpaid family caregivers through tax credits and reduced red tape.

The Trump campaign also noted enhancements to Medicare Advantage plans during his tenure as president, such as increasing access to telehealth and expanding supplemental benefits for seniors with chronic diseases.

But far less attention has been paid to whether to give even more control of Medicare to private insurers. Joe Albanese, a senior policy analyst at Paragon Health Institute, a right-leaning research group, said “a Trump administration and GOP Congress would be more friendly” to the idea.

The concept of letting private insurers run Medicare isn’t new. Former House Speaker Newt Gingrich, a Republican, asserted in 1995 that traditional Medicare would fade away if its beneficiaries could pick between the original program and private plans.

The shift to Medicare Advantage was accelerated by legislation in 2003 that created Medicare’s drug benefit and gave private health plans a far greater role in the program.

Lawmakers thought private insurers could better contain costs. Instead, the plans have cost more. In 2023, Medicare Advantage plans cost the government and taxpayers about 6% — or $27 billion — more than original Medicare, though some research shows they provide better care.

The Trump administration promoted Medicare Advantage in emails during the program’s open enrollment period each year, but support for the privately run plans has become bipartisan as they have grown.

“It helps inject needed competition into a government-run program and has proven to be more popular with those who switch,” said Roger Severino, lead architect of Project 2025’s section on the Department of Health and Human Services. He served as director of HHS’ civil rights office during the Trump administration.

But enrollees who want to switch back to traditional Medicare may not be able to. If they try to buy supplemental coverage for the 20% of costs Medicare doesn’t cover, they may find they have to pay an unaffordable premium. Unless they enroll in the plans close to the time they first become eligible for Medicare, usually at age 65, insurers selling those supplemental plans can deny coverage or charge higher premiums because of preexisting conditions.

“More members of Congress are hearing from constituents who are horrified and realize they are trapped in these plans,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a liberal public policy organization.

[Correction: This article was updated at 10:20 a.m. ET on Nov. 4, 2024, to correct the amount Medicare Advantage plans cost the government and taxpayers last year compared with original Medicare.]

María Sánchez emigró al área de Chicago desde México hace unos 30 años. Ahora, a sus 87, sigue viviendo en Estados Unidos sin papeles. Como muchos inmigrantes de larga data, ha trabajado —y pagado impuestos, incluyendo para Medicare— durante todo ese tiempo.

Pero Sánchez nunca tuvo seguro médico, y cuando cumplió 65, no pudo inscribirse en Medicare. Nunca ha tenido atención preventiva ni exámenes. No ha tenido chequeos físicos, ni mediciones de colesterol, ni mamografías.

“Nada, nada, nada”, dijo.

Cuando enfermaba, tardaba en buscar atención médica hasta que estaba tan mal que fue hospitalizada dos veces por neumonía. Finalmente, el año pasado obtuvo cobertura a través de un programa pionero en Illinois para personas mayores indocumentadas que entró en vigencia en diciembre de 2020.

Estados liderados por demócratas, como Illinois, están abriendo cada vez más programas de seguros públicos a inmigrantes sin papeles. Una docena ya cubría a niños; aún más proporcionaban cobertura prenatal. Pero ahora,  están cubriendo a adultos que viven en el país sin autorización, y algunos están ampliando la cobertura para personas mayores, que son más costosos y representan un desafío político mayor que los niños.

Estas expansiones reconocen los costos que estos pacientes pueden imponer sobre los hospitales. Pero estas políticas están bajo dura crítica del ex presidente Donald Trump y otros republicanos, quienes buscan presentar a su oponente, la vicepresidenta Kamala Harris, como la cara de políticas de inmigración irresponsables.

Los republicanos señalan la expansión de la cobertura de Medi-Cal en el estado natal de Harris, California, a inmigrantes de todas las edades independientemente de su estatus legal, argumentando que esto afecta a los ciudadanos estadounidenses.

Es una queja frecuente de Trump. “Ella va por ahí diciendo, ‘Oh, Trump va a hacer cosas malas con la Seguridad Social’”, dijo sobre Harris en una conferencia de prensa el 13 de septiembre. “No, ella va a hacerlo porque está poniendo a estos inmigrantes ilegales en la Seguridad Social, en Medicare, y va a destruir esos programas, y la gente tendrá que pagar”.

La elección de Harris del gobernador de Minnesota, Tim Walz, como compañero de fórmula ha añadido combustible a los ataques republicanos en la intersección de la inmigración y la política de salud.

Con la esperanza de presentar a la candidata demócrata presidencial Kamala Harris como extrema en inmigración, el ex presidente Trump y sus partidarios han dicho que ella quería otorgar beneficios de salud gratuitos, pagados por los contribuyentes, a inmigrantes en el país sin permiso legal. Pero esta declaración omite detalles clave.

Bajo una ley firmada por Walz, los inmigrantes que viven sin documentos en Minnesota podrán obtener cobertura de salud a partir del próximo año a través del programa MinnesotaCare del estado para personas de bajos ingresos que no son elegibles para Medicaid.

El tema es de gran interés para algunos estadounidenses. En un foro en Las Vegas el 10 de octubre, una integrante del público identificada por Univision como Ivett Castillo le preguntó a Harris qué haría su administración respecto a la atención médica para personas como su madre, quien había emigrado de México sin autorización muchos años atrás, trabajado toda su vida ahasta su muerte este año sin haber recibido “el tipo de atención y servicio que necesitaba o merecía”.

“¿Cuáles son sus planes, o tienen planes, para apoyar a ese subgrupo de inmigrantes que han estado aquí toda su vida, o la mayoría de ellos, y tienen que vivir y morir en las sombras?”, preguntó Castillo.

Harris mencionó su apoyo anterior a un camino a la ciudadanía para residentes sin papeles, y a un proyecto de ley bipartidista de seguridad fronteriza que los republicanos del Senado bloquearon a principios de este año por insistencia de Trump.

“Este es un ejemplo de que hay personas reales que sufren debido a la incapacidad de anteponer soluciones a la política”, dijo Harris.

Incluso sin estas políticas, los inmigrantes pueden recibir atención primaria gratuita o económica en clínicas comunitarias en todo el país, asumiendo que saben que es una opción y se sienten seguros en las instalaciones.

Pero la atención primaria no puede cubrir todas las necesidades médicas, especialmente a medida que las personas envejecen y desarrollan problemas de salud y enfermedades crónicas más complejas. Así que los inmigrantes suelen depender de la atención caritativa, endeudarse o, como Sánchez, evadir al doctor. Algunos incluso regresan a sus países de origen para recibir atención.

Illinois, donde Sánchez obtuvo cobertura, fue pionero en la extensión de cobertura de seguros a migrantes no autorizados. Ahora, seis estados y el Distrito de Columbia —todos liderados por demócratas— cubren al menos a algunos inmigrantes mayores de bajos ingresos bajo Medicaid o exenciones de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Minnesota se convertirá en el séptimo el próximo año. Para estas expansiones se utilizan fondos estatales, ya que los fondos federales generalmente no pueden cubrir a personas sin estatus legal.

Queda por ver si más estados seguirán esta tendencia y cuán rápido, y si Trump gana la Casa Blanca, es probable que su administración intente frenar esta tendencia, dado que ha prometido deportaciones masivas.

La cobertura para todos los inmigrantes sigue siendo una propuesta difícil tanto económica como políticamente, y la población no ciudadana no puede agradecer votando. Las iniciativas de salud para inmigrantes en varios otros estados han fracasado o se han reducido.

Maryland, por ejemplo, decidió abrir su mercado del Obamacare a personas que viven en el estado sin autorización a partir de 2026, pero sin subsidios de los contribuyentes para sus primas.

Aun así, hay suficiente actividad en los estados para que defensores de la salud de los inmigrantes crean que algo ha cambiado. La gravedad de la pandemia y su impacto desigual ayudaron a generar el apoyo para cubrir a inmigrantes mayores, dijo Lee Che Leong, defensora principal de políticas en Northwest Health Law Advocates en el estado de Washington.

“La gente está mirando a su alrededor y se da cuenta de que nuestra salud está interconectada, tanto global como localmente”, dijo Leong. “La pandemia realmente mostró eso, cuando miras las disparidades en quién se contagió de covid, quién estuvo expuesto a covid y quién murió por covid”.

Durante mucho tiempo, el acceso a la atención médica en el país ha sido un obstáculo para los inmigrantes, incluso aquellos que tienen papeles. Las personas con tarjetas de residencia deben esperar cinco años para obtener cobertura bajo Medicaid u otros programas de salud del gobierno. Algunos personas mayores con residencia tienen que pagar primas adicionales para Medicare Parte A —la parte que cubre la atención hospitalaria— si no han trabajado al menos 10 años en Estados Unidos.

Los nuevos programas de salud estatales cierran estas brechas, dijo Shelby Gonzales, vicepresidenta de política de inmigración en el Center on Budget and Policy Priorities.

En julio, el estado de Washington comenzó a cubrir a inmigrantes de bajos ingresos en un programa similar a Medicaid llamado Apple Health Expansion, utilizando una exención federal.

La inscripción es limitada y el programa se llenó rápidamente, pero se reservaron algunos lugares para personas de 65 años o más, dijo Leong. A principios de este año, el estado abrió su mercado de Obamacare a inmigrantes que viven en los EE. UU. sin autorización.

Oregon y Colorado ahora también ofrecen alguna cobertura a personas en sus estados que carecen de estatus legal, aunque el programa de Colorado no atrajo a muchos inmigrantes mayores, según datos presentados hace poco al comité de supervisión del mercado de ACA.

Nueva York ha cubierto a niños inmigrantes sin documentos durante años, y el programa de Medicaid del estado se abrió en enero para todos los inmigrantes adultos independientemente de su estatus. Aproximadamente 25,000 personas se inscribieron en los primeros cuatro meses, según el director de Medicaid de Nueva York, Amir Bassiri.

De vuelta en Illinois, María Sánchez dijo que su nueva cobertura ha cambiado su vida, y posiblemente le ha salvado la vida. Sus episodios de neumonía fueron graves, en parte porque retrasó la atención. Después de su segunda hospitalización, necesitó atención cardíaca de seguimiento. El hospital no le cobró por su estadía.

Pero ahora, con su “tarjeta médica”, puede ver a un médico. Su condición cardíaca está bajo control. Ha visto a un dentista. Va a tener una operación de cataratas. “Con mi tarjeta médica, tengo paz mental”, dijo Sánchez.

llinois ha agregado gradualmente cobertura para otros grupos de edad; en el verano de 2022, redujo la elegibilidad a los 42 años. Eso significa que inmigrantes como Gaby Piceno, de 45, pueden envejecer de manera más saludable.

“Ya no tengo que preocuparme”, dijo, refiriéndose no solo a sí misma, sino a su familia.

Pero la expansión de la cobertura ha costado más de lo proyectado en Illinois. Personas como Sánchez y Piceno, ya inscritas, siguen cubiertas, pero este año se frenó la nueva inscripción. Se inscribieron más personas de lo esperado, y muchas continuaron buscando atención en salas de emergencia de hospitales más costosos en lugar de en consultorios médicos, dijo la comisionada interina de seguros del estado, Ann Gillespie, quien era senadora estatal en Illinois cuando se estableció el programa.

El estado ahora está transfiriendo a los inmigrantes cubiertos a planes de atención administrada de Medicaid, con la esperanza de reducir el costo con el tiempo.

In the final days of the campaign, stark disagreements between Vice President Kamala Harris and former President Donald Trump over the future of American health care are on display — in particular, in sober warnings about abortion access, the specter of future cuts to the Affordable Care Act, and bold pronouncements about empowering activists eager to change course and clean house.

Trump and his campaign have been vague about plans on health care policies, though current and former Trump aides have published blueprints that go well beyond reversing programs in force under the Biden administration, to overhauling public health agencies and enabling Trump to quickly fire officials who disagree.

Harris, on the other hand, has staked out positions primarily preserving and protecting existing health care access — on abortion, transgender health care, insurance coverage, and more.

Here are some of the most consequential changes in health policies that could hinge on who wins the White House.

ACA Premiums

The election is likely to affect the cost of health insurance for millions who buy coverage on the Affordable Care Act marketplaces.

That’s because extra, pandemic-era subsidies that lower the cost of premiums will expire at the end of 2025 — unless Congress and the next president act.

Harris has pledged to make the enhanced subsidies permanent, while Trump has made no such commitment.

Letting them expire “would reduce fraud and waste,” said Brian Blase, a former Trump adviser who is president of the Paragon Health Institute, a conservative policy research firm.

About 19.7 million people with ACA coverage benefit from a subsidy — 92% of all enrollees. The expanded subsidies, started in 2021, helped increase ACA enrollment to a record high and reduce the uninsured rate to a record low.

They have also cut premium payments by an estimated 44%. Many pay no premiums at all.

Without congressional action, almost all ACA enrollees will experience steep increases in premium payments in 2026, according to KFF. The Urban Institute estimates 4 million people could wind up uninsured.

Letting the subsidies lapse could cause blowback for Republicans in 2026, said Jonathan Oberlander, a health policy expert at the University of North Carolina’s School of Medicine: “Is it worth the pain politically?”

— Phil Galewitz

Abortion

When he was president, Trump promised — and delivered — Supreme Court justices who would vote to overturn the constitutional right to an abortion. In the event of a second term, he has promised to leave abortion policy to the states — though he would have significant leeway to reduce access nationwide.

Harris has promised to restore the protections of Roe v. Wade, though doing so would require Congress’ help. At the very least, a Harris presidency would mostly preserve existing protections and prevent new federal restrictions.

Trump’s first actions would likely mirror those of many Republican presidents since the 1980s: defunding Planned Parenthood and the United Nations’ family planning agency, and, more recently, allowing employers with religious or moral objections to contraception to decline coverage through job-sponsored health plans.

But Trump could go considerably further, effectively banning abortion even in states where it is legal. For instance, the FDA could reduce availability of the abortion pill mifepristone or cancel its approval. This has been the subject of numerous lawsuits, including one before the Supreme Court that was recently revived.

Trump could also order the Justice Department to enforce the Comstock Act, an 1873 law that bans mailing “every article or thing designed, adapted, or intended for producing abortion, or for any indecent or immoral use.” That could apply not just to abortion pills, but also to supplies for abortion procedures.

— Julie Rovner

Drug Prices

Both campaigns say they are committed to lowering drug prices. Trump has offered few specifics, though the America First Policy Institute, a think tank led by close Trump allies, has put forward policies that are considerably less aggressive than Harris’ proposals.

Harris has said she would expand drug pricing negotiations and out-of-pocket drug spending caps enabled by the Inflation Reduction Act. She has also called for more transparency requirements for pharmacy benefit managers, or PBMs, the powerful drug-industry middlemen.

America First’s plan would cut costs by lowering reimbursements to doctors for some expensive infused drugs, using trade policy to force other developed countries to increase what they pay for drugs, and making more prescription medications available over the counter.

The plan makes no mention of bipartisan legislation under consideration in both chambers of Congress that seeks to achieve lower drug prices through new transparency requirements for PBMs.

— Arthur Allen

Trans People’s Health

The presidential election could determine whether transgender Americans hold on to broad protections ensuring access to gender-affirming medical care. Trump has said he would seek to ban hormone replacement therapy, gender reassignment surgery, and other treatments for minors — and make the services more difficult for adults to receive.

In the closing days of the campaign, Trump and his political action committees have leaned into divisive ads attacking Harris for past comments supporting access to care for transgender people who are incarcerated.

Backed by Republicans eager to stoke culture-war social issues, Trump has pledged to repeal Biden policies affecting transgender health care, including rules prohibiting federally funded providers and insurers from discriminating based on gender identity.

As some states passed legislation that opposed transgender rights, the Biden administration expanded coverage for gender-affirming care and increased research funding for the National Institutes of Health.

In a video on his campaign site, Trump vowed to order federal agencies to “cease all programs that promote the concept of sex and gender transition at any age” and bar government programs such as Medicare and Medicaid from paying for gender-affirming care.

Trump also said he would strip federal funding from hospitals that provide such care, create a right to sue doctors who perform gender-affirming procedures on children, and investigate whether the pharmaceutical industry and hospitals have “deliberately covered up horrific long-term side effects” of transition treatments.

Harris has been largely silent on the Trump campaign’s rhetoric targeting trans people. But she has said she would “follow the law” in providing transgender Americans the same right as others to access medically necessary care.

— Daniel Chang

Medicaid

Though the word “Medicaid” was barely uttered on the campaign trail this year, the election will determine future benefits for its 80 million primarily low-income and disabled enrollees.

“The stakes are very high,” said UNC’s Oberlander.

While Harris has described Medicaid as a key program to improve health, Trump has framed it as a broken welfare program in need of cuts.

Nearly half of Medicaid enrollees are children, and the program pays for about 40% of births nationwide.

The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level, or $20,783 this year. All but 10 states, which are GOP-led, have opted to expand their program.

The Biden administration has largely focused on efforts to protect and expand Medicaid to reduce the number of uninsured people.

The Trump administration, and GOP proposals since then, sought to reduce Medicaid spending by stiffening eligibility standards, such as adding work requirements, and by changing federal financing to a block grant, which would put more burden on states.

— Phil Galewitz

Shaking Up Biomedical Agencies

Trump said at an Oct. 27 rally in New York City that he would give anti-vaccine activist Robert F. Kennedy Jr. free rein to “go wild” on health and food policy in a second term.

Even a Republican-controlled Senate would be unlikely to confirm Kennedy for any top government position. Regardless of whether he had a specific role, RFK Jr.’s influence could be powerful, said Georges Benjamin, executive director of the American Public Health Association.

Kennedy said Trump promised to give him “control” of public health, including naming leaders of the NIH, FDA, and the Centers for Disease Control and Prevention. He has advocated for a doctor who made a name for herself as a right-wing health guru, Casey Means, to head the FDA. This week, in a discussion on CNN during which he put forward the debunked theory that vaccines cause autism, Trump transition team co-chair Howard Lutnick said Kennedy wanted data on vaccines “so he can say these things are unsafe,” at which point “the companies will yank the vaccines right off … the market.”

Numerous Trump allies have urged disempowering public health agencies — stripping the CDC of much of its research and promotional authority while streamlining NIH and adding congressional oversight over its grant-making.

Project 2025, the Heritage Foundation blueprint disavowed by Trump but whose authors include many former Trump officials, says the drug industry and other corporations have “captured” regulatory agencies: “We must shut and lock the revolving door” between agencies like the NIH, CDC, and FDA, and the industries they regulate, it states.

Kennedy recently posted on the social platform X that “FDA’s war on public health” — by which he meant restrictions on disproven therapies and cure-alls like raw milk and ivermectin — “was about to end.”

He warned FDA employees who are “part of the corrupt system” that they should “1. Preserve your records, and 2. Pack your bags.”

— Arthur Allen

Maria Sanchez immigrated to the Chicago area from Mexico about 30 years ago. Now 87, she’s still living in the U.S. without authorization. Like many longtime immigrants, she has worked — and paid taxes, including Medicare taxes — all that time.

But Sanchez never had health insurance, and when she turned 65, she couldn’t enroll in Medicare. She has never had preventive care or screenings. No physicals. No cholesterol checks. No mammograms.

“Nada, nada, nada,” she said in an interview conducted in Spanish. Nothing, nothing, nothing.

When she did get sick, she delayed seeking care until she was so ill that she was twice hospitalized with pneumonia. She finally got covered last year under a landmark Illinois program for older people without legal residency that took effect in December 2020.

Democratic-led states such as Illinois are increasingly opening public insurance programs to immigrants lacking permanent legal status. A dozen had already covered children; even more provided prenatal coverage. But now more states are covering adults living in the country without authorization — and some are phasing in coverage for seniors, who are more expensive and a harder political sell than kids.

The expansions recognize the costs that patients living here illegally can otherwise impose on hospitals. But the policies are under harsh attack from former President Donald Trump and other Republicans who seek to make his opponent, Vice President Kamala Harris, the face of reckless immigration policies.

Republicans point to Harris’ home state of California’s expansion of Medi-Cal coverage to immigrants of all ages regardless of legal status, saying it comes at the expense of American citizens.

It’s a regular complaint for Trump. “She’ll go around saying, ‘Oh, Trump is going to do bad things to Social Security,’” he said of Harris at a Sept. 13 news conference. “No, she’s going to do it because she’s putting these illegal immigrants onto Social Security, onto Medicare, and she’s going to destroy those programs, and the people are going to have to pay.”

Harris’ choice of Minnesota Gov. Tim Walz as her running mate has added fuel to Republican attacks at the intersection of immigration and health policy.

Under a law Walz signed, immigrants living without authorization in Minnesota will be able to gain health coverage starting next year through the state’s MinnesotaCare program for people with low incomes who aren’t eligible for Medicaid.

The issue is top of mind for some Americans. At an Oct. 10 town hall in Las Vegas, an audience member event host Univision identified as Ivett Castillo asked Harris what her administration would do about health care for people like her mother, who had immigrated from Mexico without authorization many years ago, worked her whole life, and died this year without ever receiving “the type of care and service that she needed or deserved.”

“What are your plans, or do you have plans, to support that subgroup of immigrants who have been here their whole lives, or most of them, and have to live and die in the shadows?” Castillo asked.

Harris noted her past support for a path to citizenship for unauthorized residents — and for a bipartisan border security bill that Senate Republicans killed earlier this year at the behest of Trump.

“This is one example of the fact that there are real people who are suffering because of an inability to put solutions in front of politics,” Harris said.

Even without such policies, immigrants can get free or inexpensive primary care at community clinics throughout the country — assuming they know it’s an option and feel safe at the facilities. But primary care can’t take care of all medical needs, particularly as people age and develop more complex health problems and chronic illnesses. So immigrants often rely on charity care, go into debt, or, like Sanchez, skimp. Some even return to their home countries for care.

Illinois, where Sanchez got covered, was a pioneer in extending insurance coverage to unauthorized migrants. Now, six states and the District of Columbia — all led by Democrats — cover at least some low-income older immigrants under Medicaid or Affordable Care Act waivers. Minnesota next year will become the seventh. State funds must be used for the expansions, as federal dollars generally can’t cover people lacking legal status.

Whether or how quickly more states follow remains to be seen, and if Trump wins the White House, his administration would likely try to thwart the trend, given that he has pledged mass deportations. Coverage for all immigrants is still a tough sell economically and politically — and the noncitizen population can’t vote its gratitude at the ballot box. Immigrant health initiatives in several other states have fizzled or been scaled back.

Maryland, for example, settled on opening its Obamacare exchange to people living in the state without authorization, starting in 2026 — but without taxpayer subsidies for their premiums.

Still, there’s enough activity in states to make advocates for immigrant health believe something has shifted. The pandemic’s severity and its uneven toll helped build support for covering older immigrants, said Lee Che Leong, the senior policy advocate at Northwest Health Law Advocates in Washington state.

“People are looking around and realizing that our health is interconnected, both globally and locally,” Leong said. “The pandemic really brought that home, that when you look at the disparities in who got covid, who was exposed to covid, and who died from covid.”

Access to U.S. health care has long been an obstacle for immigrants, even those in the country legally. People with green cards must wait five years for coverage under Medicaid or other government health programs. Some older green-card holders have to pay extra premiums for Medicare Part A — the portion that covers hospital care — if they haven’t been employed for at least 10 years in the U.S.

The new state health programs close those gaps, said Shelby Gonzales, vice president for immigration policy at the Center on Budget and Policy Priorities.

In July, Washington state started covering low-income immigrants in a Medicaid-like program called Apple Health Expansion, using a federal waiver. Enrollment is capped and the program filled quickly, but some slots were reserved for people 65 and older, Leong said. Earlier this year, the state opened its Obamacare exchange to immigrants living in the U.S. without authorization.

Oregon and Colorado now also offer some coverage to people in their states who lack legal status, though the Colorado program didn’t attract many older immigrants, according to data recently presented to the state Affordable Care Act exchange oversight committee.

New York has covered child immigrants lacking legal residency for years, and the state’s Medicaid program was opened in January to all adult immigrants regardless of status. About 25,000 people signed up in the first four months, according to New York Medicaid Director Amir Bassiri.

Back in Illinois, Maria Sanchez said her new coverage has been life-changing — and possibly lifesaving. Her bouts of pneumonia were severe, partly because she had delayed care. After her second hospitalization, she needed follow-up cardiac care. The hospital didn’t charge her for her stay.

But now, with her “tarjeta médica” — her medical card — she can see a doctor. Her heart condition is under control. She has seen a dentist. She’s getting her cataracts removed.

“With my medical card, I have peace of mind,” Sanchez said.

Illinois has gradually added coverage for other age groups; in summer 2022, it lowered eligibility to age 42. That means immigrants like Gaby Piceno, 45, can age more healthily.

“I don’t have to worry anymore,” she said, referring not just to herself but to her family.

But the coverage expansion has cost more than Illinois projected. People like Sanchez and Piceno, already on the rolls, remain covered, but new enrollment was paused this year. More people signed up than expected, and many continued seeking care in more costly hospital emergency departments rather than at doctors’ offices, said the state’s acting insurance commissioner, Ann Gillespie, who was an Illinois state senator when the program was established.

The state is now shifting covered immigrants into Medicaid managed-care plans, hoping to bring down the cost over time.

Conservative groups are working to undermine support for Montana’s Medicaid expansion in hopes the state will abandon the program. The rollback would be the first in the decade since the Affordable Care Act began allowing states to cover more people with low incomes.

Montana’s expansion, which insures roughly 78,800 people, is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, which quotes him as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a visiting fellow at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began calling on Montana lawmakers to reject reauthorizing the program. It also released a video this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of KFF Health News, an independent national newsroom that is part of the health information nonprofit KFF.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, showed 66% of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a KFF Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

Reports released by the state show its standard monthly reimbursement per Medicaid enrollee remained relatively flat for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, cited data from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, according to a KFF report.

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to leave Medicaid expansion alone. In February, an FGA representative testified in support of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “Resisting the Wave of Medicaid Expansion,” and Blase testified to Texas lawmakers this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he said.

It’s that time of year again: open enrollment for Affordable Care Act insurance — a period that runs from tomorrow to Jan. 15 in most states, a bit longer in some, and shorter in Idaho.

One of the biggest changes this time around: a new rule from the Biden administration that opens enrollment to Deferred Action for Childhood Arrivals recipients. DACA is a federal program offering some protection from deportation and providing work authorization to some people brought to the country as children by family members lacking permanent legal residency.

While the rule could allow an estimated 100,000 DACA recipients to sign up for health insurance in 2025, its fate is uncertain. That’s because it’s being challenged in federal court by Kansas and 18 other states, including Virginia, New Hampshire, North Dakota, and several others in the South and Midwest.

Separately, 19 states and D.C. filed a brief in support of the Biden administration rule that allows DACA recipients to enroll in ACA plans. Those states, led by New Jersey, include many on the East and West Coasts, including California, New York, Oregon and Washington.

The plaintiff states argue that the rule will cause management and resource burdens as more people enroll, and that it will encourage additional people to remain in the United States when they don’t have the proper paperwork. The lawsuit, filed in U.S. District Court for the District of North Dakota in August, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

ACA plans are open to American citizens and lawfully present immigrants. Now the group often dubbed “Dreamers” will qualify as lawfully present for the purpose of enrolling and applying for tax credits to help cover premiums.

“More than one third of DACA recipients currently do not have health insurance, so making them eligible to enroll in coverage will improve their health and wellbeing, and help the overall economy,” Health and Human Services Secretary Xavier Becerra said in a May news release.

On Oct. 15, the district court heard arguments in the case, and a ruling might come soon, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute’s Health Care Litigation Tracker.

But that hearing also launched a flurry of related motions and orders. For instance, U.S. District Judge Daniel Traynor ordered the federal government to provide North Dakota with the names of 128 DACA recipients in the state, under seal, to calculate any financial costs associated with complying with the Biden administration rule in order to determine whether the case should be heard there. The state has until Nov. 12 to respond. The federal government sought to squelch the order, but Traynor denied the request Monday.

And there could be more back-and-forth.

Once Traynor issues a final ruling in the case, it could be appealed by either side, delaying resolution of the lawsuit possibly into next year, when the outcome of Tuesday’s presidential election might also play a role. A new administration, for example, could issue new rules to change or reverse decisions made by the Biden administration.

Find more here on sign-up season, including deadlines, projected premium increases and scams.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact [email protected].

CITRUS COUNTY, Fla. — It was hard enough for Stephanie to get methadone treatment when she moved to Florida from Indiana last year. The nearest clinic was almost an hour’s drive away and she couldn’t drive herself. But at least she didn’t have to worry about the cost of care.

As a parent with young children who was unable to find a job after moving, Stephanie qualified for Medicaid despite Florida’s tight eligibility rules. The state insurance program for people with low incomes or disabilities covers the methadone she needs to reduce her opioid cravings and prevent withdrawal sickness.

For nearly a decade, methadone has helped her hold down a job and take care of her kids. “Just have a normal, really normal, life,” said Stephanie, 39, who asked that her last name be withheld because her two youngest children don’t know about her history of opioid use disorder or that she has been in treatment for opioid addiction. “All the things that some people take for granted.”

So it was devastating for Stephanie when she visited her clinic in summer 2023 and learned she had been dropped from the state’s Medicaid rolls as the program worked to redetermine the eligibility of each enrollee. Suddenly, her methadone prescription cost much more than she could afford.

She panicked, afraid a disruption in care would trigger debilitating withdrawal symptoms like vomiting, fever, cramps, joint pain, and tremors. “That’s the first thing I thought,” she said. “I’m going to be so sick. How am I going to get up and take care of the kids?”

As of September, more than 25 million Americans — including 1.9 million Floridians — had lost Medicaid coverage since the expiration of federal covid-19 pandemic protections in March 2023 that had kept people continually enrolled. Among them were patients in treatment for opioid addiction, such as Stephanie, for whom a loss of coverage could be deadly.

Research shows that, when taken as prescribed, medications for opioid use disorder — such as methadone and a similar medicine, buprenorphine — can reduce dangerous drug use and cut overdose fatalities by more than half. Other studies have found the risk of overdose and death increases when treatment is interrupted.

It is unclear how many people with opioid addiction have lost coverage in the Medicaid disenrollment, known as the “unwinding.” But researchers at KFF, a health information nonprofit that includes KFF Health News, estimate that more than 1 million low-income Americans depend on the federal-state Medicaid program for lifesaving addiction care.

At Operation PAR — a nonprofit addiction treatment provider from which Stephanie and thousands of others along Florida’s Gulf Coast get care — the percentage of opioid treatment patients with Medicaid has dropped from 44 to 28 since the unwinding began last year, the organization said.

Dawn Jackson, who directs Operation PAR’s newest clinic, about an hour north of Tampa in the small Citrus County city of Inverness, said it has been a struggle trying to stretch limited grant dollars to cover the recent surge of uninsured patients.

“There’s been sleepless nights,” Jackson said. “We’re saving lives — we’re not handing out Happy Meals here.”

Methadone and buprenorphine are considered the gold standard of care for opioid addiction. The drugs work by binding to the brain’s opioid receptors to block cravings and withdrawal symptoms without making a person feel high. Treatment reduces illicit drug use and the accompanying overdose risk.

However, few Americans who could benefit from the medicines actually receive them: The latest federal data shows that in 2021 only about 1 in 5 people who needed the medicines got them. The low numbers offer a sharp contrast to the record-high drug overdose epidemic, which killed nearly 108,000 Americans in 2022 and is driven primarily by opioids.

Zachary Sartor, a family medicine doctor in Waco, Texas, who specializes in addiction treatment, described the effect of such medications as “nothing short of remarkable.”

“The evidence in the medical literature shows us that things like employment and quality of life overall increase with access to these medications, and that definitely bears out with what we see in the clinic,” Sartor said. “That benefit just seems to grow over time as people stay on medications.”

Sartor, who works at a safety net clinic, prescribes buprenorphine, and most of his patients are uninsured or on Medicaid. Some are among the 2.5 million Texans who lost coverage during the state’s unwinding, he said, causing their out-of-pocket buprenorphine costs to abruptly rise as much as fourfold.

The loss of coverage — which also cuts access to health care beyond addiction treatment — often requires patients to make risky trade-offs.

Sartor said that can mean patients having to choose between medications to treat their addiction and drugs for other medical conditions. “You start to see the cycle of patients having to ration their care,” he said.

Many people who lost their insurance in the Medicaid unwinding have since seen it reinstated. But even a brief disruption in care is serious for someone with opioid use disorder, said Maia Szalavitz, a journalist and an author who writes about addiction.

“If you want to save people’s lives and you have a lifesaving medication available, you don’t interrupt their access to health care,” Szalavitz said. “They end up in withdrawal and they end up dying.”

When Stephanie lost her Medicaid coverage last year, Operation PAR was able to subsidize her out-of-pocket methadone costs, so she paid only $30 a week. That was inexpensive enough for her to stick with treatment for the six months it took to restore her Medicaid coverage.

But the patchwork of federal and state grants that Operation PAR uses to cover uninsured patients doesn’t always meet demand, and waiting lists for subsidized methadone treatment are not uncommon, said Jackson, who directs the clinic in Citrus County.

Even before the Medicaid unwinding, about 13% of people younger than 65 in Florida were uninsured, one of the highest rates in the country, according to census data. Florida is also one of 10 states that have not expanded Medicaid for low-income adults.

Jon Essenburg, chief business officer at Operation PAR, said a recent infusion of opioid settlement money wiped out the group’s waiting lists, at least for now. But he said settlement dollars — Florida expects to receive $3.2 billion over 18 years from opioid manufacturers and distributors — are not a long-term solution to persistent coverage gaps, which is why stabler reimbursement sources like Medicaid can help.

“Turning people away over money is the last thing we want to do,” Jackson said. “But we also know that we can’t treat everybody for free.”

Stephanie is grateful she never had to go without her medicine.

“I don’t even want to think about what it would have been like if they wouldn’t have worked with me and helped me with the funding,” Stephanie said. “It would have been a very dark rabbit hole, I’m afraid.”

Kim Krisberg is a contributing writer for Public Health Watch and co-leads the reporting project The Holdouts. Stephanie Colombini is a reporter for WUSF’s Health News Florida project.

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 spring, a few days after his 2nd birthday, Brigland Pfeffer was playing with his siblings in their San Diego backyard.

His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”

“I saw a small rattlesnake coiled up by the firepit,” she said.

Pfeffer called 911, and an ambulance transported Brigland to Palomar Medical Center Escondido.

The Medical Procedure

When they arrived, Brigland’s hand was swollen and purple.

Antivenom, an antibody therapy that disables certain toxins, is usually administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.

“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” Pfeffer said.

Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.

It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip.

He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.

The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.

Then the bills came.

The Final Bill

$297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.

The Billing Problem: The High Cost of Antivenom

The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.

Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.

It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and a former president of the American College of Medical Toxicology.

Manufacturing, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.

Why the high price? One explanation is that hospitals mark up products to balance overhead costs and generate revenue.

Brigland received Anavip at two hospitals that charged different prices.

Palomar, where emergency staffers treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.

Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.

Neither hospital responded to requests for comment.

Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”

For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.

Leslie Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment for this article.)

Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total.

More than 70% of the price tag — $10,250 — is attributable to hospital markups, her research showed.

Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.

Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.

The Resolution

The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars.

The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.

Insurance did not pay all the claims, including one ambulance bill. Pfeffer said she received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted bills for ground ambulances.

Brigland’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.

“He’s very, very lucky,” Pfeffer said.

The family has since installed snake fencing around the yard.

The Takeaway

There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.

Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing emergency rooms.

When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.

You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

When open enrollment for the Affordable Care Act, or Obamacare, starts nationwide this week, a group that had previously been barred from signing up will be eligible for the first time: The “Dreamers.” That’s the name given to children brought to the United States without immigration paperwork who have since qualified for the Deferred Action for Childhood Arrivals program.

Under a Biden administration rule that has become contentious in some states, DACA recipients will be able to enroll in — and, if their income qualifies, receive premium subsidies for — Obamacare coverage. The government estimates that about 100,000 previously uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, which is the sign-up season start date in all states except Idaho.

Yet the fate of the rule remains uncertain. It is being challenged in federal court by Kansas and 18 other states, including several in the South and Midwest, as well as Montana, New Hampshire, and North Dakota.

Separately, 19 states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many on the East and West coasts, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

The rule, finalized in May, clarifies that those who qualify for DACA will be considered “lawfully present” for the purpose of enrolling in plans under the ACA, which are open to American citizens and lawfully present immigrants.

“The rule change is super important as it corrects a long-standing and erroneous exclusion of DACA recipients from ACA coverage,” said Nicholas Espíritu, a deputy legal director for the National Immigration Law Center, which has also filed briefs in support of the government rule.

President Barack Obama established DACA in June 2012 by executive action to protect from deportation and provide work authorization to some unauthorized residents brought to the U.S. as children by their families if they met certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were a veteran.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The lawsuit, filed in August in U.S. District Court for the District of North Dakota, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

On Oct. 15, U.S. District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, heard arguments in the case.

Plaintiff states are pushing for fast action, and it is possible a ruling will come in the days before open enrollment begins nationwide in November, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

But the outlook is complicated.

For starters, in a legal battle like this, those who file a case must demonstrate the harm being alleged, such as additional costs the rule will force the states to absorb. There are only about 128 DACA recipients in North Dakota, where the case is being heard, and not all of them are likely to enroll in ACA insurance.

Furthermore, North Dakota is not among the states that run their own enrollment marketplace. It relies on the federal healthcare.gov site, which makes the legal burden harder to meet.

“Even though North Dakota does not pay any money to purchase ACA health care, they are still claiming somehow that they are harmed,” said Espíritu, at the immigration law center, which is representing several DACA recipients and CASA, a nonprofit immigrant advocacy group, in opposing the state efforts to overturn the rule.

During the hearing, Traynor focused on this issue and noted that a state running its own marketplace might be a better venue for such a case. He ordered the defendants to present more information by Oct. 29 and for North Dakota to respond by Nov. 12.

On Monday, the judge denied a motion from the federal government asking him to reconsider his order requiring it to provide the state with the names of 128 DACA recipients who live there, under seal, for the purpose of helping calculate any financial costs associated with their presence.

In addition, it’s possible the case will be transferred to another district court, but that could lead to delays in a decision, attorneys following the case said.

The judge also could take a number of directions in his decision. He could postpone the rule’s effective date, as requested in part of the lawsuit, preventing DACA recipients from enrolling in Obamacare while the case is decided. Or he could leave the effective date as it stands while the case proceeds.

With any decision, the judge could decide to apply the ruling nationally or limit it to just the states that challenged the government rule, Baron said.

“The approach taken by different judges has varied,” Baron said. “There has been a practice to vacate some regulatory provisions nationwide, but a lot of judges, including justices on the Supreme Court, also have cited concerns about individual judges being able to affect policy this way.”

Even as the case moves along, Espíritu said his organization is encouraging DACA recipients to enroll once the sign-up period begins nationally in November.

“It’s important to enroll as soon as possible,” he said, adding that organizations such as his will continue to monitor the case and give updates if the situation changes. “We know that getting access to good affordable health care can be transformative to people’s lives.”

This case challenging the rule is wholly separate from another case, brought by some of the same states as those opposed to the ACA rule, seeking to entirely end the DACA program. That case is currently in the appeals process in federal court.

Cuando comience el período de inscripción abierta para adquirir cobertura médica en los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio, conocida como Obamacare, un grupo que antes no podía inscribirse será elegible por primera vez: los “Dreamers”. Ese es el nombre de los niños traídos a los Estados Unidos sin papeles que están bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA).

Bajo una normativa de la administración Biden, que ha sido objeto de controversia en algunos estados, los beneficiarios de DACA podrán inscribirse para la cobertura del Obamacare y, si cumplen con los requisitos de ingresos, recibir subsidios para pagar sus primas.

Del medio millón de beneficiarios de DACA, el gobierno estima que alrededor de 100.000 que anteriormente no tenían seguro podrían inscribirse a partir del 1 de noviembre, fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

Sin embargo, el destino de esta normativa sigue siendo incierto. Está siendo impugnada en un tribunal federal por Kansas y otros 18 estados, incluidos varios en el sur y el medio oeste, así como Montana, New Hampshire y Dakota del Norte.

Por otro lado, 19 estados y el Distrito de Columbia presentaron un escrito en apoyo a la normativa de la administración de Biden. Liderados por Nueva Jersey, estos estados incluyen a muchos en las costas este y oeste, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

La normativa, finalizada en mayo, aclara que aquellos que califican para DACA serán considerados como “presencia legal” para el propósito de inscribirse en lo planes médicos bao ACA, los cuales están abiertos a ciudadanos estadounidenses e inmigrantes con papeles.

“El cambio de normativa es muy importante, ya que corrige una exclusión errónea y de larga data de los beneficiarios de DACA para la cobertura de ACA,” dijo Nicholas Espíritu, director legal adjunto del National Immigration Law Center, que también ha presentado escritos en apoyo a este cambio.

El presidente Barack Obama estableció DACA en junio de 2012 mediante una acción ejecutiva para proteger de la deportación y proporcionar autorización de trabajo a algunos residentes sin documentos, que habían sido traídos al país de niños por sus familias. Esto si cumplían con ciertos requisitos, incluidos haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o haber servido en las fuerzas armadas.

Los estados que impugnan la normativa de ACA dicen que causará cargas administrativas y de recursos a medida que más personas se inscriban, y que fomentará que más personas permanezcan en el país sin papeles. La demanda, presentada en agosto en el Tribunal de Distrito de EE.UU. para el Distrito de Dakota del Norte, busca posponer la fecha de entrada en vigencia de la normativa y anularla, argumentando que la expansión de la definición de “presencia legal” por parte de la administración Biden viola la ley.

El 15 de octubre, el juez de distrito de EE.UU., Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, escuchó los argumentos en el caso.

Los estados demandantes están presionando para que se actúe rápido, y es posible que se emita un fallo antes del inicio de la inscripción abierta a nivel nacional, dijo Zachary Baron, experto legal en la Facultad de Derecho de Georgetown, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Sin embargo, el panorama es complicado.

Para empezar, en una batalla legal como ésta, quienes presentan el caso deben demostrar el daño que se alega, como los costos adicionales que la normativa obligará a los estados a absorber. Solo hay alrededor de 128 beneficiarios de DACA en Dakota del Norte, donde se está llevando a cabo el caso, y no todos probablemente se inscribirán en el seguro de ACA.

Además, Dakota del Norte no se encuentra entre los estados que administran su propio mercado de inscripción. Depende del sitio federal cuidadodesalud.gov, lo que hace que sea más difícil cumplir con la carga legal.

“Aunque Dakota del Norte no gasta dinero para adquirir atención médica de ACA, aún están afirmando de alguna manera que están siendo perjudicados,” dijo Espíritu, del centro de leyes de inmigración, que representa a varios beneficiarios de DACA y a CASA, una organización sin fines de lucro de defensa de los inmigrantes, en oposición a los esfuerzos estatales por anular la normativa.

Durante la audiencia, Traynor se centró en este tema y señaló que un estado que administre su propio mercado podría ser un mejor lugar para un caso así. Ordenó a los demandados presentar más información antes del 29 de octubre, y a Dakota del Norte responder antes del 12 de noviembre.

El lunes 28 de octubre, el juez denegó una moción del gobierno federal que le solicitaba reconsiderar su orden de proporcionar al estado, bajo sello, los nombres de 128 beneficiarios de DACA que residen allí, con el fin de ayudar a calcular los costos financieros asociados con su presencia.

Además, es posible que el caso sea transferido a otro tribunal de distrito, lo que podría causar demoras en una decisión, según los abogados que siguen el caso.

El juez también podría tomar decidir en varias direcciones. Podría posponer la fecha de vigencia de la normativa, como se solicita en parte de la demanda, impidiendo que los beneficiarios de DACA se inscriban en Obamacare mientras se resuelve el caso. O podría dejar la fecha de vigencia tal como está mientras el caso avanza.

Con cualquiera de las opciones, el juez podría decidir aplicar el fallo a nivel nacional o limitarlo solo a los estados que impugnaron la normativa gubernamental, explicó Baron.

“El enfoque adoptado por diferentes jueces ha variado”, dijo Baron. “Ha habido una práctica de anular algunas disposiciones reglamentarias a nivel nacional, pero muchos jueces, incluidos jueces de la Corte Suprema, también han expresado preocupaciones sobre que jueces individuales puedan afectar la política de esta manera”.

A medida que el caso avanza, Espíritu dijo que su organización está alentando a los beneficiarios de DACA a inscribirse apenas comience el período de inscripción a nivel nacional.

“Es importante inscribirse lo antes posible”, dijo, agregando que organizaciones como la suya continuarán monitoreando el caso y dando actualizaciones si la situación cambia. “Sabemos que obtener acceso a atención médica buena y asequible puede transformar la vida de las personas”.

Este caso que impugna la normativa es completamente separado de otro caso, presentado por algunos de los mismos estados que se oponen a la normativa de ACA, que busca terminar por completo el programa DACA. Ese caso actualmente está en el proceso de apelación en un tribunal federal.

KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.

There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.

Louvenia McKinney, 77, arrived complaining about shortness of breath.

Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.

Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.

But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.

“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”

About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.

But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.

The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.

“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”

The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”

Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.

And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.

Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.

Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.

Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.

And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.

“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.

KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.

From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.

Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.

All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.

“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.

Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”

Past and Present

The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.

“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.

Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.

Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.

The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.

Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.

“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”

For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.

And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.

Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.

Now he cannot work and at times has difficulty walking.

“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.

Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.

When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.

She is convinced that being a Black woman made her challenges more likely.

“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.

“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.

In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.

President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”

“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.

The CDC, along with some state and local governments, declared racism a serious public health threat.

U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.

“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.

In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.

“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”

Governor’s Veto

The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.

But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.

Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.

There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.

Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”

Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.

“It is not a panacea,” he said.

But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.

“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”

A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.

“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”

South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”

Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.

Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”

Health care is suddenly front and center in the final sprint to the presidential election, and the outcome will shape the Affordable Care Act and the coverage it gives to more than 40 million people.

Besides reproductive rights, health care for most of the campaign has been an in-the-shadows issue. However, recent comments from former President Donald Trump and his running mate, Ohio Sen. JD Vance, about possible changes to the ACA have opened Republicans up to heavier scrutiny.

More than 1,500 doctors across the country recently released a letter calling on Trump to reveal details about how he would alter the ACA, saying the information is needed so voters can make an informed decision. The letter came from the Committee to Protect Health Care, a national advocacy group of physicians.

“It’s remarkable that a decade and a half after the ACA passed, we are still debating these fundamental issues,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “Democrats want to protect people with preexisting conditions, which requires money and regulation. Republicans have looked to scale back federal regulation, and the byproduct is fewer protections.”

The two parties’ tickets hold starkly different goals for the ACA, a sweeping law passed under former President Barack Obama that set minimum benefit standards, made more people eligible for Medicaid, and ensured consumers with preexisting health conditions couldn’t be denied health coverage.

Vice President Kamala Harris, who previously backed a universal health care plan, wants to expand and strengthen the health law, popularly known as Obamacare. She supports making permanent temporary enhanced subsidies that lower the cost of premiums. And she’s expected to press Congress to extend Medicaid coverage to more people in the 10 states that have so far not expanded the program.

Trump, who repeatedly tried and failed to repeal the ACA, said in the September presidential debate that he has “concepts of a plan” to replace or change the legislation. Although that sound bite became a bit of a laugh line because Trump had promised an alternative health insurance plan many times during his administration and never delivered, Vance later provided more details.

He said the next Trump administration would deregulate insurance markets — a change that some health analysts say could provide more choice but erode protections for people with preexisting conditions. He seemed to adjust his position during the vice presidential debate, saying the ACA’s protections for preexisting conditions should be left in place.

Such health policy changes could be advanced as part of a large tax measure in 2025, Sen. Tom Cotton (R-Ark.) told NBC News. That could also open the door to changes in Medicaid. Conservatives have long sought to remake the health insurance program for low-income or disabled people from the current system, in which the federal government contributes a formula-based percentage of states’ total Medicaid costs, to one that caps federal outlays through block grants or per capita funding limits. ACA advocates say that would shift significant costs to states and force most or all states to drop the expansion of the program over time.

Democrats are trying to turn the comments into a political liability for Trump, with the Harris campaign running ads saying Trump doesn’t have a health plan to replace the ACA. Harris’ campaign also released a 43-page report, “The Trump-Vance ‘Concept’ on Health Care,” asserting that her opponents would “rip away coverage from people with preexisting conditions and raise costs for millions.”

Republicans were tripped up in the past when they sought unsuccessfully to repeal the ACA. Instead, the law became more popular, and the risk Republicans posed to preexisting condition protections helped Democrats retake control of the House in 2018.

In a KFF poll last winter, two-thirds of the public said it is very important to maintain the law’s ban on charging people with health problems more for health insurance or rejecting their coverage.

“People in this election are focused on issues that affect their family,” said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “If people believe their own insurance will be affected by Trump, it could matter.”

Vance, in a Sept. 15 interview on NBC’s “Meet the Press,” tried to minimize this impact.

“You want to make sure that preexisting coverage — conditions — are covered, you want to make sure that people have access to the doctors that they need, and you also want to implement some deregulatory agenda so that people can choose a health care plan that fits them,” he said.

Vance went on to say that the best way to ensure everyone is covered is to promote more choice and not put everyone in the same insurance risk pool.

Risk pools are fundamental to insurance. They refer to a group of people who share the burdens of health costs.

Under the ACA, enrollees are generally in the same pool regardless of their health status or preexisting conditions. This is done to control premium costs for everyone by using the lower costs incurred by healthy participants to keep in check the higher costs incurred by unhealthy participants. Separating sicker people into their own pool can lead to higher costs for people with chronic health conditions, potentially putting coverage out of financial reach for them.

The Harris campaign has seized on the threat, saying in its recent report that “health insurers will go back to discriminating on the basis of how healthy or unhealthy you are.”

But some ACA critics think there are ways to separate risk pools without undermining coverage.

“Unsurprisingly, it’s been blown out of proportion for political purposes,” said Theo Merkel, a former Trump aide who now is a senior research fellow at the Paragon Health Institute, a right-leaning organization that produces health research and market-based policy proposals.

Adding short-term plans to coverage options won’t hurt the ACA marketplace and will give consumers more affordable options, said Merkel, who is also a senior fellow at the Manhattan Institute. The Trump administration increased the maximum duration of these plans, then Biden rolled it back to four months.

People eligible for subsidies would likely buy comprehensive ACA plans because — with the financial help — they would be affordable. Thus, the ACA market and its protections for preexisting conditions would continue to function, Merkel said. But offering short-term plans, too, would provide a more affordable option for people who don’t qualify for subsidies and who would be more likely to buy the noncompliant plans.

He also said that in states that allowed people to buy non-ACA-compliant plans outside the exchange, the exchanges performed better than in states that prohibited it. Another option, Merkel said, is a reinsurance program similar to one that operates in Alaska. Under the plan, the state pays insurers back for covering very expensive health claims, which helps keep premiums affordable.

But advocates of the ACA say separating sick and healthy people into different insurance risk pools will make health coverage unaffordable for people with chronic conditions, and that letting people purchase short-term health plans for longer durations will backfire.

“It uninsures people when they get sick,” said Leslie Dach, executive chair of Protect Our Care, which advocates for the health law. “There’s no reason to do this. It’s unconscionable and makes no economic sense. They will hide behind saying ‘we’re making it better,’ but it’s all untrue.”

Harris, meanwhile, wants to preserve the temporary expanded subsidies that have helped more people get lower-priced health coverage under the ACA. These expanded subsidies that help about 20 million people will expire at the end of 2025, setting the stage for a pitched battle in Congress between Republicans who want to let them run out and Democrats who say they should be made permanent.

Democrats in September introduced a bill to make them permanent. One challenge: The Congressional Budget Office estimated doing so would increase the federal deficit by more than $330 billion over 10 years.

In the end, the ability of either candidate to significantly grow or change the ACA rests with Congress. Polls suggest Republicans are in a good position to take control of the Senate, with the outcome in the House more up in the air. The margins, however, will likely be tight. In any case, many initiatives, such as expanding or restricting short-term health plans, also can be advanced with executive orders and regulations, as both Trump and Biden have done.

Tom Zawierucha, 58, a building services worker in New Jersey, wishes candidates would talk more about protecting older Americans from big medical bills.

Teresa Morton, 43, a freight dispatcher in Memphis, Tennessee, with two teenagers, wants to hear more about how elected officials would help working Americans saddled with unaffordable deductibles.

Yessica Gray, 28, a customer support representative in Wisconsin, craves relief from high drug prices and medical bills that have driven her and her husband deep into debt. “How much are we going to pay?” she said. “It’s just something that’s always on my mind.”

Health care hasn’t figured prominently in this increasingly acrimonious presidential campaign. And the economy has generally topped the list of voters’ concerns.

But Americans remain intensely worried about paying for medical care, national surveys show.

Two in 3 U.S. adults in a recent nationwide poll by West Health and Gallup said they’re concerned a major health event would land them in debt. A similar share said health care isn’t getting enough attention in the campaign.

To better understand voters’ health care concerns as the 2024 campaign nears an end, KFF Health News worked with research firm PerryUndem, which convened a pair of focus groups last week with 16 people from across the country. PerryUndem, which paid to organize the focus groups, is a nonpartisan firm based in Washington, D.C., that studies public views on health care and other issues.

The focus group participants represented a broad swath of the electorate, with some favoring Republican candidates, and others Democrats. But nearly all shared a common complaint: Neither presidential candidate has talked enough about how they’d help people struggling to pay for medical care.

“You don’t really hear anything much about health care costs,” said Bob Groegler, 46, who works in residential financing in eastern Pennsylvania. Groegler said he’s worried he may never be able to retire because he won’t have enough money to pay his medical bills.

Former President Donald Trump, the Republican nominee, hasn’t offered a detailed health care agenda, though he criticizes current laws and said he has “concepts of a plan” to improve the 2010 Affordable Care Act, often called Obamacare.

Vice President Kamala Harris, a Democrat, has laid out more detailed health care proposals, including building on legislation signed by President Joe Biden to lower patients’ bills.

In 2022, Biden signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35 monthly cap on insulin. The legislation also provides additional federal aid to help Americans buy health insurance through the Affordable Care Act, though this aid will expire unless Congress and the president renew it next year.

Harris has said she will expand the aid and push for new assistance to Medicare enrollees who need home care. She also has pledged to continue federal efforts to relieve medical debt, a nationwide problem that burdens about 100 million people.

But most of the focus group participants said they knew little about these proposals, complaining that hot-button issues like abortion have dominated the campaign.

Many also expressed deep skepticism that either Harris or Trump would do much to lighten the burden of medical bills.

“I believe they’re out of touch with our reality,” said Renata Bobakova, 46, a teacher and mother outside Cleveland. “We never know when we’ll get sick. We never know when we’ll fall down or sprain an ankle. And prices really can be astronomical. … I’m constantly worried about that.”

Bobakova, who is from Slovakia, said she went back to Europe to give birth to her daughter 10 years ago to avoid crippling medical debt she knew she’d incur in this country. Parents with private health coverage face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance.

Other focus group participants said they or people they knew had left the country to get cheaper prescription drugs. The U.S. has the highest medical prices in the world, research shows.

Several focus group participants, such as Kevin Gaudette, 64, a retired semiconductor engineer in North Carolina, blamed large hospitals, drug companies, and insurers for blocking efforts to lower patients’ costs to protect their profits. “I think everybody has their finger in the pie,” Gaudette said.

Martha Chapman, 64, who is also retired and lives in Philadelphia, pointed to what she called “corporate greed.” “I just don’t think it’s going to change,” she said.

In the closing days of the campaign, that cynicism represents a particular problem for Harris, said PerryUndem co-founder Michael Perry, who led the two focus groups.

Harris has tried to distinguish herself as the candidate who is more serious about policy and more sympathetic to voters’ economic struggles, Perry said. And in recent weeks, she’s begun airing new ads highlighting health care issues.

But even focus group participants who said they lean Democratic seemed to blame both candidates for not addressing Americans’ health care concerns. “They’re not feeling listened to,” Perry said.

Many of the participants nevertheless continued to express hope that an issue as important as health care would someday get the attention of elected officials, regardless of political party.

“We’re all human beings here. We’re all people just trying to make it,” said Zawierucha, the building services worker in New Jersey. “If we get sick or have to go in and get something done, we should have that peace of mind that we can go in there and not have to worry about paying it off for the next 20 years.”

“Just give us some peace of mind,” he said.

[Clarification: This article was revised at 11:35 a.m. ET on Oct. 24, 2024, to more clearly describe how the focus groups were organized.]

CUTHBERT, Ga. — While customers at Adams Family Pharmacy picked up their prescriptions on a hot summer day, some stopped in for coffee, ice cream, homemade cake, or cookies.

It wasn’t a bake sale, but the sweets bring extra revenue as pharmacist and co-owner Nikki Bryant works to achieve profitability at her business on the town square.

Bryant said she is doing all she can to bolster it against a powerful force that threatens her and other independent pharmacists: the middlemen who manage virtually all prescriptions written in the U.S., called pharmacy benefit managers, or PBMs. Serving as brokers among drugmakers, pharmacies, and health insurers, these health care entities have drawn scrutiny from Congress, the Federal Trade Commission, and state legislatures for their role in the increase in drug prices.

Bryant and other independent pharmacists say PBMs not only create higher costs but also make it harder for patients to access medications. So they were hopeful about state legislation this year that would have increased their reimbursement to match the average prices paid to retail chain pharmacies through the state employee health plan. But Gov. Brian Kemp vetoed the bill.

Kemp cited a fiscal estimate that it would cost the state as much as $45 million a year and said “the General Assembly failed to fund this initiative.”

Underlining the Georgia legislative reform effort against pharmacy benefit managers was an analysis by the American Pharmacy Cooperative, which represents independent pharmacies, that reviewed the price differential paid to a north Georgia pharmacy and nearby chain stores.

The analysis early this year showed chains were paid well beyond the family business for many of the same medications: For example, the chains received an average of nearly $54 for the antidepressant bupropion, while Bell’s Family Pharmacy in Tate, Georgia, got $5.54, the analysis said. For a drug used to treat blood pressure, amlodipine, chain pharmacies received an average of $23.55, while Bell’s got $1.51.

Bell’s Family Pharmacy closed earlier this year.

“The differences in Georgia are unbelievable,” Antonio Ciaccia, who runs Ohio-based consulting firm 3 Axis Advisors. “If you’re a pharmacist, you don’t have any control over which drugs you dispense and which you don’t.”

By controlling prices and availability, pharmacy benefit managers cause patients and employers to spend more for medications, according to the Federal Trade Commission and pharmacy groups. On Sept. 20, the FTC sued three of the largest PBMs — CVS Health’s Caremark, Cigna’s Express Scripts, and UnitedHealth Group’s Optum Rx, which together control about 80% of U.S. prescription drug sales. The agency said they created a “perverse drug rebate system” that artificially inflates the price of insulin. Each company denied the allegations.

The lawsuit followed a scathing FTC report in July that said the “dominant PBMs can often exercise significant control over which drugs are available, at what price, and which pharmacies patients can use to access their prescribed medications.”

The trade group that represents PBMs, the Pharmaceutical Care Management Association, said the insulin market is working well and blamed drugmakers for historically higher prices of the medication.

Bryant and other independent pharmacists, though, say they lose money filling certain prescriptions while reimbursements favor chain pharmacies like CVS that have corporate ties to pharmacy benefit managers. And even the chain pharmacies have retrenched, with CVS, Rite Aid, and Walgreens announcing layoffs or store closures in recent months.

“PBMs are like the mafia,” Bryant said. “They pay us what they want to pay us. They are sucking all the money out of health care.”

Pharmacy benefit managers will charge some health insurance plans more for a medication than what they reimburse a pharmacy, keeping the extra money as profit, critics say. This practice is known as “spread pricing.” Large PBMs also take money from drugmakers as a “rebate” to give their drugs preferential treatment on health plans’ lists of medications, independent pharmacies say. And by favoring certain pharmacies with whom they have business ties, experts say, these drug brokers help force independent stores such as Bell’s to close.

The veto by Kemp, a Republican, came despite the GOP-led General Assembly voting overwhelmingly for Senate Bill 198 on the last day of the legislative session.

Kemp spokesperson Garrison Douglas said, “The governor remains entirely and wholeheartedly supportive of Georgia’s independent pharmacists and the need for PBM transparency.”

In his veto message, Kemp voiced support for a study of independent pharmacy drug reimbursements and PBM practices. And he said independent pharmacists are getting an extra $3 dispensing fee this year on state employee prescriptions.

The state Department of Community Health, which oversees the State Health Benefit Plan, told KFF Health News that CVS Caremark, the PBM handling the state employee business, supplied the cost estimate Kemp used to justify his veto.

Fiona Roberts, a spokesperson for Community Health, said the department didn’t have time to conduct its own analysis.

CVS Caremark said it used historical claims data to calculate the cost impact of the higher reimbursement.

Nationally, criticism of PBM practices intensified over the summer with the Federal Trade Commission report.

The Pharmaceutical Care Management Association pushed back, saying the report “is based on anecdotes and comments from anonymous sources and self-interested parties and supported only by two cherry-picked case studies that are implied to be representative of the entire market.”

Members of both parties in Congress have tackled PBM reform. House members recently introduced another proposal, known as the Pharmacists Fight Back Act, which supporters say would add transparency, limit costs for patients, ensure they get the benefit of drugmaker discounts, and protect their pharmacy choices.

The consolidation that has combined health insurers with PBMs — including their operating their own retail, mail-order, and specialty pharmacies — has created financial behemoths, said U.S. Rep. Buddy Carter, a Georgia Republican and a pharmacist. “I’m interested in busting them up,” he said.

Alexander Oshmyansky, co-founder of Mark Cuban Cost Plus Drug Company, said the PBMs siphon off about a third of the $400 billion a year spent on pharmaceuticals.

“What we could do as a society with $100 billion as opposed to paying some companies to process drug payments,” Oshmyansky said.

PCMA, the trade group, cited a report funded by the three biggest pharmacy benefit managers that said their operating margins are less than 5%.

And the group says that discussions about congressional reform “reflect a one-sided view informed directly by the pharmaceutical industry’s blame game designed to vilify PBMs to keep prescription drug prices high and increase drug company profits.”

Underpayments by PBMs, however, have accelerated the closures of mom-and-pop pharmacies across the country, said the National Community Pharmacists Association, which represents independent pharmacies.

The U.S. loses almost one such pharmacy a day, said Anne Cassity, a senior vice president of the association. Rural pharmacies, which are hard to reach for patients lacking transportation, are especially vulnerable, she said.

Bryant’s two pharmacies deliver to several counties, including to patients who have a disability or no transportation. The cost to patients: zero.

Most states have passed some version of oversight or restrictions on pharmacy benefit managers.

In Montana, state officials have collected financial reports from pharmacy benefit managers over the past two years after passing a bill to promote transparency in these businesses.

Data from 2022 shows that rebates in Montana rarely are directly returned to people buying prescriptions. Instead, they’re pocketed by the PBMs or returned to health plans.

Josh Morris, who owns three independent rural pharmacies in southwestern Montana, said his pharmacies have seen reimbursement rates for medications bought under PBM-managed plans drop.

Morris said his business routinely either breaks even or loses money. “Our plan is that once we reach a certain level of cash, that we will be out,” Morris said. “As in ‘closed.’”

Frank Cote, with Montana’s insurance commissioner’s office, said that the state has tried to make business easier for small pharmacies but that state officials still don’t control how much PBMs pay. Cote said the state will look for ways within existing rules or future legislation to support rural pharmacies.

Following Kemp’s veto in Georgia, the pharmacy pay differential sparked criticism from an unusual place: within the board of the state Department of Community Health, the agency that runs the State Health Benefit Plan.

Mark Shane Mobley, a board member, said at an August meeting that independent pharmacies’ pay in the state employee plan should be on par with a chain’s. The PBM profit “is going to line people’s pockets that are far outside of the state,” said Mobley, president of Avilys Sleep & EEG, a Georgia provider of sleep disorder and electroencephalogram testing. “Our independent pharmacies, they’re hiring people locally. They’re taking care of the local community.”

Community Health Commissioner Russel Carlson said the agency has an ongoing dialogue with CVS Caremark, the PBM handling the state employee plan medications.

“We don’t have our head in the sand. We know there are some frustrations out there that exist in this space,” he said. “But we acknowledge that we do have contractual responsibilities.”

In Cuthbert, Bryant said she can make more profit on cake and coffee than with many medications.

Still, she’s in business while a nearby CVS pharmacy closed recently. “We outcompeted them on service,” Bryant said.

Montana correspondent Katheryn Houghton and senior correspondent Arthur Allen contributed to this report.

Cuando Pam McClure se enteró que el próximo año ahorraría casi $4,000 en sus medicamentos recetados dijo: “parece demasiado bueno para ser verdad”.

Para finales de 2024, habrá gastado casi $6,000 en estos fármacos, incluido uno para controlar su diabetes.

McClure, de 70 años, es una de las aproximadamente 3.2 millones de personas con un plan de medicamentos recetados de Medicare cuyos costos de bolsillo se limitarán a $2,000 en 2025 gracias a la Ley de Reducción de la Inflación (IRA, por sus siglas en inglés) de 2022 promulgada por la administración Biden, según un estudio de Avalere/AARP.

La IRA, una ley de atención médica y clima que el presidente Joe Biden y la vicepresidenta Kamala Harris promueven en la campaña como uno de los mayores logros de su administración, rediseñó radicalmente el beneficio de medicamentos de Medicare, conocido como Parte D, que sirve a unas 53 millones de personas de 65 años o más, o que viven con ciertas discapacidades.

Gracias a este nuevo límite en el gasto de bolsillo y otros cambios importantes, pero menos conocidos, la administración estima que alrededor de 18.7 millones de personas ahorrarán aproximadamente $7.4 mil millones solo el próximo año.

El período de inscripción anual para que los beneficiarios de Medicare renueven o cambien su cobertura de medicamentos, o elijan un plan Medicare Advantage, comenzó el 15 de octubre y se extiende hasta el 7 de diciembre. Medicare Advantage es la alternativa comercial al Medicare tradicional administrado por el gobierno y cubre atención médica y, a menudo, medicamentos recetados.

Los planes de medicamentos independientes de Medicare, que cubren medicamentos que normalmente se toman en casa, también son administrados por compañías de seguros privadas.

“Siempre alentamos a los beneficiarios a que realmente revisen los planes y elijan la mejor opción para ellos”, dijo Chiquita Brooks-LaSure, quien dirige los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), a KFF Health News. “Y este año, en particular, es importante hacerlo porque el beneficio ha cambiado mucho”.

Las mejoras a la cobertura de medicamentos de Medicare requeridas por la IRA son los cambios más importantes desde que el Congreso agregó el beneficio en 2003, pero la mayoría de los votantes no los conocen, según encuestas de KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News. Y algunos beneficiarios pueden sorprenderse por un inconveniente: algunos planes aumentarán sus primas.

El 27 de septiembre, los CMS dijeron que, a nivel nacional, la prima promedio de los planes de medicamentos de Medicare disminuyó alrededor de $1.63 al mes —aproximadamente un 4%— respecto al año pasado.

“Las personas inscritas en un plan de la Parte D de Medicare seguirán viendo primas estables y tendrán amplias opciones de planes asequibles”, dijeron los CMS en un comunicado.

Sin embargo, un análisis de KFF encontró que “muchas aseguradoras están aumentando las primas” y que grandes aseguradoras como UnitedHealthcare y Aetna también redujeron la cantidad de planes que ofrecen.

Las propuestas iniciales de primas de muchas aseguradoras de la Parte D para 2025 fueron aún más altas. Para amortiguar el impacto del precio, la administración Biden creó lo que llama un programa de demostración para pagar a las aseguradoras $15 adicionales al mes por beneficiario si aceptaban limitar los aumentos de primas a no más de $35.

“En ausencia de esta demostración, los aumentos de primas ciertamente habrían sido mayores”, escribió Juliette Cubanski, subdirectora del Programa de Políticas de Medicare en KFF, en su análisis del 3 de octubre.

Casi todas las aseguradoras de la Parte D aceptaron el acuerdo. Los republicanos lo han criticado, cuestionando la autoridad de los CMS para hacer los pagos adicionales y llamándolos una maniobra política en un año electoral.

Sea cual sea la razón, las primas están subiendo dramáticamente para algunos planes.

En el estado de Nueva York, por ejemplo, la prima del popular plan Value Script de Wellcare pasó de $3.70 mensuales a $38.70 el próximo año, un aumento de $35, más de diez veces que el costo actual.

Cubanski identificó ocho planes en California que aumentaron sus primas exactamente $35 al mes. KFF Health News encontró que las primas aumentaron en al menos el 70% de los planes de medicamentos ofrecidos en California, Texas y Nueva York, y en alrededor de la mitad de los planes en Florida y Pennsylvania, los cinco estados con más beneficiarios de Medicare.

Voceros de Wellcare y de su empresa matriz, Centene Corp., no respondieron a las solicitudes de comentarios. En una declaración este mes, la vicepresidenta senior de servicios clínicos y especializados de Centene, Sarah Baiocchi, dijo que Wellcare ofrecería el plan Value Script sin prima en 43 estados.

Además del límite de $2,000 en el gasto de medicamentos, la IRA limita los copagos de Medicare para la mayoría de los productos de insulina a no más de $35 al mes y permite que Medicare negocie directamente los precios de algunos de los medicamentos más caros directamente con las farmacéuticas.

También eliminará una de las características más frustrantes del beneficio de medicamentos, una brecha conocida como el “agujero de dona (doughnut hole)” que suspende la cobertura justo cuando las personas enfrentan crecientes costos de medicamentos, obligándolas a pagar el precio completo de las drogas de su plan de su bolsillo hasta que alcancen un umbral de gasto que cambia de un año a otro.

La ley también amplía la elegibilidad para los subsidios de “ayuda adicional” para aproximadamente 17 millones de personas de bajos ingresos en los planes de medicamentos de Medicare y aumenta el monto del subsidio. Las farmacéuticas deberán contribuir para ayudar a pagarlo.

A partir del 1 de enero, el beneficio de medicamentos rediseñado funcionará más como otras pólizas de seguro privado. La cobertura comienza después que los pacientes paguen un deducible, que no será mayor de $590 el próximo año. Algunos planes ofrecen un deducible menor o ninguno, o excluyen ciertos medicamentos, generalmente genéricos baratos, del deducible.

Después que los beneficiarios gasten $2,000 en deducibles y copagos, el resto de sus medicamentos de la Parte D serán gratuitos.

Eso se debe a que la IRA aumenta la parte de la factura asumida por las aseguradoras y las compañías farmacéuticas. La ley también intenta frenar futuros aumentos de precios de medicamentos al limitar los aumentos a la tasa de inflación al consumidor, que fue del 3.4% en 2023. Si los precios suben más rápido que la inflación, las farmacéuticas deben pagar a Medicare la diferencia.

“Antes del rediseño, la Parte D incentivaba los aumentos de precios de los medicamentos”, dijo Gina Upchurch, farmacéutica y directora ejecutiva de Senior PharmAssist, una organización sin fines de lucro en Durham, Carolina del Norte, que asesora a beneficiarios de Medicare. “La forma en que está diseñada ahora coloca más obligaciones financieras en los planes y los fabricantes, presionándolos para que ayuden a controlar los precios”.

Otra disposición de la ley permite a los beneficiarios pagar los medicamentos en un plan de pago a plazos, en lugar de tener que pagar una factura abultada en un corto período de tiempo.

Las aseguradoras deben hacer los cálculos y enviar una factura mensual a los titulares de pólizas, que se ajustará si se agregan o eliminan medicamentos.

Junto con los grandes cambios introducidos por la IRA, los beneficiarios de Medicare deben prepararse para las sorpresas inevitables que surgen cuando las aseguradoras revisan sus planes para un nuevo año. Además de aumentar las primas, las aseguradoras pueden eliminar medicamentos cubiertos y eliminar farmacias, médicos u otros servicios de las redes de proveedores que los beneficiarios deben usar.

Perder la oportunidad de cambiar de plan significa que la cobertura se renovará automáticamente, incluso si cuesta más o ya no cubre los medicamentos que el afiliado necesito o sus farmacias preferidas.

La mayoría de los beneficiarios no pueden realizar ningún cambio en sus planes, o pasar a otros por fuera del período de inscripción annual, a menos que los CMS les otorgue un “período de inscripción especial”.

Sin embargo, muchos no se toman el tiempo para comparar docenas de planes que pueden cubrir diferentes medicamentos a diferentes precios en diferentes farmacias, incluso cuando el esfuerzo podría ahorrarles dinero.

En 2021, solo el 18% de los inscritos en planes de medicamentos de Medicare Advantage y el 31% de los miembros de planes de medicamentos independientes compararon los beneficios y costos de su plan con los de los competidores, según encontraron investigadores de KFF.

Para obtener ayuda gratuita e imparcial para elegir un plan de medicamentos, los beneficiarios pueden comunicarse con el Programa de Asistencia Estatal de Seguros de Salud (SHIP) de su estado en shiphelp.org o en la línea de ayuda 1-877-839-2675.

When Pam McClure learned she’d save nearly $4,000 on her prescription drugs next year, she said, “it sounded too good to be true.” She and her husband are both retired and live on a “very strict” budget in central North Dakota.

By the end of this year, she will have spent almost $6,000 for her medications, including a drug to control her diabetes.

McClure, 70, is one of about 3.2 million people with Medicare prescription drug insurance whose out-of-pocket medication costs will be capped at $2,000 in 2025 because of the Biden administration’s 2022 Inflation Reduction Act, according to an Avalere/AARP study.

“It’s wonderful — oh my gosh. We would actually be able to live,” McClure said. “I might be able to afford fresh fruit in the wintertime.”

The IRA, a climate and health care law that President Joe Biden and Vice President Kamala Harris promote on the campaign trail as one of their administration’s greatest accomplishments, radically redesigned Medicare’s drug benefit, called Part D, which serves about 53 million people 65 and older or with disabilities. The administration estimates that about 18.7 million people will save about $7.4 billion next year alone due to the cap on out-of-pocket spending and less publicized changes.

The annual enrollment period for Medicare beneficiaries to renew or switch drug coverage or to choose a Medicare Advantage plan began Oct. 15 and runs through Dec. 7. Medicare Advantage is the commercial alternative to traditional government-run Medicare and covers medical care and often prescription drugs. Medicare’s stand-alone drug plans, which cover medicines typically taken at home, are also administered by private insurance companies.

“We always encourage beneficiaries to really look at the plans and choose the best option for them,” Chiquita Brooks-LaSure, who heads the Centers for Medicare & Medicaid Services, told KFF Health News. “And this year in particular it’s important to do that because the benefit has changed so much.”

Improvements to Medicare drug coverage required by the IRA are the most sweeping changes since Congress added the benefit in 2003, but most voters don’t know about them, KFF surveys have found. And some beneficiaries may be surprised by a downside: premium increases for some plans.

CMS said Sept. 27 that nationwide the average Medicare drug plan premium fell about $1.63 a month — about 4% — from last year. “People enrolled in a Medicare Part D plan will continue to see stable premiums and will have ample choices of affordable Part D plans,” CMS said in a statement.

However, an analysis by KFF, a health information nonprofit that includes KFF Health News, found that “many insurers are increasing premiums” and that large insurers including UnitedHealthcare and Aetna also reduced the number of plans they offer.

Many Part D insurers’ initial 2025 premium proposals were even higher. To cushion the price shock, the Biden administration created what it calls a demonstration program to pay insurers $15 extra a month per beneficiary if they agreed to limit premium increases to no more than $35.

“In the absence of this demonstration, premium increases would certainly have been larger,” Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, wrote in her Oct. 3 analysis.

Nearly every Part D insurer agreed to the arrangement. Republicans have criticized it, questioning CMS’ authority to make the extra payments and calling them a political ploy in an election year. CMS officials say the government has taken similar measures when implementing other Medicare changes, including under President George W. Bush, a Republican.

In California, for example, Wellcare’s popular Value Script plan went from 40 cents a month to $17.40. The Value Script plan in New York went from $3.70 a month to $38.70, a more than tenfold hike — and precisely a $35 increase.

Cubanski identified eight plans in California that raised their premiums exactly $35 a month. KFF Health News found that premiums went up for at least 70% of drug plans offered in California, Texas, and New York and for about half of plans in Florida and Pennsylvania — the five states with the most Medicare beneficiaries.

Spokespeople for Wellcare and its parent company, Centene Corp., did not respond to requests for comment. In a statement this month, Centene’s senior vice president of clinical and specialty services, Sarah Baiocchi, said Wellcare would offer the Value Script plan with no premium in 43 states.

In addition to the $2,000 drug spending limit, the IRA caps Medicare copayments for most insulin products at no more than $35 a month and allows Medicare to negotiate prices of some of the most expensive drugs directly with pharmaceutical companies.

It will also eliminate one of the drug benefit’s most frustrating features, a gap known as the “donut hole,” which suspends coverage just as people face growing drug costs, forcing them to pay the plan’s full price for drugs out-of-pocket until they reach a spending threshold that changes from year to year.

The law also expands eligibility for “extra help” subsidies for about 17 million low-income people in Medicare drug plans and increases the amount of the subsidy. Drug companies will be required to chip in to help pay for it.

Starting Jan. 1, the redesigned drug benefit will operate more like other private insurance policies. Coverage begins after patients pay a deductible, which will be no more than $590 next year. Some plans offer a smaller or no deductible, or exclude certain drugs, usually inexpensive generics, from the deductible.

After beneficiaries spend $2,000 on deductibles and copayments, the rest of their Part D drugs are free.

That’s because the IRA raises the share of the bill picked up by insurers and pharmaceutical companies. The law also attempts to tamp down future drug price hikes by limiting increases to the consumer price inflation rate, which was 3.4% in 2023. If prices rise faster than inflation, drugmakers have to pay Medicare the difference.

“Before the redesign, Part D incentivized drug price increases,” said Gina Upchurch, a pharmacist and the executive director of Senior PharmAssist, a Durham, North Carolina, nonprofit that counsels Medicare beneficiaries. “The way it is designed now places more financial obligations on the plans and manufacturers, pressuring them to help control prices.”

Another provision of the law allows beneficiaries to pay for drugs on an installment plan, instead of having to pay a hefty bill over a short period of time. Insurers are supposed to do the math and send policyholders a monthly bill, which will be adjusted if drugs are added or dropped.

Along with big changes brought by the IRA, Medicare beneficiaries should prepare for the inevitable surprises that come when insurers revise their plans for a new year. In addition to raising premiums, insurers can drop covered drugs and eliminate pharmacies, doctors, or other services from the provider networks beneficiaries must use.

Missing the opportunity to switch plans means coverage will renew automatically, even if it costs more or no longer covers needed drugs or preferred pharmacies. Most beneficiaries are locked into Medicare drug and Advantage plans for the year unless CMS gives them a “special enrollment period.”

“We do have a system that is run through private health plans,” CMS chief Brooks-LaSure said. But she noted that beneficiaries “have the ability to change their plans.”

But many don’t take the time to compare dozens of plans that can cover different drugs at different prices from different pharmacies — even when the effort could save them money. In 2021, only 18% of Medicare Advantage drug plan enrollees and 31% of stand-alone drug plan members checked their plan’s benefits and costs against competitors’, KFF researchers found.

For free, unbiased help selecting drug coverage, contact the State Health Insurance Assistance Program at shiphelp.org or 1-877-839-2675.

SACRAMENTO, Calif. — This year, Gov. Gavin Newsom affirmed abortion access, calling California “a proud reproductive freedom state” and criticizing Republicans across the country for trying to take away families’ rights.

He signed legislation mandating that insurance companies cover in vitro fertilization. He supported restricting students’ cellphone use in schools and signed a nation-leading ban on food dye in school snacks and drinks. And he endorsed a bill allowing businesses to operate Amsterdam-style cannabis cafés.

Still, in a heated election cycle with Vice President Kamala Harris, a Californian, on the presidential ticket, the Democratic governor was noticeably reluctant to impose additional industry regulations.

Newsom vetoed several health and safety bills, frequently citing cost concerns. But many of these proposals risked perpetuating California stereotypes trumpeted by presidential nominee Donald Trump and other Republicans. The governor rejected gas stove warning labels, as well as speeding alerts for new cars, even drawing tepid praise on social media from GOP Assembly leader James Gallagher, who credited Newsom for vetoing “some pretty bad/stupid bills.”

Most of the laws Newsom approved take effect Jan. 1, 2025, while some have longer phase-in times. Here are the governor’s actions on key health bills:

Health Care

Group health care service plans and disability insurance must cover infertility and fertility services under SB 729, including for LGBTQ+ people, generally starting in mid-2025. The California Association of Health Plans warns of higher premiums as a result.

Local health officers can inspect private detention facilities, including six immigration detention centers, under SB 1132.

And the governor signed AB 869, allowing small, rural, or “distressed” hospitals to get an extension of up to three years on a 2030 legal deadline for earthquake retrofits. But he vetoed SB 1432, which would have allowed all hospitals to apply for an extension of the deadline for up to five years.

Newsom also vetoed SB 966, which would have regulated the middlemen known as pharmacy benefit managers and banned some business practices that critics say increase costs and limit consumers’ choices. He also rejected AB 2467, which would have mandated health care coverage for menopause, and AB 3129, which would have required the state attorney general’s approval for transactions involving health care providers and private equity firms. And he vetoed AB 2104 and SB 895, which would have allowed some community college districts to offer bachelor’s degrees in nursing.

Medical Debt

Credit reporting agencies will be prohibited from including medical debt in consumers’ credit reports under SB 1061, but last-minute amendments weakened the protections. Earlier this year, the Biden administration proposed federal rules barring unpaid medical bills from affecting patients’ credit scores.

Medi-Cal

Medi-Cal, which provides health care for about 15 million low-income people, will cover hospital emergency rooms’ treatment of psychiatric emergencies under AB 1316.

But Newsom rejected AB 1975, which would have made medically supportive food and nutrition a Medi-Cal benefit, and AB 2339, which would have expanded Medi-Cal coverage of telehealth.

Mental Health

Newsom signed more than a dozen bills aimed at boosting behavioral health care, including through California’s new court-ordered treatment program.

But citing costs, Newsom rejected an annual scholarship fund for students pursuing a mental health profession if they worked for three years in that new treatment program. Critics say SB 26 should have broadened the scholarship to all county behavioral health programs.

Abortion

California will increase penalties for obstructing or impeding access to reproductive health care services, and for posting personal information or photographs of a patient or provider. These are currently misdemeanors; AB 2099 would make them punishable as misdemeanors or felonies.

Planned Parenthood Affiliates of California also backed AB 2085, smoothing approval of new health centers, and SB 1131, supporting California’s Family PACT (Planning, Access, Care, and Treatment) program for people with family incomes below 200% of the federal poverty level.

Aging

Newsom approved a dozen bills related to aging, including measures requiring increased training for law enforcement (AB 2541) and health care professionals (SB 639) in helping people with dementia. AB 1902 requires better access to prescription labels for those who have trouble seeing or who need translated instructions. And he signed another package of bills aimed more broadly at helping people with disabilities.

Violence Prevention

Assault or battery against a doctor, physician, nurse, or other health care worker within an ER could bring up to a year in county jail, a $2,000 fine, or both under AB 977. That makes it the same maximum punishment as for assaulting a medical worker in the field. California law previously set a lesser penalty for assault within an ER.

The state is taking more steps to deter gun violence with two dozen new laws. Among them, SB 53 increases requirements for safely storing firearms, in keeping with a push from the White House. AB 2621 will increase law enforcement training and revise policies on using gun violence restraining orders, while AB 2917 expands when courts can impose gun violence restraining orders.

And hospitals will eventually have to screen patients, family members, and visitors for weapons at entrances under AB 2975.

Substance Use

AB 1976 will require workplace first-aid kits to include naloxone or other drugs that can reverse opioid overdoses, while protecting those who administer the naloxone from civil liability.

Under AB 1775, local jurisdictions will allow retailers to sell noncannabis food and beverages and have live music and other performances in areas where cannabis consumption is allowed. Assembly member Matt Haney, a Democrat from San Francisco, said his intent is to allow Dutch-style cannabis coffeehouses. Newsom approved the measure despite vetoing Haney’s similar bill last year, amid critics’ concern that the measure would undermine California’s nation-leading effort outlawing indoor smoking.

And AB 3218 furthers enforcement of California’s ban on flavored tobacco, passed in 2020.

Youth Welfare

California is the first state to generally bar public schools from providing food containing red dye 40 or any of five other synthetic food dyes used in products including Froot Loops and Flamin’ Hot Cheetos. AB 2316 is Democratic Assembly member Jesse Gabriel’s follow-up to his legislation last year that banned a chemical found in Skittles candy.

A bill to increase transparency with the use of restraints and seclusion rooms in state-licensed short-term residential therapeutic programs became law with some high-profile help from celebrity Paris Hilton. She backed SB 1043, which will also require the state Department of Social Services to post the information on a public dashboard.

And school districts’ sex education curricula must include menstrual health under AB 2229.

But Newsom vetoed AB 2442, which would have sped licensing for providers of gender-affirming care, and SB 954, which would have provided free condoms in high schools.

Women’s Health

Selling menstrual products with intentionally added PFAS, also known as “forever chemicals,” will be banned under AB 2515. PFAS, short for perfluoroalkyl and polyfluoroalkyl substances, have been linked to serious health problems.

AB 2319 was passed in an effort to improve enforcement of a 2019 law aimed at reducing the disproportionate rate of maternal mortality among Black women and other pregnant women of color.

AB 2527 is aimed at improving treatment of pregnant women who are incarcerated. Critics wanted the original version, which banned solitary confinement, and were upset when it was amended to allow up to five days of confinement if prison officials find a safety or security threat.

AB 518 is aimed at increasing participation in the CalFresh nutrition program, part of a package of healthy-food bills.

And under SB 1300, the public will get more notice when hospitals plan to close their maternity wards. The measure will increase the notice requirement to 120 days, up from the current 90.

But Newsom rejected AB 1895, which would have required six months’ notice to state agencies of potential maternity ward closures. The agencies would then have been required to conduct a community impact assessment.

Social Media

SB 1504 broadens California’s Cyberbullying Protection Act regulating social media platforms to apply to minors instead of pupils. Social media platforms that intentionally violate the law could face civil penalties of up to $10,000, along with compensatory and punitive damages. Those damages could be sought by a parent, a legal guardian, or various prosecutors. Under current law, damages are capped at $7,500 and may be pursued only by the state attorney general.

SB 976 restricts “addictive feeds” to minors, including banning social media notifications to minors during school hours.

And AB 3216 will limit the use of smartphones in schools.

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

The Host

The 2024 campaign — particularly the one for president — has been notably vague on policy. But health issues, especially those surrounding abortion and other reproductive health care, have nonetheless played a key role. And while the Affordable Care Act has not been the focus of debate the way it was over the previous three presidential campaigns, who becomes the next president will have a major impact on the fate of the 2010 health law.

The panelists for this week’s special election preview, taped before a live audience at KFF’s offices in Washington, are Julie Rovner of KFF Health News, Tamara Keith of NPR, Alice Miranda Ollstein of Politico, and Cynthia Cox and Ashley Kirzinger of KFF.

Among the takeaways from this week’s episode:

• As Election Day nears, who will emerge victorious from the presidential race is anyone’s guess. Enthusiasm among Democratic women has grown with the elevation of Vice President Kamala Harris to the top of the ticket, with more saying they are likely to turn out to vote. But broadly, polling reveals a margin-of-error race — too close to call.
• Several states have abortion measures on the ballot. Proponents of abortion rights are striving to frame the issue as nonpartisan, acknowledging that recent measures have passed thanks in part to Republican support. For some voters, resisting government control of women’s health is a conservative value. Many are willing to split their votes, supporting both an abortion rights measure and also candidates who oppose abortion rights.
• While policy debates have been noticeably lacking from this presidential election, the future of Medicaid and the Affordable Care Act hinges on its outcome. Republicans want to undermine the federal funding behind Medicaid expansion, and former President Donald Trump has a record of opposition to the ACA. Potentially on the chopping block are the federal subsidies expiring next year that have transformed the ACA by boosting enrollment and lowering premium costs.
• And as misinformation and disinformation proliferate, one area of concern is the “malleable middle”: people who are uncertain of whom or what to trust and therefore especially susceptible to misleading or downright false information. Could a second Trump administration embed misinformation in federal policy? The push to soften or even eliminate school vaccination mandates shows the public health consequences of falsehood creep.

Also mentioned on this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

Patient and consumer advocates are looking to Kamala Harris to accelerate federal efforts to help people struggling with medical debt if she prevails in next month’s presidential election.

And they see the vice president and Democratic nominee as the best hope for preserving Americans’ access to health insurance. Comprehensive coverage that limits patients’ out-of-pocket costs offers the best defense against going into debt, experts say.

The Biden administration has expanded financial protections for patients, including a landmark proposal by the Consumer Financial Protection Bureau to remove medical debt from consumer credit reports.

In 2022, President Joe Biden also signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35-a-month cap on insulin. And in statehouses across the country, Democrats and Republicans have been quietly working together to enact laws to rein in debt collectors.

But advocates say the federal government could do more to address a problem that burdens 100 million Americans, forcing many to take on extra work, give up their homes, and cut spending on food and other essentials.

“Biden and Harris have done more to tackle the medical debt crisis in this country than any other administration,” said Mona Shah, senior director of policy and strategy at Community Catalyst, a nonprofit that has led national efforts to strengthen protections against medical debt. “But there is more that needs to be done and should be a top priority for the next Congress and administration.”

At the same time, patient advocates fear that if former President Donald Trump wins a second term, he will weaken insurance protections by allowing states to cut their Medicaid programs or by scaling back federal aid to help Americans buy health insurance. That would put millions of people at greater risk of sinking into debt if they get sick.

In his first term, Trump and congressional Republicans in 2017 tried to repeal the Affordable Care Act, a move that independent analysts concluded would have stripped health coverage from millions of Americans and driven up costs for people with preexisting medical conditions, such as diabetes and cancer.

Trump and his GOP allies continue to attack the ACA, and the former president has said he wants to roll back the Inflation Reduction Act, which also includes aid to help low- and middle-income Americans buy health insurance.

“People will face a wave of medical debt from paying premiums and prescription drug prices,” said Anthony Wright, executive director of Families USA, a consumer group that has backed federal health protections. “Patients and the public should be concerned.”

The Trump campaign did not respond to inquiries about its health care agenda. And the former president doesn’t typically discuss health care or medical debt on the campaign trail, though he said at last month’s debate he had “concepts of a plan” to improve the ACA. Trump hasn’t offered specifics.

Harris has repeatedly pledged to protect the ACA and renew expanded subsidies for monthly insurance premiums created by the Inflation Reduction Act. That aid is slated to expire next year.

The vice president has also voiced support for more government spending to buy and retire old medical debts for patients. In recent years, a number of states and cities have purchased medical debt on behalf of their residents.

These efforts have relieved debt for hundreds of thousands of people, though many patient and consumer advocates say retiring old debt is at best a short-term solution, as patients will continue to run up bills they cannot pay without more substantive action.

“It’s a boat with a hole in it,” said Katie Berge, a lobbyist for the Leukemia & Lymphoma Society. The patient group was among more than 50 organizations that last year sent letters to the Biden administration urging federal agencies to take more aggressive steps to protect Americans from medical debt.

“Medical debt is no longer a niche issue,” said Kirsten Sloan, who works on federal policy for the American Cancer Society’s Cancer Action Network. “It is key to the economic well-being of millions of Americans.”

The Consumer Financial Protection Bureau is developing regulations that would bar medical bills from consumer credit reports, which would boost credit scores and make it easier for millions of Americans to rent an apartment, get a job, or secure a car loan.

Harris, who has called medical debt “critical to the financial health and well-being of millions of Americans,” enthusiastically backed the proposed rule. “No one should be denied access to economic opportunity simply because they experienced a medical emergency,” she said in June.

Harris’ running mate, Minnesota Gov. Tim Walz, who has said his own family struggled with medical debt when he was young, signed a state law in June cracking down on debt collection.

CFPB officials said the regulations would be finalized early next year. Trump hasn’t indicated if he’d follow through on the medical debt protections. In his first term, the CFPB did little to address medical debt, and congressional Republicans have long criticized the regulatory agency.

If Harris prevails, many consumer groups want the CFPB to crack down even further, including tightening oversight of medical credit cards and other financial products that hospitals and other medical providers have started pushing on patients. These loans lock people into interest payments on top of their medical debt.

“We are seeing a variety of new medical financial products,” said April Kuehnhoff, a senior attorney at the National Consumer Law Center. “These can raise new concerns about consumer protections, and it is critical for the CFPB and other regulators to monitor these companies.”

Some advocates want other federal agencies to get involved, as well.

This includes the mammoth Health and Human Services department, which controls hundreds of billions of dollars through the Medicare and Medicaid programs. That money gives the federal government enormous leverage over hospitals and other medical providers.

Thus far, the Biden administration hasn’t used that leverage to tackle medical debt.

But in a potential preview of future actions, state leaders in North Carolina recently won federal approval for a medical debt initiative that will make hospitals take steps to alleviate patient debts in exchange for government aid. Harris praised the initiative.

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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Defensores de pacientes y consumidores confían en que Kamala Harris acelere los esfuerzos federales para ayudar a las personas que luchan con deudas médicas, si gana en las elecciones presidenciales del próximo mes.

Y ven a la vicepresidenta y candidata demócrata como la mejor esperanza para preservar el acceso de los estadounidenses a seguros de salud. La cobertura integral que limita los costos directos de los pacientes es la mejor defensa contra el endeudamiento, dicen los expertos.

La administración Biden ha ampliado las protecciones financieras para los pacientes, incluyendo una propuesta histórica de la Oficina de Protección Financiera del Consumidor (CFPB) para eliminar la deuda médica de los informes de crédito de los consumidores.

En 2022, el presidente Joe Biden también firmó la Ley de Reducción de la Inflación, que limita cuánto deben pagar los afiliados de Medicare por medicamentos recetados, incluyendo un tope de $35 al mes para la insulina. Y en legislaturas de todo el país, demócratas y republicanos han trabajado juntos de manera discreta para promulgar leyes que frenen a los cobradores de deudas.

Sin embargo, defensores dicen que el gobierno federal podría hacer más para abordar un problema que afecta a 100 millones de estadounidenses, obligando a muchos a trabajar más, perder sus hogares y reducir el gasto en alimentos y otros artículos esenciales.

“Biden y Harris han hecho más para abordar la crisis de deuda médica en este país que cualquier otra administración”, dijo Mona Shah, directora senior de política y estrategia en Community Catalyst, una organización sin fines de lucro que ha liderado los esfuerzos nacionales para fortalecer las protecciones contra la deuda médica. “Pero hay más por hacer y debe ser una prioridad para el próximo Congreso y administración”.

Al mismo tiempo, los defensores de los pacientes temen que si el ex presidente Donald Trump gana un segundo mandato, debilitará las protecciones de los seguros permitiendo que los estados recorten sus programas de Medicaid o reduciendo la ayuda federal para que los estadounidenses compren cobertura médica. Eso pondría a millones de personas en mayor riesgo de endeudarse si enferman.

En su primer mandato, Trump y los republicanos del Congreso intentaron en 2017 derogar la Ley de Cuidado de Salud a Bajo Precio (ACA), un movimiento que, según analistas independientes, habría despojado de cobertura médica a millones de estadounidenses y habría aumentado los costos para las personas con afecciones preexistentes, como diabetes y cáncer.

Trump y sus aliados del Partido Republicano continúan atacando a ACA, y el ex presidente ha dicho que quiere revertir la Ley de Reducción de la Inflación, que también incluye ayuda para que los estadounidenses de bajos y medianos ingresos compren seguros de salud.

“Las personas enfrentarán una ola de deuda médica por pagar primas y precios de medicamentos recetados”, dijo Anthony Wright, director ejecutivo de Families USA, un grupo de consumidores que ha apoyado las protecciones federales de salud. “Los pacientes y el público deberían estar preocupados”.

La campaña de Trump no respondió a consultas sobre su agenda de salud. Y el ex presidente no suele hablar de atención médica o deuda médica en la campaña, aunque dijo en el debate del mes pasado que tenía “conceptos de un plan” para mejorar la ACA. Trump no ha ofrecido detalles.

Harris ha prometido repetidamente proteger ACA y renovar los subsidios ampliados para las primas mensuales del seguro creados por la Ley de Reducción de la Inflación. Esa ayuda está programada para expirar el próximo año.

La vicepresidenta también ha expresado su apoyo a un mayor gasto gubernamental para comprar y cancelar deudas médicas antiguas de los pacientes. En los últimos años, varios estados y ciudades han comprado deuda médica en nombre de sus residentes.

Estos esfuerzos han aliviado la deuda de cientos de miles de personas, aunque muchos defensores dicen que cancelar deudas antiguas es, en el mejor de los casos, una solución a corto plazo, ya que los pacientes seguirán acumulando facturas que no pueden pagar sin una acción más sustantiva.

“Es un bote con un agujero”, dijo Katie Berge, una cabildera de la Sociedad de Leucemia y Linfoma. Este grupo de pacientes fue una de más de 50 organizaciones que el año pasado enviaron cartas a la administración Biden instando a las agencias federales a tomar medidas más agresivas para proteger a los estadounidenses de la deuda médica.

“La deuda médica ya no es un problema de nicho”, dijo Kirsten Sloan, quien trabaja en política federal para la Red de Acción contra el Cáncer de la Sociedad Americana de Cáncer. “Es clave para el bienestar económico de millones de estadounidenses”.

La Oficina de Protección Financiera del Consumidor está desarrollando regulaciones que prohibirían que las facturas médicas aparezcan en los informes de crédito de los consumidores, lo que mejoraría los puntajes crediticios y facilitaría que millones de estadounidenses alquilen una vivienda, consigan un trabajo o consigan un préstamo para un automóvil.

Harris, quien ha calificado la deuda médica como “crítica para la salud financiera y el bienestar de millones de estadounidenses”, apoyó con entusiasmo la propuesta de regulación. “No se debería privar a nadie del acceso a oportunidades económicas simplemente porque experimentó una emergencia médica”, dijo en junio.

El compañero de fórmula de Harris, el gobernador de Minnesota, Tim Walz, quien ha dicho que su propia familia luchó con la deuda médica cuando era joven, firmó en junio una ley estatal que reprime el cobro de deudas.

Los funcionarios de la CFPB dijeron que las regulaciones se finalizarán a principios del próximo año. Trump no ha indicado si seguiría adelante con las protecciones contra la deuda médica. En su primer mandato, la CFPB hizo poco para abordarla, y los republicanos en el Congreso han criticado durante mucho tiempo a la agencia reguladora.

Si Harris gana, muchos grupos de consumidores quieren que la CFPB refuerce aún más las medidas, incluyendo una mayor supervisión de las tarjetas de crédito médicas y otros productos financieros que los hospitales y otros proveedores médicos han comenzado a ofrecer a los pacientes. Por estos préstamos, las personas están obligadas a pagar intereses adicionales sobre su deuda médica.

“Estamos viendo una variedad de nuevos productos financieros médicos”, dijo April Kuehnhoff, abogada senior del Centro Nacional de Derecho del Consumidor. “Estos pueden generar nuevas preocupaciones sobre las protecciones al consumidor, y es fundamental que la CFPB y otros reguladores supervisen a estas empresas”.

Algunos defensores quieren que otras agencias federales también se involucren.

Esto incluye al enorme Departamento de Salud y Servicios Humanos (HHS), que controla cientos de miles de millones de dólares a través de los programas de Medicare y Medicaid. Ese dinero otorga al gobierno federal una enorme influencia sobre los hospitales y otros proveedores médicos.

Hasta ahora, la administración Biden no ha utilizado esa influencia para abordar la deuda médica.

Pero en un posible anticipo de futuras acciones, los líderes estatales en Carolina del Norte recientemente obtuvieron la aprobación federal para una iniciativa de deuda médica que obligará a los hospitales a tomar medidas para aliviar las deudas de los pacientes a cambio de ayuda gubernamental. Harris elogió la iniciativa.

Montana is looking to fast-track Medicaid access for older adults who need help to stay in their homes or towns.

Medicaid, the joint federal-state health care program for low-income Americans, opens the door to services such as paying for help to prepare meals or shower safely. But applying for and obtaining that coverage can take weeks or months, leaving aging people in a dangerous limbo: too vulnerable to live at home without assistance, but too healthy to merit a hospital or nursing home bed.

Montana lawmakers drafted a bill for the legislative session that begins in January that would create a shortcut to that care. The Children, Families, Health, and Human Services Interim Committee’s proposal would allow older people and those with a physical disability who are likely eligible for Medicaid to start receiving in-home and community-based care while awaiting final approval.

The goal of presumptive eligibility is to avoid delays in providing stabilizing care outside of medical facilities. Supporters of the plan say local care is also a lot less expensive than hospital or nursing home care.

Montana would join at least 11 states that have presumptive eligibility for seniors and people with disabilities to access in-home care, according to AARP. Washington state began expediting Medicaid coverage in 2023 for people recently discharged from a hospital and plans to expand coverage further. Rhode Island authorizes such benefits to new long-term care applicants. And a law signed last winter in New Jersey means seniors there will have similar access.

People who are hospitalized or checked into a nursing home can struggle to find the middle-ground option for care they need.

Katy Mack, a spokesperson for the Montana Hospital Association, said bottlenecks in the process are difficult for patients, long-term care providers, and hospitals.

“Many elderly patients do ‘get stuck’ in hospitals waiting for transfer to a more appropriate level of care,” Mack said in an email. “This is due to a variety of issues, including staffing, bed availability, and appropriate payments from the patient’s source of health coverage.”

Tyler Amundson, executive director of Big Sky Senior Services, a nonprofit that helps seniors stay in their home, said in one case, a couple without the support they needed ended up in the hospital dozens of times over two months.

“There are a lot of seniors in our community struggling,” Amundson said. “They’ll go home from a hospital with just enough care to get by for a little while.”

The nation’s pool of older Americans is getting bigger. With age comes more medical complications. People 65 or older have the highest rate of preventable hospitalizations, and medical emergencies risk worse health outcomes.

Rising health care costs are fueling anxiety among tens of millions of seniors, with 1 in 10 living below the federal poverty level. Older adults are struggling to pay the combined cost of housing and medical care, and some become homeless.

For years, states have had the option through the Affordable Care Act to allow qualified hospitals to extend presumptive eligibility to some adults based on their income, on top of the opportunity that most states give pregnant women and children. But in states such as Montana, people 65 and older haven’t been included. States need a federal waiver to expand who qualifies for that early access.

Alice Burns, who researches Medicaid issues at KFF, a health information nonprofit that includes KFF Health News, said widening presumptive eligibility for in-home and community-based care gained momentum during the covid-19 pandemic.

“It’s easy to understand why,” Burns said. “When we had the fatality rates in nursing facilities that we did, it was like, OK, we cannot send these people to the nursing facilities unnecessarily.”

The Montana proposal would, after state training, allow tribal entities, area agencies on aging, and hospitals, among others, to screen patients for presumptive eligibility. Approved patients would begin receiving services while state health officials review their applications.

The draft bill spells out some covered services, such as meal delivery and in-home medical equipment. Lawmakers noted it’s not clear if the proposal would help people move into long-term care, such as assisted living facilities, which offer daily support rather than medical treatment.

Montana officials don’t have an estimate for how much the temporary coverage would cost. Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, declined to comment on the proposal.

Mike White is a co-owner of Caslen Living Centers, which has six small assisted living facilities across central and southwestern Montana. His company no longer accepts Medicaid applicants until their coverage is final, and White said it’s not alone. He said that process can take anywhere from three to six months due to cumbersome paperwork, which he said is too long for small businesses to go without pay.

State officials have said delays in Medicaid approval often stem from ongoing communication with applicants.

The state’s Medicaid program has gone through major upheaval in the past year as states nationwide reviewed eligibility for everyone on the program. Montana officials dropped more than 115,300 people from coverage in that process, according to the state’s final report. Those disenrollments continued as nonprofits and patients alike cited problems in the state’s process, including delays in application processing and access to help for other safety net services.

Now, state lawmakers predict a major political fight during the legislative session over whether to continue to allow expanded Medicaid access to people who earn up to 138% of the federal poverty level, or about $43,000 a year for a family of four.

State Rep. Mike Yakawich, the Billings Republican behind the presumptive eligibility proposal, said he wants to keep some of its language vague. He’s leaving room for negotiations and potential amendments during the legislative session and beyond.

“The focus is to keep people at home, and it’s still going to be a hard lift to get it past the session,” Yakawich said. “We can add more to it two years from now.”

Not everyone on the interim committee was on board.

Sen. Daniel Emrich, a Republican from Great Falls, voted against the policy, saying it sounded too much like a gamble for families.

“We run the risk of taking and providing a service that’s then going to be pulled out from under them,” Emrich said.

The counterargument is that such cases would be rare. Burns, with KFF, said there is no reliable data nationally to show how often people are denied Medicaid after being presumed eligible. Presumptive access to Medicaid in-home programs is relatively new. And, from hospital data for other patients, it’s difficult to know whether a person was denied Medicaid because they didn’t qualify or because they didn’t complete the paperwork after leaving the hospital.

“There’s all these places where the ball could get dropped,” Burns said.

She said the difference with measures like Montana’s is that support services follow patients in their daily life, making it less likely patients would fall off the radar.

The Host

As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.

Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.

This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.

Among the takeaways from this week’s episode:

• Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
• Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
• Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
• The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
• The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.

Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.

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

Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.

Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.

Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.

Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.

Also mentioned on this week’s podcast:

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning.

In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans.

PBM leaders say they save companies and patients billions of dollars annually by obtaining rebates from drugmakers that they pass along to employers. Drugmakers, meanwhile, say they raise their list prices so high in order to afford the rebates that PBMs demand in exchange for placing the drugs on formularies that make them available to patients.

Leaders of the three largest PBMs — CVS Caremark, Optum RX and Express Scripts — all testified in Congress in July that 95% to 98% of the rebates they collect from drugmakers flow to employers.

For KFF’s survey of 2,142 randomly selected companies, officials from those with 500 or more employees were asked how much of the rebates negotiated by PBMs returned to the company as savings. About 19% said they received most of the rebates, 27% said some, and 16% said little. Thirty-seven percent of the respondents didn’t know.

While a larger percentage of officials from the largest companies said they got most or some of the rebates, the answers — and their contrast with the testimony of PBM leaders — reflect the confusion or ignorance of employers about what their drug benefit managers do, said survey leader Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News.

“I don’t think they can ever know all the ways the money moves around because there are so many layers, between the wholesalers and the pharmacies and the manufacturers,” he said.

Critics say big PBMs — which are parts of conglomerates that include pharmacies, providers, and insurers — may conceal the size of their rebates by conducting negotiations through corporate-controlled rebate aggregators, or group purchasers, mostly based overseas in tax havens, that siphon off a percentage of the cash before it goes on the PBMs’ books.

PBMs also make money by encouraging or requiring patients to use affiliated specialty pharmacies, by skimping on payments to other pharmacies, and by collecting extra cash from drug companies through the federal 340B drug pricing program, which is aimed at lowering drug costs for low-income patients, said Antonio Ciaccia, CEO of 46brooklyn Research.

The KFF survey indicates how little employers understand the PBMs and their pricing policies. “Employers are generally frustrated by the lack of transparency into all the prices out there,” Claxton said. “They can’t actually know what’s true.”

Billionaire Mark Cuban started a company to undercut the PBMs by selling pharmaceuticals with transparent pricing policies. He tells Fortune 500 executives he meets, “You’re getting ripped off, you’re losing money because it’s not your core competency to understand how your PBM and health insurance contracts work,” Cuban told KFF Health News in an interview Tuesday.

Ciaccia, who has conducted PBM investigations for several states, said employers are not equipped to understand the behavior of the PBMs and often are surprised at how unregulated the PBM business is.

“You’d assume that employers want to pay less, that they would want to pay more attention,” he said. “But what I’ve learned is they are often underequipped, underresourced, and oftentimes not understanding the severity of the lack of oversight and accountability.”

Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.

Prices can be all over the map, even those charged by the same PBM, Ciaccia said. In a Medicaid study he recently conducted, a PBM was billing employers anywhere from $2,000 to $8,000 for a month’s worth of imatinib, a cancer drug that can be bought as a generic for as little as $30.

PBM contracts often guarantee discounts of certain percentage points for generics and brand-name drugs. But the contracts then contain five pages of exclusions, and “no employer will know what they mean,” Ciaccia said. “That person doesn’t have enough information to have an informed opinion.”

The KFF survey found that companies’ annual premiums for coverage of individual employees had increased from an average of $7,739 in 2021 to $8,951 this year, and $22,221 to $25,572 for families. Among employers’ greatest concerns was how to cover increasingly popular weight loss drugs that list at $2,000 a month or more.

Only 18% of respondents said their companies covered drugs such as Wegovy for weight loss. The largest group of employers offering such coverage — 28% — was those with 5,000 or more employees.

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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It’s that time of year again: In most states, the Affordable Care Act’s annual open enrollment season for health plans begins Nov. 1 and lasts through Jan. 15.

Current enrollees who do not update their information or select an alternative will be automatically reenrolled in their current plan or, if that plan is no longer available, into a plan with similar coverage.

Last year marked a record enrollment of about 21 million people. This time around, consumers will find a few things have changed.

Don’t Fall for Advertising Scams

While some health plans offer small-dollar gift cards or other incentives to encourage participation in wellness efforts, they would not offer cash cards worth thousands of dollars a month to help with groceries, gas, or rent. Even so, social media and online sites are rife with such promises.

Such ads are among the avenues allegedly used by unscrupulous brokers who enroll or switch plans without the express permission of consumers, according to a lawsuit filed in Florida.

Also, be cautious about the websites you use to search for coverage.

Type “Obamacare” or “cheap health insurance” into a search engine and often what pops up first are sponsored private sector websites unaffiliated with the official state or federal government marketplaces for ACA coverage.

While they may try to look official, they are not. Many such sites offer various options, including non-ACA coverage with limited benefits, a “secret shopper” study found in 2023. Such non-ACA coverage would not qualify for federal subsidies to help consumers pay premiums.

The fine print on some websites says that consumers who provide personal information automatically consent to be contacted by sales agents via phone calls, emails, text messages, or automated systems with prerecorded messages.

When exploring plans, always start with the official federal marketplace’s website, healthcare.gov.

Even if you don’t live in one of the 29 states served by the federal marketplace, its website provides the link to your official enrollment site when you select your state, or the District of Columbia, from a drop-down list. The federal and state marketplaces also have call centers and other ways to get enrollment assistance. The “find local help” link on healthcare.gov, for example, gives consumers a choice of finding assisters or sales agents near them.

Is It Real Insurance?

Another concern: Regulators are seeing an increase in complaints from consumers about offers of health coverage requiring consumers to join a limited liability corporation, or otherwise attest they are working for a specific company. Indeed, at least two states — Maryland and Maine — have issued warnings, saying that instead of comprehensive ACA coverage, these are often non-ACA products, amounting to a hodgepodge of discount cards, for example, or limited-indemnity plans. This type of plan pays a flat-dollar amount — say, $50 for a doctor visit or $1,000 for a hospital stay — and is meant to buttress more comprehensive coverage, not replace it.

“Unlike major medical plans, some of these self-funded plans only cover preventive services such as a yearly check-up or annual health screening,” the warning from the Maine Bureau of Insurance says.

Premiums Might Be Higher … and Other New Things

Some insurers will lower premium rates for 2025, but many others are increasing them.

Although final numbers are still being crunched, experts estimate a median increase of 7% for premiums, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. Most people who buy ACA coverage are eligible for a subsidy to help with the premiums, which is likely to offset much of the increase, although the higher cost means the government will be paying out more for those subsidies.

Rising health costs — including for hospital care and the new class of weight loss drugs — are contributing to the increase.

Some other changes this open season:

• People often referred to as “Dreamers” because they qualified for the Deferred Action for Childhood Arrivals — a federal program offering some protection to those brought to the country as children without proper immigration documentation — can now enroll in ACA coverage and are eligible for subsidies.
• Short-term plans, which are technically not ACA coverage and not subject to its benefit rules and preexisting benefit protections, can be issued for, at most, only four months of coverage, based on a Biden administration action that took effect with plans starting Sept. 1. It walks back a Trump administration rule that loosened requirements to allow insurers to offer coverage that ranged up to 364 days, and allowed insurers the option of renewing the policies for up to two additional years. Existing plans and those issued before Sept. 1 don’t fall under the new rules. But consumers who relied on the longer periods need to check their plans’ details and consider enrolling in an ACA plan instead to avoid a situation in which their short-term plan expires early or midyear, potentially leaving them unable to get coverage elsewhere for the remainder of the year.

The Sign-Up Process Might Take Longer, Too

Federal regulators this year wrestled with a growing number of complaints — 200,000 in the first six months alone — from consumers who were being enrolled into or switched from ACA plans without their express permission by agents seeking to gain commissions.

To thwart such efforts, they put new rules in place.

What does that mean for most consumers? If you are working with a new agent — one who wasn’t already listed on your ACA plan — you will likely need to get on a three-way call with the federal marketplace to confirm that you are, indeed, authorizing that agent to make changes to your policy for the coming year. Plan on this taking additional time. No one knows how busy the call lines will get during open enrollment.

You don’t need to use a broker to enroll. But sorting through the dozens of options on the marketplace is challenging, so most people do seek assistance. Consumers need to weigh not only the monthly premium cost, but also variations in deductibles and copayments for such things as doctor visits, hospitalization, and drugs.

Shop Around

Experts say another consideration when choosing a plan is to check whether its network includes the doctors and hospitals you typically see, as well as whether its formulary covers your prescription medications, and how much it charges for them.

To help with making comparisons, rules kicked in two years ago requiring insurers to include some “standardized plans” as options, which must all have the same deductibles, and costs for such things as doctor visits, emergency room care, and other consumer cost sharing.

Even so, many people have dozens of options available, which can be daunting.

But one piece of advice remains constant: Whether you are enrolling for the first time or have an existing plan, it’s always worth it to shop around. Even if you don’t change plans, you can make sure the one you have is still your best option.

In most states, consumers must enroll by Dec. 15 to get coverage that begins Jan. 1. Heads up in Idaho, where open enrollment starts earlier — Oct. 15 — but also ends sooner, closing on Dec. 15. In California, New Jersey, New York, Rhode Island, and the District of Columbia, residents can enroll through Jan. 31.

Estamos en esa época del año otra vez. En la mayoría de los estados, la temporada de inscripción abierta de la Ley de Cuidado de Salud a Bajo Precio (ACA) para los planes de salud comienza el 1 de noviembre y dura hasta el 15 de enero.

Los consumidores que no actualicen su información o seleccionen una alternativa serán automáticamente reinscriptos en su plan actual o, si ese plan ya no está disponible, en uno con cobertura similar.

El año pasado se registró un récord de inscripciones, con unas 21 millones de personas. Esta vez, los consumidores descubrirán que han cambiado algunas cosas.

No seas víctima de estafas publicitarias

Aunque algunos planes de salud ofrecen tarjetas de regalo de poco valor u otros incentivos para fomentar la participación en iniciativas de bienestar, nunca ofrecerían tarjetas en efectivo por valor de miles de dólares al mes para ayudar a pagar las compras, la gasolina o el alquiler. Aun así, las redes sociales y los sitios web están plagados de promesas de este tipo.

Según una demanda presentada en Florida, este tipo de anuncios es una de las vías supuestamente utilizadas por corredores sin escrúpulos que inscriben o cambian de plan sin el permiso expreso de los consumidores.

Además, hay que tener cuidado con los sitios de internet que utilizamos para buscar cobertura.

Si escribes “Obamacare” o “seguro médico barato” en un buscador, a menudo, lo que aparece en primer lugar son sitios web patrocinados por el sector privado no afiliados a los mercados federales o estatales oficiales para la cobertura de ACA.

Aunque intenten parecer oficiales, no lo son. Muchos de estos sitios ofrecen varias opciones, incluida cobertura que no es de ACA con beneficios limitados, según descubrió en 2023 un studio de “comprador secreto”. Con estas coberturas no se pueden obtener subsidios federales para ayudar a los consumidores a pagar las primas.

La letra chica de algunos sitios web dice que los consumidores que facilitan información personal consienten automáticamente que agentes de ventas se pongan en contacto con ellos a través de llamadas telefónicas, correos electrónicos, mensajes de texto o sistemas automatizados con mensajes pregrabados.

Cuando busques un plan, empieza siempre por el sitio web oficial del mercado federal, cuidadodesalud.gov (healthcare.gov).

Incluso si no vives en uno de los 29 estados en los que funciona el mercado federal, el sitio web proporciona el enlace a tu sitio oficial de inscripción cuando seleccionas tu estado, o el Distrito de Columbia, en una lista desplegable.

Los mercados estatales y el federal también tienen centros de llamadas y otras formas de obtener ayuda para la inscripción. Por ejemplo, el enlace “encuentre ayuda local” en cuidadodesaludgov, ofrece a los consumidores la posibilidad de encontrar asistentes o agentes de ventas cerca de sus domicilios.

¿Es un seguro real?

Otra preocupación: los reguladores han observado un aumento en las quejas de los consumidores sobre ofertas de coberturas de salud en las que se les exige que se afilien a una corporación de responsabilidad limitada o que den fe de que trabajan para una empresa concreta.

De hecho, al menos dos estados —Maryland y Maine—- han emitido advertencias, señalando que en lugar de una cobertura completa de ACA, a menudo se trata de productos que no pertenecen a ACA, y que equivalen a cosas como una mezcla de tarjetas de descuento o planes de indemnización limitada.

Este tipo de plan paga una cantidad fija —por ejemplo, $50 por una visita al médico o $1,000 por una hospitalización— y está pensado para reforzar una cobertura más completa, no para sustituirla.

“A diferencia de los planes medicos grandes, algunos de estos planes autofinanciados sólo cubren servicios preventivos, como un chequeo o un examen médico anual”, advierte la Oficina de Seguros de Maine.

Las primas podrían ser más altas… y otras novedades

Algunas aseguradoras reducirán las primas para 2025, pero muchas otras las aumentarán.

Aunque todavía no hay cifras oficiales, los expertos estiman un aumento promedio del 7% para las primas, según un análisis de KFF. La mayoría de las personas que compran cobertura médica en los mercados de seguros de ACA son elegibles para recibir subsidios para ayudar con las primas, lo que probablemente compensará gran parte del aumento, aunque el mayor costo significa que el gobierno pagará más por esos subsidios.

El aumento de los costos de salud —incluida la atención hospitalaria y la nueva clase de medicamentos para adelgazar— contribuye a este incremento.

Otros cambios en esta temporada:

—Las personas a menudo conocidas como “Dreamers” porque calificaron para la Acción Diferida para los Llegados en la Infancia (DACA) —un programa federal que ofrece cierta protección a los traídos al país cuando eran niños sin documentación migratoria adecuada— ahora pueden inscribirse en la cobertura de ACA y son elegibles para los subsidios.

—Los planes de corto plazo, que técnicamente no son parte de la cobertura de ACA y no están sujetos a sus normas de beneficios y protecciones de beneficios preexistentes, pueden ser emitidos por sólo cuatro meses de cobertura, como máximo, según lo dispuesto por la administración Biden, que entró en vigencia  con planes que empezaron el 1 de septiembre.  Esto ha revocado una norma de la administración Trump que flexibilizaba los requisitos para permitir a las aseguradoras ofrecer una cobertura de hasta 364 días, con la opción de renovar las pólizas hasta por dos años más. Los planes existentes y los emitidos antes del 1 de septiembre no caen bajo las nuevas reglas. Pero los consumidores que contaban con períodos más largos deben comprobar los detalles de sus planes y considerar la posibilidad de cambiar a un plan de ACA para evitar una situación en la que su plan a corto plazo expire antes de tiempo o a mediados de año, arriesgándose así a no poder obtener otra cobertura por el resto del año.

El proceso de inscripción también podría alargarse

Este año, los reguladores federales han tenido que hacer frente a un número creciente de quejas —200,000 sólo en los primeros seis meses— de consumidores que estaban siendo inscritos o transferidos a otros planes de ACA sin su permiso por agentes que pretendían obtener comisiones.

Para evitarlo, se han establecido nuevas normas.

¿Qué significa esto para la mayoría de los consumidores? Si trabajas con un nuevo agente —uno que no estaba ya en la lista en tu plan de ACA— es probable que tengas que ser parte de una llamada con dos representantes del mercado federal para confirmar que autorizas a ese agente para hacer cambios en tu plan para el próximo año. Esto te llevará más tiempo. Nadie sabe lo ocupadas que estarán las líneas telefónicas durante la inscripción abierta.

No es necesario recurrir a un intermediario para inscribirse. Pero la búsqueda entre las docenas de opciones del mercado es un reto, por lo que la mayoría de las personas busca ayuda. Los consumidores deben sopesar no sólo el costo mensual de la prima, sino también las variaciones en deducibles y copagos por cosas como visitas al médico, hospitalización y medicamentos.

Compara precios

Los expertos señalan que otra consideración a tener en cuenta al elegir un plan es comprobar si tu red incluye los médicos y hospitales a los que sueles acudir, y si se cubren tus medicamentos recetados y cuánto cobran por ellos.

Para facilitar las comparaciones, hace dos años entraron en vigencia unas normas que obligan a las aseguradoras a incluir como opciones algunos “planes estandarizados”, que deben tener los mismos deducibles y costos por conceptos como visitas al médico, atención en urgencias y otros gastos compartidos por el consumidor.

Aun así, muchas personas disponen de docenas de opciones, lo que puede resultar desalentador.

Pero hay un consejo que no cambia: tanto si te inscribes por primera vez, como si ya tienes un plan, vale la pena comparar precios. Aunque no cambies de plan, puedes asegurarte de que el que tienes sigue siendo tu mejor opción.

En la mayoría de los estados, los consumidores deben inscribirse antes del 15 de diciembre para obtener cobertura a partir del 1 de enero. Atención a Idaho, donde la inscripción abierta empieza antes, el 15 de octubre, pero también termina antes, el 15 de diciembre. En California, Nueva Jersey, Nueva York, Rhode Island y el Distrito de Columbia, los residentes pueden inscribirse hasta el 31 de enero.

The Host

Julie Rovner
KFF Health News

@jrovner

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.

When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.

Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.

Panelists

Anna Edney
Bloomberg

@annaedney

Read Anna’s stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice’s stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya’s stories.

Among the takeaways from this week’s episode:

• This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
• Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
• On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
• Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
• And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.

Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.

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’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.

Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.

Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.

Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.

Also mentioned on this week’s podcast:

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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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It was expected that the past year and a half would be a fraught time for Medicaid, the workhorse of the nation’s health system, which covers more people than any other government health insurance program.

In April 2023, states resumed screening people for Medicaid eligibility and terminating coverage for those they said no longer qualified or failed to renew, which had been prohibited under pandemic-era protections. Many health advocates feared the uninsured rate, which had just hit historic lows, would resurge.

But while more than 25 million Americans have lost Medicaid coverage during the Medicaid “unwinding,” many also gained coverage as more than a dozen states expanded health coverage for lower-income people, including children, pregnant women and incarcerated people. And early data shows the uninsured rate has risen only modestly.

The expansions will mitigate the effects of the unwinding, though it’s too early to know by how much.

“The pandemic was destructive and concerning and clearly demonstrated that Medicaid is so crucially important for our national safety net,” said Jennifer Babcock, senior vice president for Medicaid policy at the Association for Community Affiliated Plans, a trade group representing nonprofit health insurers that cover people on Medicaid. “These expansions are incredibly meaningful.”

The biggest expansion occurred in December, when North Carolina joined 39 other states and D.C. in widening Medicaid eligibility to include adults with incomes up to 138 percent of the federal poverty level, or $20,783 for an individual. More than 500,000 North Carolinians gained coverage.

Other expansions since spring 2023 include:

• South Dakota, like North Carolina, expanded Medicaid coverage under the Affordable Care Act last year. About 22,000 people enrolled in the first eight months.
• In July, Oregon launched a Medicaid-like coverage option for those who earn too much to qualify for Medicaid under federal limits. More than 50,000 people have enrolled so far, Oregon officials say.
• In January, a new federal law required states to allow children under the age of 19 to stay covered under Medicaid or the related Children’s Health Insurance Program for at least a year after signing up. Several are going beyond that: New Mexico and Washington, for example, allow children to stay covered up to age 6. California passed legislation to expand continuous eligibility for children up to age 4 but has not yet implemented the policy.
• Three states widened income eligibility for children to qualify for Medicaid: Arizona, Maine and North Dakota.
• This year, Utah began offering a Medicaid-like coverage option for children regardless of immigration status, though the program is capped at about 2,000 children.
• Several states expanded coverage for pregnant women, including Alabama and Maryland, which expanded eligibility to pregnant residents regardless of immigration status. And with changes in Maine, Oregon and Vermont, 46 states and D.C. now offer one year of postpartum coverage.
• In June, five states — Illinois, Kentucky, Oregon, Utah and Vermont — received approval from the Biden administration to extend Medicaid coverage to incarcerated people up to 90 days before their release. Those states will join several others in offering that coverage.

This article is not available for syndication due to republishing restrictions. If you have questions about the availability of this or other content for republication, please contact [email protected].

“Donald Trump said he was going to allow Medicare to negotiate drug prices. He never did. We did.”

Vice President Kamala Harris at the ABC News presidential debate, Sept. 10

Since Vice President Kamala Harris entered the presidential race, she and former President Donald Trump have sparred over their approaches to lowering prescription drug costs. Harris has described this as an important campaign promise that Trump made but didn’t deliver on.

“Donald Trump said he was going to allow Medicare to negotiate drug prices,” Harris said during the ABC News debate on Sept. 10 in Philadelphia. “He never did. We did.”

She previously told CNN that Trump’s promise to pursue such negotiations “never happened” during his administration.

During the 2016 presidential campaign, Trump repeatedly promised, if elected, to take steps to allow the government to negotiate drug prices. He never enacted such a policy in office. The Trump administration pursued smaller, temporary programs aimed at lowering drug costs.

However, experts say the effect of Trump’s moves fell far short of the expected effect of the Medicare drug price negotiation program included in President Joe Biden’s Inflation Reduction Act and of what Trump promised.

Medicare Drug Price Negotiation Policy, Explained

The Inflation Reduction Act — a sweeping climate and health care law Biden signed in August 2022 — included a measure authorizing the Centers for Medicare & Medicaid Services to negotiate Medicare prescription drug prices directly with pharmaceutical companies.

“The idea behind drug price negotiation is that Medicare can use its buying power to get a better price than what is currently being negotiated for these drugs,” according to Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.

Medicare covers more than 67 million Americans, giving it enormous potential influence over prices for U.S. drugs and medical services.

In August, CMS announced it had secured significant discounts on the list prices of 10 drugs because of its negotiations. Those discounts ranged from a 38% reduction for blood cancer medication Imbruvica on the low end to a 79% cut for diabetes drug Januvia on the high side. (List prices and the prices Medicare drug plans pay can differ.)

The new prices are expected to save Medicare $6 billion in the first year, with Medicare beneficiaries set to save an additional $1.5 billion in out-of-pocket costs, according to the White House.

Those new prices aren’t set to take effect until 2026 — though Biden and Harris have highlighted other aspects of the law that are bringing down drug costs sooner, such as a $35-a-month out-of-pocket price cap on insulin for Medicare enrollees and a $2,000 yearly out-of-pocket spending cap for Part D drugs effective in January. The Part D program covers most generic and brand-name outpatient prescription drugs.

CMS will start negotiating prices for the next group of drugs — 15 a year for the next two years — in early 2025, and those talks will continue annually at least through the end of the decade.

Trump’s Promises Versus His Actions

As a presidential candidate in 2016, Donald Trump pledged to pursue prescription drug price negotiation programs — and sometimes overstated such a policy’s power to cut prices.

During multiple campaign rallies and media interviews that year, Trump suggested allowing the government to negotiate drug prices directly with manufacturers would save $300 billion a year, a claim a fact-checker said was “absurd” then.

“The problem is, we don’t negotiate,” Trump said during an MSNBC town hall in Charleston, South Carolina, on Feb. 17, 2016. “We’re the largest drug buyer in the world. We don’t negotiate.” He went on to say: “If we negotiated the price of drugs, Joe, we’d save $300 billion a year.”

Similarly, at a Feb. 24, 2016, rally in Virginia Beach, Virginia, Trump reiterated his interest in making this change. “If you bid them out we’ll save $300 billion … and we don’t even do it. We’re going to do it.” The pharmaceutical industry would push back, he said, but he added: “Trust me I can do it.”

In office, however, Trump backed away from those promises, rejecting a bill spearheaded by then-House Speaker Nancy Pelosi (D-Calif.) to authorize such negotiations. The Democratic-led House ultimately passed that legislation, though the Republican-led Senate didn’t consider it.

“Pelosi and her Do Nothing Democrats drug pricing bill doesn’t do the trick,” Trump wrote on X, the social platform then known as Twitter.

Trump pursued smaller initiatives that sought to lower drug costs. One such program, the “most favored nation” model, tried to cap the cost of some Part B medications — those administered in a doctor’s office or hospital outpatient setting — at the lowest price paid in certain peer nations with a per capita GDP of at least 60% that of the United States.

“Medicare is the largest purchaser of drugs anywhere in the world by far,” Trump said in announcing the program. “We’re finally going to use that incredible power to achieve a fairer and lower price for everyone.”

The Trump campaign didn’t respond to an inquiry about prescription drug price negotiations or the most favored nation model.

The program would have started in January 2021 and lasted seven years. CMS officials estimated the government would save more than $85 billion on Part B spending. But some of those savings came from assumptions that Medicare beneficiaries would lose access to some Part B medications under the model, with some manufacturers unlikely to sell products at the lower, foreign prices.

Trump’s program never took effect. Amid lawsuits from several drug companies and industry groups, a federal judge stayed the plan in December 2020. The Biden administration scrapped it in 2022.

Even if the most favored nation model had been enacted, experts say it wouldn’t have come close to saving Americans or the government as much money as the IRA’s drug price negotiation provisions. A contemporaneous analysis of Trump’s proposal estimated that 7% of the 60 million Medicare beneficiaries in 2018 would have benefited.

More importantly, the most favored nation model did not authorize the government to negotiate prescription drug prices with manufacturers — the policy Trump promised to implement.

What Comes Next?

A recent KFF poll shows 85% of Americans, including more than three-quarters of Republicans, favor allowing Medicare to negotiate prices with drug companies.

And lowering drug costs continues to be a key issue for both campaigns, with Trump and Harris sparring over everything from the price of insulin to the impact of the Inflation Reduction Act on Medicare spending.

“I’ll lower the cost of insulin and prescription drugs for everyone with your support, not only our seniors,” Harris told supporters at an Aug. 16 campaign event in Raleigh, North Carolina, promising to extend the IRA’s price caps.

A Trump campaign spokesperson, meanwhile, previously told KFF Health News that the former president “will do everything possible to lower drug costs for Americans when he’s back in the White House, just like he accomplished in his first term.” She provided no specifics.

Trump, however, has also repeatedly promised to repeal parts of the Inflation Reduction Act — though he has never specifically mentioned the drug price negotiation provision — and to rescind unspent money. Congressional Republicans have spoken publicly about their intentions to roll back the drug price negotiation provision.

Even without legislative changes, the next president will have the opportunity to steer Medicare’s prescription drug price negotiation process.

“An administration that wants to be more lenient on drug companies might be more lax in the negotiations process,” said Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy. “Or the administration could perhaps be tougher than the Biden administration.”

Our Ruling

As a presidential candidate in 2016, Donald Trump promised to let the government negotiate prescription drug prices directly with pharmaceutical companies. As president, however, he instead tried to tie some U.S. drug prices to their costs in other countries. Drugmakers and industry groups sued, challenging the move, and courts blocked it.

Harris, therefore, is correct that Trump never was able to open Medicare up to drug negotiations despite his sweeping campaign promises.

We rate Harris’ claim True.

Our Sources:

ABC News, “READ: Harris-Trump Presidential Debate Transcript,” Sept. 10, 2024

Axios, “Hill GOP Sets Sights on Scrapping Drug Price Talks,” Sept. 17, 2024

Centers for Medicare & Medicaid Services, “Trump Administration Announces Prescription Drug Payment Model To Put American Patients First,” Nov. 18, 2020

CNN, “READ: Harris and Walz’s Exclusive Joint Interview With CNN,” Aug. 30, 2024

Congress.gov, “H.R.3 – Elijah E. Cummings Lower Drug Costs Now Act,” accessed Sept. 17, 2024

Factbase, “Donald Trump Attends an MSNBC Town Hall in Charleston, South Carolina,” Feb. 17, 2016

Factbase, “Donald Trump in Pawleys Island, SC,” Feb. 19, 2016

Federal Register, “42 CFR Part 513,” Nov. 27, 2020

KFF, “A Status Report on Prescription Drug Policies and Proposals at the Start of the Biden Administration,” Feb. 11, 2021

KFF, “KFF Health Tracking Poll September 2024: Support for Reducing Prescription Drug Prices Remains High, Even As Awareness of IRA Provisions Lags,” Sept. 13, 2024

KFF, “Most People Are Unlikely To See Drug Cost Savings From President Trump’s ‘Most Favored Nation’ Proposal,” Aug. 27, 2020

KFF Health News, “5 Things To Know About the New Drug Pricing Negotiations,” Aug. 30, 2023

KFF Health News, “Harris Did Not Vote To ‘Cut Medicare,’ Despite Trump’s Claim,” Aug. 20, 2024

KFF Health News, “Trump Is Wrong in Claiming Full Credit for Lowering Insulin Prices,” July 18, 2024

Phone interview with Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy, Sept. 13, 2024

Reuters, “Federal Judge Blocks Trump Administration Drug Pricing Rule,” Dec. 23, 2020

The Washington Post, “Trump’s Truly Absurd Claim He Would Save $300 Billion a Year on Prescription Drugs,” Feb. 18, 2016

The White House, “Remarks by President Trump at Signing of Executive Orders on Lowering Drug Prices” July 24, 2020

The White House, “Remarks by Vice President Harris at a Campaign Event in Raleigh, NC,” Aug. 16, 2024

X, then known as Twitter, “@RealDonaldTrump,” Nov. 22, 2019

Ohio Republican Sen. JD Vance and Minnesota Democratic Gov. Tim Walz met in an Oct. 1 vice presidential debate hosted by CBS News that was cordial and heavy on policy discussion — a striking change from the Sept. 10 debate between Vice President Kamala Harris and former President Donald Trump. 

Vance and Walz acknowledged occasional agreement on policy points and respectfully addressed each other throughout the debate. But they were more pointed in their attacks on their rival’s running mate for challenges facing the country, including immigration and inflation.

The moderators, “CBS Evening News” anchor Norah O’Donnell and “Face the Nation” host Margaret Brennan, had said they planned to encourage candidates to fact-check each other, but sometimes clarified statements from the candidates.

After Vance made assertions about Springfield, Ohio, being overrun by “illegal immigrants,” Brennan pointed out that a large number of Haitian immigrants in Springfield, Ohio, are in the country legally. Vance objected and, eventually, CBS exercised the debate ground rule that allowed the network to cut off the candidates’ microphones.

Most points were not fact-checked in real time by the moderators. Vance resurfaced a recent health care theme — that as president, Donald Trump sought to save the Affordable Care Act — and acknowledged that he would support a national abortion ban.

Walz described how health care looked before the ACA compared with today. Vance offered details about Trump’s health care “concepts of a plan” — a reference to comments Trump made during the presidential debate that drew jeers and criticism for the former president, who for years said he had a plan to replace the ACA that never surfaced. Vance pointed to regulatory changes advanced during the Trump administration, used weedy phrases like “reinsurance regulations,” and floated the idea of allowing states “to experiment a little bit on how to cover both the chronically ill but the non-chronically ill.”

Walz responded with a quick quip: “Here’s where being an old guy gives you some history. I was there at the creation of the ACA.” He said that before then insurers had more power to kick people off their plans. Then he detailed Trump’s efforts to undo the ACA as well as why the law’s preexisting condition protections were important.

“What Sen. Vance just explained might be worse than a concept, because what he explained is pre-Obamacare,” Walz said.

The candidates sparred on numerous topics. Our PolitiFact partners fact-checked the debate here and on their live blog.

The health-related excerpts follow.

The Affordable Care Act:

Vance: “Donald Trump could have destroyed the [Affordable Care Act]. Instead, he worked in a bipartisan way to ensure that Americans had access to affordable care.”

False.

As president, Trump worked to undermine and repeal the Affordable Care Act. He cut millions of dollars in federal funding for ACA outreach and navigators who help people sign up for health coverage. He enabled the sale of short-term health plans that don’t comply with the ACA consumer protections and allowed them to be sold for longer durations, which siphoned people away from the health law’s marketplaces.

Trump’s administration also backed state Medicaid waivers that imposed first-ever work requirements, reducing enrollment. He also ended insurance company subsidies that helped offset costs for low-income enrollees. He backed an unsuccessful repeal of the landmark 2010 health law and he backed the demise of a penalty imposed for failing to purchase health insurance.

Affordable Care Act enrollment declined by more than 2 million people during Trump’s presidency, and the number of uninsured Americans rose by 2.3 million, including 726,000 children, from 2016 to 2019, the U.S. Census Bureau reported; that includes three years of Trump’s presidency.  The number of insured Americans rose again during the Biden administration.

Abortion and Reproductive Health:

Vance: “As I read the Minnesota law that [Walz] signed into law … it says that a doctor who presides over an abortion where the baby survives, the doctor is under no obligation to provide lifesaving care to a baby who survives a botched late-term abortion.”

False.

Experts said cases in which a baby is born following an attempted abortion are rare. Less than 1% of abortions nationwide occur in the third trimester. And infanticide, the crime of killing a child within a year of its birth, is illegal in every state.

In May 2023, Walz, as Minnesota governor, signed legislation updating a state law for “infants who are born alive.” It said babies are “fully recognized” as human people and therefore protected under state law. The change did not alter regulations that already required doctors to provide patients with appropriate care.

Previously, state law said, “All reasonable measures consistent with good medical practice, including the compilation of appropriate medical records, shall be taken by the responsible medical personnel to preserve the life and health of the born alive infant.” The law was updated to instead say medical personnel must “care for the infant who is born alive.”

When there are fetal anomalies that make it likely the fetus will die before or soon after birth, some parents decide to terminate the pregnancy by inducing childbirth so that they can hold their dying baby, Democratic Minnesota state Sen. Erin Maye Quade told PolitiFact in September.

This update to the law means infants who are “born alive” receive appropriate medical care dependent on the pregnancy’s circumstances, Maye Quade said.

Vance supported a national abortion ban before becoming Trump’s running mate.

CBS News moderator Margaret Brennan told Vance, “You have supported a federal ban on abortion after 15 weeks. In fact, you said if someone can’t support legislation like that, quote, ‘you are making the United States the most barbaric pro-abortion regime anywhere in the entire world.’ My question is, why have you changed your position?”

Vance said that he “never supported a national ban” and, instead, previously supported setting “some minimum national standard.”

But in a January 2022 podcast interview, Vance said, “I certainly would like abortion to be illegal nationally.” In November, he told reporters that “we can’t give in to the idea that the federal Congress has no role in this matter.”

Since joining the Trump ticket, Vance has aligned his abortion rhetoric to match Trump’s and has said that abortion legislation should be left up to the states.

— Samantha Putterman of PolitiFact, on the live blog

A woman’s 2022 death in Georgia following the state passing its six-week abortion ban was deemed “preventable.”

Walz talked about the death of 28-year-old Amber Thurman, a Georgia woman who died after her care was delayed because of the state’s six-week abortion law. A judge called the law unconstitutional this week.

A Sept. 16 ProPublica report found that Thurman had taken abortion pills and encountered a rare complication. She sought care at Piedmont Henry Hospital in Atlanta to clear excess fetal tissue from her uterus, called a dilation and curettage, or D&C. The procedure is commonly used in abortions, and any doctor who violated Georgia’s law could be prosecuted and face up to a decade in prison.

Doctors waited 20 hours to finally operate, when Thurman’s organs were already failing, ProPublica reported. A panel of health experts tasked with examining pregnancy-related deaths to improve maternal health deemed Thurman’s death “preventable,” according to the report, and said the hospital’s delay in performing the procedure had a “large” impact.

— Samantha Putterman of PolitiFact, on the live blog

What Project 2025 Says About Some Forms of Contraception, Fertility Treatments

Walz said that Project 2025 would “make it more difficult, if not impossible, to get contraception and limit access, if not eliminate access, to fertility treatments.”

Mostly False. The Project 2025 document doesn’t call for restricting standard contraceptive methods, such as birth control pills, but it defines emergency contraceptives as “abortifacients” and says they should be eliminated from the Affordable Care Act’s covered preventive services. Emergency contraception, such as Plan B and ella, are not considered abortifacients, according to medical experts.

PolitiFact did not find any mention of in vitro fertilization throughout the document, or specific recommendations to curtail the practice in the U.S., but it contains language that supports legal rights for fetuses and embryos. Experts say this language can threaten family planning methods, including IVF and some forms of contraception.

— Samantha Putterman of PolitiFact, on the live blog

Walz: “Their Project 2025 is gonna have a registry of pregnancies.”

False. 

Project 2025 recommends that states submit more detailed abortion reporting to the federal government. It calls for more information about how and when abortions took place, as well as other statistics for miscarriages and stillbirths.

The manual does not mention, nor call for, a new federal agency tasked with registering pregnant women.

Fentanyl and Opioids:

Vance: “Kamala Harris let in fentanyl into our communities at record levels.”

Mostly False.

Illicit fentanyl seizures have been rising for years and reached record highs under Biden’s administration. In fiscal year 2015, for example, U.S. Customs and Border Protection seized 70 pounds of fentanyl. As of August 2024, agents have seized more than 19,000 pounds of fentanyl in fiscal year 2024, which ended in September.

But these are fentanyl seizures — not the amount of the narcotic being “let” into the United States. 

Vance made this claim while criticizing Harris’ immigration policies. But fentanyl enters the U.S. through the southern border mainly at official ports of entry. It’s mostly smuggled in by U.S. citizens, according to the U.S. Sentencing Commission. Most illicit fentanyl in the U.S. comes from Mexico made with chemicals from Chinese labs.

Drug policy experts have said that the illicit fentanyl crisis began years before Biden’s administration and that Biden’s border policies are not to blame for overdose deaths. 

Experts have also said Congress plays a role in reducing illicit fentanyl. Congressional funding for more vehicle scanners would help law enforcement seize more of the fentanyl that comes into the U.S. Harris has called for increased enforcement against illicit fentanyl use.

Walz: “And the good news on this is, is the last 12 months saw the largest decrease in opioid deaths in our nation’s history.”

Mostly True.

Overdose deaths involving opioids decreased from an estimated 84,181 in 2022 to 81,083 in 2023, based on the most recent provisional data from the Centers for Disease Control and Prevention. This decrease, which took place in the second half of 2023, followed a 67% increase in opioid-related deaths between 2017 and 2023.

The U.S. had an estimated 107,543 drug overdose deaths in 2023 — a 3% decrease from the 111,029 deaths estimated in 2022. This is the first annual decrease in overall drug overdose deaths since 2018. Nevertheless, the opioid death toll remains much higher than just a few years ago, according to KFF. 

More Health-Related Comments:

Vance Said ‘Hospitals Are Overwhelmed.’ Local Officials Disagree.

We asked health officials ahead of the debate what they thought about Vance’s claims about Springfield’s emergency rooms being overwhelmed.

“This claim is not accurate,” said Chris Cook, health commissioner for Springfield’s Clark County.

Comparison data from the Centers for Medicare & Medicaid Services tracks how many patients are “left without being seen” as part of its effort to characterize whether ERs are able to handle their patient loads. High percentages usually signal that the facility doesn’t have the staff or resources to provide timely and effective emergency care.

Cook said that the full-service hospital, Mercy Health Springfield Regional Medical Center, reports its emergency department is at or better than industry standard when it comes to this metric.

In July 2024, 3% of Mercy Health’s patients were counted in the “left-without-being-seen” category — the same level as both the state and national average for high-volume hospitals. In July 2019, Mercy Health tallied 2% of patients who “left without being seen.” That year, the state and national averages were 1% and 2%, respectively.  Another CMS 2024 data point shows Mercy Health patients spent less time in the ER per visit on average — 152 minutes — compared with state and national figures: 183 minutes and 211 minutes, respectively. Even so, Springfield Regional Medical Center’s Jennifer Robinson noted that Mercy Health has seen high utilization of women’s health, emergency, and primary care services. 

— Stephanie Armour, Holly Hacker, and Stephanie Stapleton of KFF Health News, on the live blog

Minnesota’s Paid Leave Takes Effect in 2026

Walz signed paid family leave into law in 2023 and it will take effect in 2026.

The law will provide employees up to 12 weeks of paid medical leave and up to 12 weeks of paid family leave, which includes bonding with a child, caring for a family member, supporting survivors of domestic violence or sexual assault, and supporting active-duty deployments. A maximum 20 weeks are available in a benefit year if someone takes both medical and family leave.

Minnesota used a projected budget surplus to jump-start the program; funding will then shift to a payroll tax split between employers and workers. 

— Amy Sherman of PolitiFact, on the live blog

Dave Lantz is no stranger to emergency department or doctor bills. With three kids in their teens and early 20s, “when someone gets sick or breaks an arm, all of a sudden you have thousand-dollar medical bills,” Lantz said.

The family’s health plan that he used to get as the assistant director of physical plant at Lycoming College, a small liberal arts school in central Pennsylvania, didn’t start to cover their costs until they had paid $5,600 in medical bills. The Lantzes were on the hook up to that annual threshold. The high-deductible plan wasn’t ideal for the family of five, but it was the only coverage option available to them.

Things are very different now. In mid-2022, the college ditched its group health plan and replaced it with a new type of plan — an individual coverage health reimbursement arrangement, or ICHRA.

Now Lantz gets a set amount from his employer every month that he puts toward a family plan on the individual insurance market. He opted for a zero-deductible plan with a richer level of coverage than the group plan. Though its $790 monthly premium is higher than the $411 he used to pay, he ends up saving money overall by not having to pay down that big deductible. Plus, he now has more control over his health spending.

“It’s nice to have the choice to balance the high deductible versus the higher premium,” Lantz said. Before, “it was tough to budget for that deductible.”

As health insurance costs continue to rise, employers are eyeing this type of health reimbursement arrangement to control their health care spending while still providing a benefit that workers value. Some consumer advocates are concerned the plans could result in skimpier, pricier coverage for certain consumers, especially sicker, older ones.

The plans allow employers to make tax-preferred contributions to employees to use to buy coverage on the individual market. Employers thus limit their financial exposure to rising health care costs. Everybody wins, say backers of the plans, which were established in 2019 as part of a group of proposals the Trump administration said would increase health insurance choice and competition.

“It’s a way to offer coverage to more diverse employee groups than ever before and set a budget that controls costs for the companies,” said Robin Paoli, executive director of the HRA Council, an advocacy group.

Some health insurance specialists say the plans aren’t necessarily a good option for consumers or the individual insurance market. Even though the rules prevent employers from offering this type of coverage to specific workers who may be sicker and more expensive to cover than others, employers with relatively unhealthy workforces may find the arrangements appealing. This, in turn, may drive up premiums in the individual market, according to an analysis by the University of Southern California-Brookings Schaeffer Initiative for Health Policy.

Plans sold on the individual market often have smaller provider networks and higher deductibles than employer-sponsored coverage. Premiums are often higher than for comparable group coverage. Workers, especially lower-wage ones, might be better off financially with premium tax credits and cost-sharing reductions to buy an Affordable Care Act marketplace plan, but using the work-based ICHRA benefit would disqualify them.

“From a worker perspective, the largest impact is that being offered affordable coverage by your employer makes you ineligible for marketplace subsidies,” said Matthew Fiedler, a senior fellow at the Brookings Institution who co-authored the analysis of the rule establishing the plans.

The plans are currently offered to only a tiny slice of workers: an estimated 500,000 of the roughly 165 million people with employer-sponsored coverage, according to the HRA Council. But interest is growing. The number of employers offering ICHRAs and an earlier type of plan, called qualified small-employer HRAs, increased 29% from 2023 to 2024, according to the council. And, although small employers have made up the bulk of adopters to date, larger employers with at least 50 workers are the fastest-growing cohort.

Individual market insurers like Oscar Health and Centene see opportunities to expand their footprint through the plans. Some venture capitalists are touting them as well.

“The [traditional group] health insurance cornerstone from 60 years ago has outlived its usefulness,” said Matt Miller, whose Headwater Ventures has invested in the ICHRA administrator Venteur. “The goal is to ensure people have coverage, detaching it from the employment construct and making it portable.”

Employers can offer this type of health reimbursement arrangement to some classes of employees and group plans to others based on characteristics such as geography, full-time vs. part-time status, or salaried vs. hourly pay.

Lycoming College wasn’t aiming to be on the cutting edge when it made this coverage switch. Faced with a 60% premium increase after some members had high claims, the school, which covers roughly 400 faculty and staff and their family members, needed to look at alternatives, said Kacy Hagan, its associate vice president for human resources and compliance.

In the end, they opted to offer ICHRA coverage to any employee who worked at least 30 hours a week.

In the first year of offering the new benefit, the college saved $1.4 million in health care costs over what they would have spent if they’d stayed with its group plan. Employees saved an average of $1,200 each in premiums.

“The finance folks really like it,” Hagan said. As for employees, “from a cost standpoint, people tend to be pretty happy with it, and people really like having a choice of plans,” she said. However, there have been issues with the plan’s administration. Some employees’ coverage was dropped and had to be reinstated, she said. Those problems have been largely resolved since they switched plan administrators this year.

This coverage arrangement can be complicated to manage. Instead of a company paying one group health plan premium, dozens of individual health insurers may need to be paid. And employees who’ve never shopped for a plan before need help figuring out what coverage works for them and signing up.

The complexity can be off-putting. This year, a number of companies that have tried this type of health reimbursement arrangement decided they’d rather go back to a group plan, said Tim Hebert, managing partner of Sage Benefit Advisors, based in Fort Collins, Colorado.

“They say, ‘Employees are all over the place in different plans, and they don’t feel like they’re being taken care of,’” Hebert said.

Vendors continue to crop up to help employers like Lycoming College and their workers manage their plans.

“If you just say, ‘Here’s $1,000,’ it’s extremely discombobulating and confusing,” said Jack Hooper, CEO of Take Command Health, which now administers the Lycoming ICHRA.

It’s unclear whether the plans will take off or remain a niche product.

“It’s a big disrupter, like 401(k)s,” said Mark Mixer, board chair of the HRA Council and CEO of HealthOne Alliance in Dalton, Georgia. Still, it’s not for everyone. “It’s simply another tool that employers should consider. When it fits, do it.”

Federal officials resolved more than a decade ago to crack down on whopping government overpayments to private Medicare Advantage health insurance plans, which were siphoning off billions of tax dollars every year.

But Centers for Medicare & Medicaid Services officials have yet to demand any refunds — and over the years the private insurance plans have morphed into a politically potent juggernaut that has signed up more than 33 million seniors and is aggressively lobbying to stave off cuts.

Critics have watched with alarm as the industry has managed to deflate or deflect financial penalties and steadily gain clout in Washington through political contributions; television advertising, including a 2023 Super Bowl feature; and other activities, including mobilizing seniors. There’s also a revolving door, in which senior CMS personnel have cycled out of government to take jobs tied to the Medicare Advantage industry and then returned to the agency.

Sen. Chuck Grassley (R-Iowa) said Medicare Advantage fraud “is wasting taxpayer dollars to the tune of billions.”

“The question is, what’s CMS doing about it? The agency must tighten up its controls and work with the Justice Department to prosecute and recover improper payments,” Grassley said in a statement to KFF Health News. “Clearly that’s not happening, at least to the extent it should be.”

David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said policymakers have an unsettling history of yielding to industry pressure. “The health plans throw a temper tantrum and then CMS will back off,” he said.

Government spending on Medicare Advantage, which is dominated by big health insurance companies, is expected to hit $462 billion this year.

New details of the government’s failure to rein in Medicare Advantage overcharges are emerging from a Department of Justice civil fraud case filed in 2017 against UnitedHealth Group, the insurer with the most Medicare Advantage enrollees. The case is pending in Los Angeles. The DOJ has accused the giant insurer of cheating Medicare out of more than $2 billion by mining patient records to find additional diagnoses that added revenue while ignoring overcharges that might have reduced bills. The company denies the allegations and has filed a motion for summary judgment.

Records from the court case are surfacing as the Medicare Advantage industry ramps up spending on lobbying and public relations campaigns to counter mounting criticism.

While critics have argued for years that the health plans cost taxpayers too much, the industry also has come under fire more recently for allegedly scrimping on vital health care, even dumping hundreds of thousands of members whose health plans proved unprofitable.

“We recognize this is a critical moment for Medicare Advantage,” said Rebecca Buck, senior vice president of communications for the Better Medicare Alliance, which styles itself as “the leading voice for Medicare Advantage.”

Buck said initiatives aimed at slashing government payments may prompt health plans to cut vital services. “Seniors are saying loud and clear: They can’t afford policies that will make their health care more expensive,” she said. “We want to make sure Washington gets the message.”

AHIP, a trade group for health insurers, also has launched a “seven-figure” campaign to promote its view that Medicare Advantage provides “better care at a lower cost,” spokesperson Chris Bond said.

Revolving Door

CMS, the Baltimore-based agency that oversees Medicare, has long felt the sting of industry pressure to slow or otherwise stymie audits and other steps to reduce and recover overpayments. These issues often attract little public notice, even though they can put billions of tax dollars at risk.

In August, KFF Health News reported how CMS officials backed off a 2014 plan to discourage the health plans from overcharging amid an industry “uproar.” The rule would have required that insurers, when combing patients’ medical records to identify underpayments, also look for overcharges. Health plans have been paid billions of dollars through the data mining, known as “chart reviews,” according to the government.

The CMS press office declined to respond to written questions posed by KFF Health News. But in a statement, it called the agency a “good steward of taxpayer dollars” and said in part: “CMS will continue to ensure that the MA program offers robust and stable options for people with Medicare while strengthening payment accuracy so that taxpayer dollars are appropriately spent.”

Court records from the UnitedHealth case show that CMS efforts to tighten oversight stalled amid years of technical protests from the industry — such as arguing that audits to uncover overpayments were flawed and unfair.

In one case, Jeffrey Grant, a CMS official who had decamped for a job supporting Medicare Advantage plans, protested the audit formula to several of his former colleagues, according to a deposition he gave in 2018.

Grant has since returned to CMS and now is deputy director for operations at the agency’s Center for Consumer Information and Insurance Oversight. He declined to comment.

At least a dozen witnesses in the UnitedHealth case and a similar DOJ civil fraud case pending against Anthem are former ranking CMS officials who departed for jobs tied to the Medicare Advantage industry.

Marilyn Tavenner is one. She led the agency in 2014 when it backed off the overpayment regulation. She left in 2015 to head industry trade group AHIP, where she made more than $4.5 million during three years at the helm, according to Internal Revenue Service filings. Tavenner, who is a witness in the UnitedHealth case, had no comment.

And in October 2015, as CMS department chiefs were batting around ideas to crack down on billing abuses, including reinstating the 2014 regulation on data mining, the agency was led by Andy Slavitt, a former executive vice president of the Optum division of UnitedHealth Group. The DOJ fraud suit focuses on Optum’s data mining program.

In the legal proceedings, Slavitt is identified as a “key custodian regarding final decision making by CMS” on Medicare Advantage.

“I don’t have any awareness of that conversation,” Slavitt told KFF Health News in an email. Slavitt, who now helps run a health care venture capital firm, said that during his CMS tenure he “was recused from all matters related to UHG.”

‘Improper’ Payments

CMS officials first laid plans to curb escalating overpayments to the insurers more than a decade ago, according to documents filed in August in the UnitedHealth case.

In a January 2012 presentation, CMS officials estimated they had made $12.4 billion worth of “improper payments” to Medicare Advantage groups in 2009, mostly because the plans failed to document that patients had the conditions the government paid them to treat, according to the court documents.

As a remedy, CMS came up with an audit program that selected 30 plans annually, taking a sample of 201 patients from each. Medical coders checked to make sure patient files properly documented health conditions for which the plans had billed.

The 2011 audits found that five major Medicare Advantage chains failed to document from 12.3% to 25.8% of diagnoses, most commonly strokes, lung conditions, and heart disease.

UnitedHealth Group, which had the lowest rate of unconfirmed diagnoses, is the only company named in the CMS documents in the case file. The identities of the four other chains are blacked out in the audit records, which are marked as “privileged and confidential.”

In a May 2016 private briefing, CMS indicated that the health plans owed from $98 million to $163 million for 2011 depending on how the overpayment estimate was extrapolated, court records show.

But CMS still hasn’t collected any money. In a surprise action in late January 2023, CMS announced that it would settle for a fraction of the estimated overpayments and not impose major financial penalties until 2018 audits, which have yet to get underway. Exactly how much plans will end up paying back is unclear.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said CMS has largely failed to rein in billions of dollars in Medicare Advantage overpayments.

“It is reasonable to think that pressure from the industry is part of the reason that CMS has not acted more aggressively,” Kronick said.

CMS records show that officials considered strengthening the audits in 2015, including by limiting health plans from conducting “home visits” to patients to capture new diagnosis codes. That didn’t happen, for reasons that aren’t clear from the filings.

In any case, audits for 2011 through 2015 “are not yet final and are subject to change,” CMS official Steven Ferraina stated in a July court affidavit.

“It’s galling to me that they haven’t recovered more than they have,” said Edward Baker, a whistleblower attorney who has studied the issue.

“The government needs to be more aggressive in oversight and enforcement of the industry,” he said.

Senior CMS official Cheri Rice recommended in the October 2015 email thread with key staff that CMS could devote more resources to supporting whistleblowers who report overbilling and fraud.

“We think the whistleblower activity could be as effective – or even more effective – than CMS audits in getting plans to do more to prevent and identify risk adjustment overpayments,” Rice wrote.

But the handful of cases that DOJ could realistically bring against insurers cannot substitute for CMS fiscal oversight, Baker said.

“Unfortunately, that makes it appear that fraud pays,” he said.

Spending Surge

In December, a bipartisan group of four U.S. senators, including Bill Cassidy (R-La.), wrote to CMS to voice their alarm about the overpayments and other problems. “It’s unclear why CMS hasn’t taken stronger action against overpayments, despite this being a longstanding issue,” Cassidy told KFF Health News by email.

In January, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) called for CMS to crack down, including by restricting use of chart reviews and home visits, known as health risk assessments, to increase plan revenues.

Cassidy, a physician, said that “upcoding and abuses of chart review and health risk assessments are well-known problems CMS could address immediately.”

Advocates for Medicare Advantage plans, whose more than 33 million members comprise over half of people eligible for Medicare, worry that too much focus on payment issues could harm seniors. Their research shows most seniors are happy with the care they receive and that the plans typically cost them less out-of-pocket than traditional Medicare.

Buck, the spokesperson for the Better Medicare Alliance, said that as the annual open enrollment period starts in mid-October, seniors may see “fewer benefits and fewer plan choices.”

The group has ramped up total spending in recent years to keep that from happening, IRS filings show.

In 2022, the most recent year available, the Better Medicare Alliance reported expenses of $23.1 million, including more than $14 million on advertising and promotion, while in 2023, it paid for a Super Bowl ad featuring seniors in a bowling alley and left viewers with the message: Cutting Medicare Advantage was “nuts.”

Bruce Vladeck, who ran CMS’ predecessor agency from 1993 through 1997, said that when government officials first turned to Medicare managed care groups in the 1990s, they quickly saw health plans enlist members to help press their agenda.

“That is different from most other health care provider groups that lobby,” Vladeck said. “It’s a political weapon that Medicare Advantage plans have not been at all reluctant to use.”

The Better Medicare Alliance reported lobbying on 18 bills this year and last, according to OpenSecrets. Some are specific to Medicare Advantage, such as one requiring insurers to report more detailed data about treatments and services and another to expand the benefits they can offer, while others more broadly concern health care costs and services.

Proposed reforms aside, CMS appears to believe that getting rid of health plans that allegedly rip off Medicare could leave vulnerable seniors in the lurch.

Testifying on behalf of CMS in a May 2023 deposition in the UnitedHealth Group suit, former agency official Anne Hornsby said some seniors might not “find new providers easily.” Noting UnitedHealth Group is the single biggest Medicare Advantage contractor, she said CMS “is interested in protecting the continuity of care.”

When Preston Nafz was 12, he asked his dad for permission to play lacrosse.

“First practice, he came back, he said, ‘Dad, I love it,’” recalled his father, Lothar Nafz, of Hoover, Alabama. “He lives for lacrosse.”

But years of youth sports took a toll on Preston’s body. By the time the teenager limped off the field during a lacrosse tournament last year, the pain in his left hip had become so intense that he had trouble with simple activities, such as getting out of a car or turning over in bed. Months of physical therapy and anti-inflammatory drugs didn’t help.

Not only did he have to give up sports, but “I could barely do anything,” said Preston, now 17.

The Medical Procedure

A doctor recommended Preston undergo a procedure called a sports hernia repair to mend damaged tissue in his pelvis, believed to be causing his pain.

The sports medicine clinic treating Preston told Lothar that the procedure had no medical billing code — an identifier that providers use to charge insurers and other payers. It likely would be a struggle to persuade their insurer to cover it, Lothar was told, which is why he needed to pay upfront.

With his son suffering, Lothar said, the surgery “needed to be done.” He paid more than $7,000 to the clinic and the surgery center with a personal credit card and a medical credit card with a zero-interest rate.

Preston underwent surgery in November, and his father filed a claim with their insurer, hoping for a full reimbursement. It didn’t come.

The Final Bill

$7,105, which broke down as $480 for anesthesia, a $625 facility fee, and $6,000 for the surgery.

The Billing Problem: No CPT Code

Before the surgery, Lothar said, he called Blue Cross and Blue Shield of Alabama and was encouraged to learn that his policy typically covers most medical, non-cosmetic procedures.

But during follow-up phone calls, he said, insurance representatives were “deflecting, trying to wiggle out.” He said he called several times, getting a denial just before the surgery.

Lothar said he trusted his son’s doctor, who showed him research indicating the surgery works. The clinic, Andrews Sports Medicine and Orthopaedic Center, has a good reputation in Alabama, he said.

Other medical providers not involved in the case called the surgery a legitimate treatment.

A sports hernia — also known as an “athletic pubalgia” — is a catchall phrase to describe pain that athletes may experience in the lower groin or upper thigh area, said David Geier, an orthopedic surgeon and sports medicine specialist in Mount Pleasant, South Carolina.

“There’s a number of underlying things that can cause it,” Geier said. Because of that, there isn’t “one accepted surgery for that problem. That’s why I suspect there’s not a uniform CPT.”

CPT stands for “Current Procedural Terminology” and refers to the numerical or alphanumeric codes for procedures and services performed in a clinical or outpatient setting. There’s a CPT code for a rapid strep test, for example, and different codes for various X-rays.

The lack of a CPT code can cause reimbursement headaches, since insurers determine how much to pay based on the CPT codes providers use on claims forms.

More than 10,000 CPT codes exist. Several hundred are added each year by a special committee of the American Medical Association, explained Leonta Williams, director of education at AAPC, previously known as the American Academy of Professional Coders.

Codes are more likely to be proposed if the procedure in question is highly utilized, she said.

Not many orthopedic surgeons in the U.S. perform sports hernia repairs, Geier said. He said some insurers consider the surgery experimental.

Preston said his pain improved since his surgery, though recovery was much longer and more painful than he expected.

By the end of April, Lothar said, he’d finished paying off the surgery.

The Resolution: A billing statement from the surgery center shows that the CPT code assigned to Preston’s sports hernia repair was “27299,” which stands for “a pelvis or hip joint procedure that does not have a specific code.”

After submitting more documentation to appeal the insurance denial, Lothar received a check from the insurer for $620.26. Blue Cross and Blue Shield didn’t say how it came up with that number or which costs it was reimbursing.

Lothar said he has continued to receive confusing messages from the insurer about his claim.

Both the insurer and the sports medicine clinic declined to comment.

The Takeaway

Before you undergo a medical procedure, try to check whether your insurer will cover the cost and confirm it has a billing code.

Williams of the AAPC suggests asking your insurer: “Do you reimburse this code? What types of services fall under this code? What is the likelihood of this being reimbursed?”

Persuading an insurer to pay for care that doesn’t have its own billing code is difficult but not impossible, Williams said. Your doctor can bill insurance using an “unlisted code” along with documentation explaining what procedure was performed.

“Anytime you’re dealing with an unlisted code, there’s additional work needed to explain what service was rendered and why it was needed,” she said.

Some patients undergoing procedures without CPT codes may be asked to pay upfront. You can also offer a partial upfront payment, which may motivate your provider to team up to get insurance to pay.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

Donald Trump could have destroyed the Affordable Care Act, but “he chose to build upon [it].”

Sen. JD Vance (R-Ohio) on “Meet the Press,” Sept. 15

Sen. JD Vance (R-Ohio) on Sept. 15 told viewers of NBC’s “Meet the Press” that former President Donald Trump built up the Affordable Care Act, even though Trump could have chosen to do the opposite.

“Donald Trump had two choices,” Vance, Trump’s running mate, said. “He could have destroyed the program, or he could actually build upon it and make it better so that Americans didn’t lose a lot of health care. He chose to build upon a plan, even though it came from his Democratic predecessor.”

The remarks follow statements the former president made during his Sept. 10 debate with Vice President Kamala Harris in Philadelphia. Trump said of the ACA, “I saved it.”

The Affordable Care Act, aka Obamacare, has grown more popular as Americans have increasingly used it to gain health coverage. More than 20 million people enrolled this year in plans sold through the marketplaces it created. That makes the law a tricky political issue for Republicans, who have largely retreated from their attempts over the past decade to repeal it.

Both Vance’s and Trump’s statements are false. We contacted Vance’s campaign; it provided no additional information. But here’s a review of policies related to Obamacare that Trump pursued as president.

So What Did Trump Do With the ACA?

Most of the Trump administration’s ACA-related actions involved cutting the program, including reducing by millions of dollars funding for marketing and enrollment assistance and backing the many failed efforts in Congress and the courts to overturn the law. In June 2020, for example, the administration asked the Supreme Court to overturn the law in a case brought by more than a dozen GOP states. The high court eventually rejected the case.

“The fact the ACA survived the Trump administration is a testament to the strength of the underlying statutory framework, and that the public rallied around it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

Most ACA provisions took effect in 2014, during Barack Obama’s presidential administration.

Average premium costs, already rising when Trump took office, jumped for some plans in 2018, before beginning a modest decline for the rest of his term, according to statistics from KFF, a health information nonprofit that includes KFF Health News.

Some of those increases were tied to a 2017 Trump administration decision to stop making payments to insurers, which was intended to reduce deductibles and copayments for people with low to moderate incomes. By law, though, insurers still had to offer the plans.

Two months earlier, the Congressional Budget Office warned that stopping the payments could cause some insurers to leave the ACA marketplace — and that premiums would rise by 20% in the first year.

Most states, however, let insurers make up for the lost payments by increasing monthly premiums. That had the unintended effect of boosting federal subsidies for people who buy Obamacare plans, because the subsidies are tied to the cost of premiums.

“By accident, that gave people cheaper access to better coverage in the exchange plans,” said Joe Antos, a senior fellow emeritus with the American Enterprise Institute.

Some Republicans think Trump deserves credit for this inadvertent improvement.

But Larry Levitt, KFF’s executive vice president for health policy, said that wasn’t the Trump administration’s intention.

“The one time when Trump improved the ACA, it was an unintended consequence of an attempt to weaken it,” he said.

Meanwhile, the Trump administration expanded access to some kinds of less expensive health coverage that aren’t compliant with ACA rules, including short-term plans that generally have more restrictions on care and can leave consumers with surprise medical bills. Democrats call the plans “junk insurance.”

Brian Blase, president of the Paragon Health Institute, a conservative health research group, said broader access to cheaper, less comprehensive plans helped more people get coverage. The plans’ critics say that if they had attracted too many healthy people from ACA-compliant insurance, increases could have spiked for people who remained.

Trump also supported congressional repeal-and-replace efforts, all of which failed — including on the memorable night when Sen. John McCain (R-Ariz.) helped kill the effort with a thumbs-down vote. The Trump administration never issued its own replacement plan, despite the former president’s many promises that he would.

Trump, during the debate with Harris, said that he has “concepts of a plan” to replace Obamacare and that “you’ll be hearing about it in the not-too-distant future.”

On “Meet the Press,” host Kristen Welker asked Vance when Trump’s plan would be ready. He didn’t answer directly but said it would involve “deregulating the insurance market.”

Critics say that’s code for letting insurers do business as they did pre-ACA, when sick people could be denied coverage or charged exorbitant premiums based on preexisting conditions.

Our Ruling

Vance’s assertion that Trump as president took steps to build upon the ACA and protect the health coverage of 20 million Americans is simply not supported by the record.

Trump administration policies, for example, didn’t buttress the ACA but often undermined enrollment outreach efforts or were advanced to sabotage the insurance marketplace. Also, Trump vocally supported congressional efforts to overturn the law and legal challenges to it.

By the numbers, Affordable Care Act enrollment declined by more than 2 million people during Trump’s presidency, and the number of uninsured Americans rose by 2.3 million, including 726,000 children, from 2016 to 2019, according to the U.S. Census Bureau. That includes nearly three years of Trump’s presidency.

We rate Vance’s statement False.

SOURCES:

“Meet the Press” interview with Sen. JD Vance, Sept. 15, 2024.

Brookings Institution, “Six Ways Trump Has Sabotaged the Affordable Care Act,” Oct. 9, 2020.

Vox, “Trump Is Slashing Obamacare’s Advertising Budget by 90%,” Aug. 31, 2017.

Center on Budget and Policy Priorities, “Trump Administration Has Cut Navigator Funding by Over 80 Percent Since 2016,” Sept. 13, 2018.

The New York Times, ‘Trump Administration Asks Supreme Court To Strike Down Affordable Care Act,” June 26, 2020.

Constitutional Accountability Center, Texas v. United States, accessed Sept. 16, 2024.

Harvard T.H. Chan School of Public Health, “Quantifying Health Coverage Losses Under Trump,” Nov. 3, 2020.

Center on Budget and Policy Priorities, “Uninsured Rate Rose Again In 2019, Further Eroding Earlier Progress,” Sept. 15, 2020.

U.S. Census Bureau, Health Insurance Historical Tables, revised Aug. 22, 2024.

KFF, Marketplace Average Benchmark Premiums, accessed Sept. 16, 2024.

Brookings Institution, “The Case for Replacing ‘Silver Loading,’” May 20, 2021.

KFF Health News, “Trump Administration Loosens Restrictions on Short-Term Health Plans,” Aug. 1, 2018.

The New York Times, “Biden Administration Finalizes Rule Curbing Use of Short-Term Health Plans,” March 28, 2024.

Telephone interview, Sabrina Corlette, co-director of the Center on Health Reforms at Georgetown University, Sept. 16, 2024.

Telephone interview, Joe Antos, senior fellow emeritus, American Enterprise Institute, Sept. 16, 2024.

Email correspondence, Brian Blase, president of the Paragon Health Institute, Sept. 16, 2024.

Email correspondence, Larry Levitt, KFF executive vice president for health policy, Sept. 18, 2024.

Congressional Budget Office, “The Effects of Terminating Payments for Cost-Sharing Reductions,” Aug. 15, 2017.

USA Today, “Trump To End Cost-Sharing Subsidies to Insurance Companies,” Oct. 12, 2017.

New York magazine, “Vance: Trump’s Health-Care Plan Is To Let Insurers Charge More for Preexisting Conditions,” Sept. 17, 2024.

TUSCALOOSA, Ala. — Like most medical offices, the small suite of exam rooms at the PhiferCares Clinic fills daily with patients seeking help with bumps and bruises, sore throats, and stuffy noses.

But there’s an important difference about this clinic in central Alabama: No one gets a bill, including for prescriptions.

That’s because the clinic is owned by a manufacturing company with a specific agenda. “We don’t want you to spend money on health care,” said Russell DuBose, vice president of human resources at Phifer.

Phifer, a global manufacturer of window screens, opened the clinic five years ago in a bid to control its health care costs and stop big medical bills from driving its workers into debt. The strategy has paid big dividends. Phifer has saved so much on health care that the company was able to open a free summer camp for the children of employees.

Workers have dramatically boosted retirement savings, too. And Phifer is now adding chiropractic care and orthotics, all at no cost to workers.

Benefits like these remain out of reach for most U.S. workers, millions of whom drain savings, take out second mortgages, or cut back on food and other essentials to stay ahead of health care debt. Overall, about 100 million people in the U.S. are burdened by some form of this debt, KFF Health News has found.

Many of those people have health plans through employers who, unable to control their health care costs, now force workers to pay thousands of dollars out-of-pocket when they go to a doctor. Phifer has shown there’s another way. The company not only saved itself money, it’s sharing the benefits with workers and shielding them from debt.

“It’s really remarkable,” said Shawn Gremminger, president of the National Alliance of Healthcare Purchaser Coalitions, which works with employers on improving health benefits.

“If I had to point to a single employer in our network that’s been the most aggressive tackling this problem and coming up with the most innovative solutions,” he said, “it’s a relatively small, privately owned manufacturer in a small town in the South.”

‘Unacceptable’ Health Costs

Phifer is a family-owned company founded after World War II by a former pilot. J. Reese Phifer saw an opportunity to turn aluminum produced for the war effort into window screens for America’s booming suburbs.

Today Phifer still makes screens at a cavernous plant outside Tuscaloosa that stretches over more than 34 acres of factory floor. Inside, massive rolls of aluminum coil are unwound, stretched, and spun on rows of spools and looms. Elsewhere, fiberglass is woven into material for window shades, patio furniture, and other products.

Business has been good for the company, which employs about 2,000 people and operates plants in Alabama and overseas. A few years ago, though, Phifer noticed its workers weren’t saving enough for retirement. The culprit was medical bills.

“Copays, coinsurance, cost sharing. All these things were taking money away from our plan members,” DuBose said. “The amount of money employees were having to spend on health care was unacceptable.”

That’s not unusual. Most U.S. workers and their families are in a health plan with significant cost sharing, requiring they pay thousands of dollars out-of-pocket before coverage kicks in.

The average deductible for an employer-provided health plan now exceeds $1,500, data shows. And for family plans, deductibles can be several times that. That’s a big reason health care debt is such a big problem, even for people with health coverage.

For Phifer, which relies on skilled workers to operate its machines, reducing employees’ financial stress became a priority, DuBose said. “When you have somebody who wants to be here every day, wants to be here every year,” he said, “they can do some pretty awesome stuff.”

Removing Barriers

Phifer landed on a deceptively simple idea: Make it easier — and cheaper — for workers to see a doctor and fill a prescription. That, the company reasoned, could improve employee health and control costly complications.

The cornerstone of this plan was the PhiferCares Clinic and pharmacy.

The company set up the clinic in a small park and recreation space Phifer owned down the road from the factory. It contracted with a local health system to provide the physician and nurses. Inside is a small pharmacy.

At no cost, employees and their families can go in for basic primary care, including checkups, vaccinations, and help managing chronic illnesses like diabetes. “It’s almost a concierge service,” DuBose said.

Phifer did something else, too. It directs patients to specialists and hospitals with the highest quality ratings. That can save money for patients and the company. Workers who choose one of these providers typically don’t get a bill.

That kind of no-cost access makes a huge difference, said Ronald Lewis, who visited the PhiferCares Clinic recently for a checkup.

“I’m saving thousands of dollars, easy. Easy $3,000,” said Lewis, whose wife works at the plant. “All you’ve got to do is come in, make an appointment, and they come in and see you. … It is a life-changer.”

The clinic has helped Lewis lose weight and keep his blood pressure in check. A doctor also caught early signs of prostate cancer.

Cherry Wilson, who has worked on a production line at Phifer since 2017, said she still has medical debt from a gallbladder surgery she had before she joined the company. But when she broke her foot more recently and got surgery from a preferred specialist, there were no medical bills. “I don’t pay anything here,” she said.

Big Dividends

Other companies have experimented with workplace clinics with mixed results.

Running a medical office can be expensive. The strategy may not work if employees aren’t centrally located or if employee turnover is high. And savings can take a while to materialize. But research on employer health benefits has shown that reducing how much workers pay for primary care and prescription drugs yields better outcomes for workers and can save everybody money.

Phifer is reaping rewards.

Despite years of high inflation nationally, the company’s net spending on health care was lower in 2023 than in 2019, declining from $15.8 million to $14.9 million in constant dollars, according to data provided by DuBose.

The cost of the company’s most popular health plan — which comes with no deductible and includes dental benefits — is lower, as well. Phifer workers pay $394 a month for this family plan. By comparison, workers nationally contribute $548 monthly on average for family coverage that typically comes with a sizable deductible.

“We’ve seen the power of prevention,” DuBose said.

With savings from its health care strategy, Phifer opened the summer camp last year. And the company is offering college scholarships to workers’ children.

Workers are saving more, too. About 90% are hitting their retirement goals, DuBose said, up from around 75% five years ago.

The protections from big medical bills have had another benefit, said Jerry Wheat, who has worked for Phifer for 38 years and runs a production line for fiberglass screens.

“It makes you want to take care of yourself and do better for the company,” Wheat said. “If somebody’s going to take care of you, don’t you want to take care of them? That’s the way I look at it. But I’m old-school.”

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.

USE OUR CONTENT

This story can be republished for free (details).

The proponents of Proposition 35, a November ballot initiative that would create a dedicated stream of funding to provide health care for California’s low-income residents, have assembled an impressive coalition: doctors, hospitals, community clinics, dentists, ambulance companies, several county governments, numerous advocacy groups, big business, and both major political parties.

The Yes on Prop 35 campaign has raised over $48 million as of Sept. 9, according to campaign filings with the secretary of state. The measure would use money from a tax on managed-care health plans mainly to hike the pay of physicians, hospitals, community clinics, and other providers in Medi-Cal, the state’s version of Medicaid.

For many months, there was no organized opposition. But shortly after Labor Day, a small group of community advocates, including the League of Women Voters of California, California Pan-Ethnic Health Network, and The Children’s Partnership, announced they were united against it.

“We do not have the deep pockets that the proponents of the initiative do,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network. No fundraising has been recorded from opposition groups thus far.

Gov. Gavin Newsom hasn’t taken a public stance, but he has warned that the proposal to lock in how proceeds from the managed-care tax are used would hamstring his administration’s ability to address the state’s yawning budget gap.

The people represented by some of the opposition groups include Medi-Cal patients who are among the state’s most vulnerable — children, seniors, people with disabilities, and the chronically ill — as well as some workers who provide ancillary care to them.

The opponents say that if Proposition 35 passes, the patients, workers, and programs they care about could lose millions of dollars included for them in this year’s state budget. That’s because the ballot measure would supersede the budget, and it leaves them out of the health tax proceeds.

The budget currently provides tens of millions of dollars a year to raise the pay of community health workers, nonemergency medical transport drivers, and private-duty nurses, among other personnel. It also funds the cost of a new program, scheduled to start Jan. 1, that allows children through age 4 to stay on Medi-Cal without requiring their families to prove eligibility every year. Child health advocates say that will help avoid potentially harmful gaps in coverage.

Mayra Alvarez, president of The Children’s Partnership, estimates the program would bring coverage stability to about 1.2 million California kids. But funding for it will be at risk if Proposition 35 passes, she warns.

It’s not that the money for that program, or the pay increases for ancillary health care workers, would necessarily go away forever. But advocates would have to fight for it in subsequent budget rounds.

Dustin Corcoran, CEO of the California Medical Association, told me that in addition to the Medi-Cal pay hikes, and some funding for medical education and extra residency slots, the initiative would provide $2 billion a year in 2025 and 2026 to the state’s general fund, “which the legislature can appropriate as they see fit, which vastly exceeds the cost of the programs you mentioned.” CMA and Planned Parenthood Affiliates of California are leading the charge on Proposition 35.

Corcoran’s comments suggest that the groups worried about losing funding if Proposition 35 passes should be able to get it restored in future budgets. Given the current fiscal crisis, however, not everyone is buying it.

“We’re short tens of billions of dollars,” says Ramon Castellblanch, vice president of the California Alliance for Retired Americans, which opposes the measure. “For these people to say, ‘Wait, the general fund is going to cover it’ — is that called gaslighting?”

Proposition 35 proponents say that children, seniors, and disabled or chronically ill people also use doctors, hospitals, and community clinics, for which the measure does provide extra money.

They argue the initiative will go a long way toward addressing Medi-Cal’s historically low pay rates, enticing more providers to participate in the program and enabling those who already do to take more Medi-Cal patients.

“This will be the most significant investment in the Medi-Cal system since the Affordable Care Act,” Corcoran says. “I think it holds great promise for improved access to care, improved quality of care, shorter wait times for all Californians in our ERs, and elimination of health care deserts that are popping up in too many parts of our state.”

Another concern raised by Proposition 35 skeptics is that a long-threatened change in federal rules governing how states collect managed-care taxes to fund Medicaid could torpedo the plans of California — and some of the other 18 states with such a tax.

Proposition 35 sets specific dollar amounts through 2026, which are based on the managed-care tax approved by the federal government last year. But the tax, which California has had in some form since 2009, must be renewed and federally approved every three years. That means that the tax requires another federal approval starting in 2027, the year the ballot measure would make funding permanent.

California’s managed-care tax comes from a levy imposed on health plans, based on monthly numbers of both Medi-Cal and commercial insurance enrollees. The money raised is matched by the federal government, doubling the spending power.

Federal rules require that the health plans be reimbursed for the tax they pay on their Medi-Cal membership. Since the Medi-Cal rate is around 100 times as much as the rate on commercial membership, 99% of the revenue from the tax is on the Medi-Cal side, thus holding many of the health plans almost entirely harmless and minimizing any impact on premiums.

But the federal government has been warning California for years, most recently in a letter it sent in late 2023 accompanying its approval of the managed-care tax, that it will require more balance between the commercial and Medi-Cal levies. Were it to change the rules in that direction, it could cause a major headache in California for a couple of reasons.

First, as proponents of Proposition 35 readily acknowledge, there is no political appetite for an increase in the amount of tax raised on commercial health plan memberships. That’s because it would likely lead to a rebellion by health plans or a jump in premiums that would anger employers, privately insured individuals, and plenty of other people. In that case, the only way to comply would be to lower the tax rate on Medi-Cal enrollment, which would significantly reduce revenue.

Second, though the ballot measure contains flexibility for small changes, it requires a three-fourths majority vote in the legislature for any major changes. That would be a tall order.

“Say the federal administration comes back and says, ‘You can’t do this anymore,’ which seems likely,” says Savage-Sangwan, who is also a spokesperson for the opposing coalition. “We’re going to be stuck with a whole lot less money.”

So far, however, the feds have not followed through on repeated warnings, and Proposition 35 proponents seem to be betting the threat of changes will prove nothing more than bluster.

We’ll see.

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

Six weeks after an emergency cesarean section, with her newborn twins still in neonatal intensive care, Maya Gobara went to a pharmacy in West Little Rock, Arkansas, to fill a prescription.

“The pharmacy told me I didn’t have insurance,” Gobara said.

Arkansas is the only state that has not taken the step to expand what’s called postpartum Medicaid coverage, an option for states paid for almost entirely by the federal government that ensures poor women have uninterrupted health insurance for a year after they give birth. Forty-six states now have the provision, encouraged by the Biden administration, and Idaho, Iowa, and Wisconsin either have plans in place to enact legislation or have bills pending in their legislatures.

Federal law requires states to provide pregnancy-related Medicaid coverage through 60 days after delivery. But maternal health advocates say Arkansas often begins the process of moving women out of the program after six weeks, or 42 days.

Gobara said she thinks that’s what happened to her: She was transferred to another health plan with a different slate of doctors, and she didn’t receive notice of the change.

Gobara, who is 38 and a freelance copywriter, said the health plan switch happened to her just as a cascade of previous health problems — an autoimmune disorder, postpartum depression, and rheumatoid arthritis — flared up.

“Everything that I had before hit me like a ton of bricks at once after I had the boys,” she said.

Maternal health advocates say many lower-income women in Arkansas have fallen into that familiar health care gap.

Arkansas has one of the highest rates of maternal mortality in the nation, a grim tally of women who die from any cause related to pregnancy or childbirth, including weeks after delivery. In Arkansas, 20% to 29% of women are uninsured at some point over the period before they conceive to after they give birth. 

In March, Arkansas Gov. Sarah Huckabee Sanders, a Republican, signed an executive order creating a committee of experts charged with improving the state’s dismal maternal health outcomes and better educating women about their health insurance options.

At a press conference announcing the initiative, Gov. Huckabee Sanders said, “This specific group that we’re establishing through the executive order, they’re going to look at every option on the table.”

When asked by reporters at the press conference about whether she would support expanding postpartum Medicaid to 12 months of coverage as other states have done, the answer was a firm “no.”

“I don’t believe creating a duplicative program just for the sake of creating a program is actually going to fix the issue,” she said. “We already have so many women who aren’t taking advantage of the coverage that exists. Creating more coverage doesn’t get more women to the doctor.”

Huckabee Sanders, 42, is the youngest governor currently serving, and she is the parent of three school-age children.

In Arkansas, postpartum women can apply for other insurance coverage in Arkansas six weeks after delivery, but they must send in a paper application, said Zenobia Harris, executive director of the Arkansas Birthing Project, a mentor program that works with pregnant and postpartum women.

“Women get told things like their paperwork got misplaced or lost or they have to resubmit paperwork. They get put on hold when they make phone calls in trying to connect with people,” Harris said. “So, some people, they quit trying.”

Lower-income women, like Maya Gobara, are shifted into ARHOME, a state program touted by Huckabee Sanders, that uses Medicaid funding to buy private health insurance.

The shift to new health coverage happened to Gobara while her twins, Amir and Bryson, were on breathing tubes and needed multiple brain surgeries and she required urgent gallbladder surgery.

“I was supposed to have my gallbladder taken out in one week, but with this new plan I needed a referral for that surgery, but I no longer could see my primary care doctor because she wasn’t under that plan that they put me under,” she said.

Seized with gallbladder pain, Gobara spent days sorting out what had happened to her postpartum Medicaid coverage.

“It felt like the system was set up so I would give up,” Gobara said. “And, honestly, if it was not for my mother sitting next to me and helping me go through step by step by step, I probably would have given up.”

New mothers shouldn’t be shuttled from plan to plan or uninsured when they are dealing with their own health and their newborns, said Camille Richoux, health policy director for Arkansas Advocates for Children & Families, a nonprofit advocacy and policy group. Richoux is part of the governor’s maternal health initiative, a committee tasked with developing recommendations to improve maternal health and increase access to maternal health services. 

Richoux said the switch to a new health plan can disrupt the continuity of care when health care is vital. “Especially when so many pregnancy-related deaths occur after that 60-days-postpartum coverage,” she said.

The committees tasked with making recommendations to Gov. Huckabee Sanders have been meeting this summer and recently prepared draft recommendations.

But missing from the list is an expansion of postpartum Medicaid coverage, despite widespread agreement by health organizations and the state’s Maternal Mortality Review Committee that doing so would reduce pregnancy-related deaths.

One of the tasks of the maternal health initiative is “making sure Medicaid does a better job of educating women postpartum on their health insurance options that already exist today, to ensure they get enrolled and have the coverage they need,” said Alexa Henning, communications director for Gov. Huckabee Sanders in an emailed statement last month.

“The data indicates that most women have continuous coverage, they just need to access it,” Henning said. “But if we identify gaps, the Governor is open to all options to help moms and babies.”

The final recommendations are expected to be released this month.

SACRAMENTO, Calif. — California Gov. Gavin Newsom will soon decide whether the most populous U.S. state will join 25 others in regulating the middlemen known as pharmacy benefit managers, or PBMs, whom many policymakers blame for the soaring cost of prescription drugs.

PBMs have been under fire for years for alleged profiteering and anticompetitive conduct, but efforts to regulate the industry at the federal level have stalled in Congress.

The three largest PBMs are owned by insurers and retail pharmacy chains, and about 80% of prescription drug sales in the United States are controlled by them: OptumRx, owned by UnitedHealth Group; CVS Caremark, owned by CVS Health, which also owns the insurer Aetna; and Express Scripts, owned by The Cigna Group.

The proposed law, spearheaded by state Sen. Scott Wiener of San Francisco, a Democrat, would require PBMs to apply for a license by 2027 and would mandate that licensed PBMs pass along 100% of pharmaceutical manufacturers’ rebates to health plans or insurers. Drug companies often offer substantial discounts on medications to boost demand, and one of the major criticisms of PBMs is that they pocket rebates rather than pass savings along to customers.

The law would also mostly bar PBMs from steering patients to pharmacies they own, which includes the major mail-order pharmacies. And it would prohibit them from giving independent pharmacies lower insurance reimbursements than they offer the big chains — a major issue for the dwindling number of independents around the country.

Wiener said the law aimed to rein in what he called “the worst abuses by PBMs.” Proponents of the legislation say the experiences in the 25 states that require PBM licensing and the 16 that ban steering of patients to preferred vendors show that regulations reduce costs for consumers.

“When they’re licensed like we’re looking at, the cost goes down. States without licensing saw costs go up,” said Assembly member Devon Mathis, one of two Republicans to co-author the bill, citing the National Community Pharmacists Association.

Health insurance premiums increased an average of 16.7% nationwide from 2015 to 2019, the association calculated, with premiums in states that license PBMs increasing 0.3 of a percentage point below the national average and those without, 0.4 above. The association claimed similar benefits from several other reforms affecting pharmacies.

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, said Wiener’s bill “blatantly” favors independent retail pharmacies over chains.

“This legislation does nothing to lower costs for patients; it simply seeks to financially promote one industry over another with no consumer benefit,” the group said.

Insurance companies argue that the California bill would reduce the PBMs’ ability to negotiate lower drug prices, resulting in higher coverage premiums for everyone. But drugmakers argue that reforms don’t raise premiums.

Supreme Court Decision Looms

States have stepped in to regulate PBMs in the absence of any federal action; Congress has been holding oversight hearings on PBMs, and the Federal Trade Commission in July said PBMs “may be profiting by inflating drug costs and squeezing Main Street pharmacies,” but there has been no new legislation or efforts to crack down based on existing laws barring anticompetitive conduct.

The U.S. Supreme Court could soon weigh in on whether states have the authority to regulate PBMs. A federal appellate court blocked Oklahoma regulations on PBMs on the grounds that federal law held sway, and a group of 35 state attorneys general, including California’s Rob Bonta, have asked the Supreme Court to overturn the ruling.

A central complaint about PBMs is that they take money from pharmaceutical companies, in the form of “rebates,” to give their drugs preferential treatment on health plans’ lists of medications that are covered by insurance, known as formularies. Those rebates may play a role in raising drug prices, found a 2020 paper by the University of Southern California’s Schaeffer Center for Health Policy & Economics.

Under the California bill, those rebates are to be used “for the sole purpose of lowering deductibles and out-of-pocket cost for consumers,” said Assembly member Jim Wood, a Democrat. “There is a perverse incentive by PBMs to choose for their formulary the drugs that will give them the biggest rebate, the largest rebate, even if there are other drugs just as effective and lower-cost. That alone should send shivers down your spine.”

Crackdown in California

California collected more than $215 million last year from the nation’s largest Medicaid insurer, Centene, after it failed to disclose or pass along drug discounts negotiated by its PBM to the state Medicaid agency.

Independent pharmacies say provisions in the proposed California law requiring PBMs to offer them the same pricing as the chains could be a lifeline.

Clint Hopkins, who has co-owned Pucci’s Pharmacy in Sacramento for eight years, said he’s forced to regularly turn away customers rather than lose hundreds of dollars each time he fills their high-cost prescriptions.

For instance, he said his cost for a monthly dose of Biktarvy, used to treat HIV, is $3,881.68. But he said pharmacy benefit managers short him up to $360 on the reimbursement.

“They dictate the rates to us, and they will not negotiate,” said Hopkins, who testified for the bill on behalf of the California Pharmacists Association. “Sometimes I have to say, ‘I’m sorry, I want to help you, but I can’t lose this much money on your prescription.’”

While the bill passed with unusual legislative support, it faces an uncertain future with the Democratic governor, who has until Sept. 30 to sign or veto it.

Newsom vetoed a 2021 bill that would have barred PBMs from steering patients to their own pharmacies, citing potential unintended consequences.

And his Department of Finance said administering the licensing and collecting the data required by the law would cost several million dollars. In vetoing other legislation, Newsom has repeatedly cited costs, as the state struggles with a massive budget deficit.

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

SAN FRANCISCO — Andrew Douglass shoved his clothes and belongings into plastic trash bags as five police officers surrounded his encampment — a drab gray tent overflowing along a bustling sidewalk in the gritty Tenderloin neighborhood, where homeless people lie sprawled on public sidewalks, sometimes in drug overdoses.

Officers gave him a choice: Go to a shelter or get arrested and cited for sleeping outside.

Douglass was trying to figure out what to do as he dismantled his tent. If he accepted temporary shelter, he’d risk missing an important appointment with his street medicine case manager, who was due to meet him at his tent in the morning to help him secure a low-income housing unit with wraparound services — and he worried about losing his medications, ID, and other vital documents again in another homeless sweep.

Douglass, who didn’t have a working cellphone, knew if he moved from where he’d slept for months, his case manager might not be able to find him. “I’m so close to getting housing. I need to be here tomorrow morning so I can try and get inside,” he said, trying to reason with officers as he was handcuffed and arrested for illegal lodging.

California, the epicenter of the U.S. homelessness crisis, is cracking down on people living outside like never before, taking an aggressive new stance to dismantling and clearing homeless encampments in the wake of a watershed U.S. Supreme Court ruling in late June that makes it easier for government agencies to fine and arrest people for living on streets and sidewalks, in broken-down vehicles, or within public parks — even if there is no shelter or housing available. From San Francisco to Los Angeles, communities are launching cleanup operations, ratcheting up enforcement of existing anticamping laws, and, in some places, passing new laws to try to prevent people from living outdoors.

On the ground, health care experts and homeless service providers say the law enforcement crackdown is undercutting taxpayer investments in evidence-based treatment and housing services that are being deployed by cities and states around the nation as politicians look to the health care system to aggressively move people off the streets.

The sweeps — which have taken off under Democratic Gov. Gavin Newsom, who issued an executive order in late July requiring state agencies to remove encampments and encouraging local governments to do the same — have unleashed chaos for homeless people and are breaking crucial connections with health care providers, social service agencies, and housing navigators trying to help them get healthy and off the streets.

Newsom’s hard-line stance is undermining his signature Medicaid initiative, known as CalAIM, which dedicates $12 billion over five years in part to helping homeless people receive health care, housing, and social services. The experimental program, meant to stabilize the most vulnerable and keep low-income patients out of costly institutional care in hospitals, jails, and nursing homes, for instance, launched in early 2022 with backing from the Biden administration, and provides state and national health care funding to street medicine teams, hospitals, health insurance companies, community clinics, and other organizations to serve homeless people.

It comes as Newsom announced this month that his health secretary, Mark Ghaly, who has spearheaded the state’s infusion of social services for homeless people into the health care system, would be stepping down.

Encampment clearings are also upheaving long-standing federal health policies that provide billions of dollars each year to street medicine providers, case management teams, and front-line community clinic workers, including through the national “Health Care for the Homeless” program, which is also aimed at helping homeless people get healthy and navigate a path to permanent housing.

Newsom has been emphatic that streets are not a home and that it’s unsafe to let people live outside amid public health hazards like rats, drug needles, and piles of trash. The second-term governor, who has threatened to withhold homelessness funding from communities that fail to show enough progress, argues that his policies are helping get people long-term housing and services.

“There are simply no more excuses,” Newsom said in July.

Health care providers and homelessness experts say the result is a slow-moving health care catastrophe instigated by the very Democratic politicians touting the need for care and services around California, home to more homeless people than any other state in the nation.

No place is going as hard as San Francisco, a fiercely liberal city that has long embraced its reputation as a place where homeless people could find refuge and robust services.

Now, case managers, housing navigators, and street medicine teams say vulnerable people are growing sicker amid the crackdown and that many of their patients have simply disappeared. Others have lost medications and critical documents like birth certificates and Social Security cards, setting back efforts to stabilize people with housing, mental health services, and addiction treatment. Front-line providers here say the city has become a glaring example of homelessness policy gone wrong.

“All the sweeps and arrests are doing is moving people to the next sidewalk and disrupting their continuity of care. It’s a huge waste of resources,” said Shannon Heuklom, a primary care provider and an expert in street medicine for the San Francisco Community Health Center, with a clinic nestled in the heart of the Tenderloin.

“Some portion of folks may end up in a shelter, but for the most part the city is just moving them all around and making them more unwell, making their mental health worse, making their physical health worse,” she said.

Disrupted Care

In the Tenderloin, Douglass was frantic. Police told him and his wife, Jasmine Byron, and another partner, Christina Richardson, that they could avoid arrest if they went into a massive congregate shelter. But they’d have to sacrifice most of their stuff, taking just two bags each. They’d already lost lifesaving medications, including for epilepsy, in a previous camp clearing. And Douglass had finally replaced his ID and asthma medication; he didn’t want more stuff thrown away amid the chaos.

On this early August morning, Douglass opted to stay with his belongings. The trio are part of about 70 homeless arrests in San Francisco since the city’s mayor, London Breed, ratcheted up cleanup operations in the beginning of August following the Supreme Court’s decision in late June, according to San Francisco Police Department spokesperson Evan Sernoffsky.

“We’re here to enforce the law,” said Lt. Wayman Young, one of the five officers. “We get a lot of complaints: People can’t use the sidewalk; there’s a lot of garbage.”

As the three were separated and cuffed, a woman driving by stuck her hands out her window and clapped, cheering the sidewalk arrest and yelled “Thank you!” A passerby in a wheelchair averted the tense standoff by rolling into a traffic lane, dodging vehicles as he looked for a vacant section of sidewalk to use.

Douglass missed his housing appointment the morning after his arrest, confirmed his street medicine case manager, Justin Jackson from the San Francisco Community Health Center. Amid his tossed belongings were his ID card, which is required to get into housing, so he was back in line at the clinic the next day filling out a Department of Motor Vehicles voucher form to replace it for free.

Because Douglass is homeless and on Medi-Cal, California’s version of Medicaid, he is eligible for CalAIM services that assist homeless patients with finding a permanent place to live, as well as helping to cover security deposits and utility bills. CalAIM also offers eviction prevention support, and next year California is expected to add a new Medi-Cal benefit providing up to six months of free rent or temporary housing.

But with his documents thrown away, his eligibility for housing was delayed.

Front-line workers are now spending immense time and resources helping people replace valuables like medications, Social Security cards, and birth certificates lost due to sweeps. They notice patients are skipping routine health care and spot an uptick in drug use, anxiety, and depression.

“This is just making homelessness worse,” said Evelyn Peña, a CalAIM care manager at the Mission Neighborhood Health Center in San Francisco.

Taylor Cuffaro, a nurse practitioner and street medicine provider with the San Francisco Community Health Center, trudged the streets of the Tenderloin with Eli Benway, a licensed clinical social worker who provides talk therapy and other behavioral health treatment on the street, searching for patients on a bright August afternoon.

Some needed help managing chronic diseases and mental health conditions. Others were due for antipsychotic injectables that last longer than pill medications. Some needed refills of HIV medications.

“Health insurance companies aren’t just going to give you more medication,” Cuffaro said. “That’s not how it works, so people really are at risk of dying faster.”

Part of what’s being squandered is trust, which is vital for getting people off the streets. “These sweeps are just making our job impossible,” Cuffaro said, searching unsuccessfully for a patient in an alley.

Politics of Homelessness

The statewide crackdown is playing out despite a growing body of evidence showing that providing robust health care, along with social services and intensive case management, can effectively move homeless people off the streets and improve health, while also saving taxpayer and health care spending on costly institutional care.

Democrats are embracing a get-tough approach as public patience wears thin over the intractable crisis. Newsom’s stance is not entirely new: During his tenure as San Francisco mayor, from 2004 to 2011, he spearheaded controversial homelessness ideas, including an ordinance known as sit/lie, which made it illegal to sit or lie on public sidewalks.

Newsom and local leaders, including Breed, say they must balance ensuring public safety and clean streets with a humane approach to clearing camps, while trying to get people indoors. Breed administration officials argue that while some homeless people do accept shelter, many are opting to stay on the streets while declining treatment.

“People won’t accept shelter, and they won’t follow up on their medical care or behavioral health treatment or any of that, often because they need to stay and monitor their belongings, some of which are totally soiled and becoming a health hazard,” said David Nakanishi, a clinical social worker who heads the Breed administration’s Healthy Streets Operation Center, which spearheads the sweeps.

In Los Angeles, meanwhile, street medicine provider Brett Feldman is losing his patients amid the sweeps. “It really undermines our housing efforts,” he said.

A city report released in May found that clearing camps and enforcing anticamping laws that ban people from sleeping, sitting, or keeping belongings on sidewalks in certain sensitive areas, including school zones, parks, or freeway underpasses, is not effectively helping people into housing. After spending roughly $3 million enforcing anticamping laws from 2021 to 2023, the report found, the city placed just two people into permanent housing and 81% of encampment sites have been repopulated.

In one central Los Angeles district where law enforcement is not aggressively enforcing anticamping laws, street homelessness fell roughly 38% in a one-year period from 2023 to 2024, said Indu Subaiya, interim CEO for the nonprofit Healthcare in Action, which has been housing and treating patients there.

“We’re starting to actually see results and reductions in unsheltered homelessness,” Subaiya said. “However, in Southern California counties aggressively enforcing Newsom’s executive order and clearing encampments, we’re seeing our patients and their medical conditions set back profoundly.”

Once Douglass was released, he was back in the Tenderloin hunting for housing and popping his tent up the street from his previous hangout.

“Every time I try to get my documents to get housing, I get knocked backwards,” he said. “I guess the city thinks we all need to be in handcuffs.”

By the next morning, the encampment had grown twice in size.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its newsletters here.

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

ATLANTA — On a recent summer evening, Raymia Taylor wandered into a recreation center in a historical downtown neighborhood, the only enrollee to attend a nearly two-hour event for people who have signed up for Georgia’s experimental Medicaid expansion.

The state launched the program in July 2023, requiring participants to document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage. At the event, booths were set up to help people join the Marines or pursue a GED diploma.

Taylor, 20, already met the program’s requirements — she studies nursing and works at a fast-food restaurant. But she said it wasn’t clear what paperwork to submit or how to upload her documents. “I was struggling,” she said.

Georgia is the only state that requires certain Medicaid beneficiaries to work to get coverage. Republicans have long touted such programs, arguing they encourage participants to maintain employment. About 20 states have applied to enact Medicaid work requirements; 13 won approval under the Trump administration. The Biden administration has worked to block such initiatives.

The Georgia Pathways to Coverage program shows the hurdles ahead for states looking to follow its lead. Georgia’s GOP leaders have spent millions of dollars to launch Pathways. By July 29, nearly 4,500 people had enrolled, the state’s Medicaid agency told KFF Health News.

That’s well short of the state’s own goal of more than 25,000 in its first year, according to its application to the federal government, and a fraction of the 359,000 who might have been eligible had Georgia simply expanded Medicaid under the Affordable Care Act, as 40 other states did.

So far, the pricey endeavor has forced participants to navigate bureaucratic hurdles rather than support employment. The state would not confirm whether it could even verify if people in the program are working.

Research shows such red tape disproportionately affects Black and Hispanic people.

“The people that need access to health care coverage the most are going to struggle with that administrative burden because the process is so complicated,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

At an August press event, Georgia Republican Gov. Brian Kemp announced a $10.7 million ad campaign to boost enrollment in Pathways, one of his administration’s major health policy initiatives. The plan has cost more than $40 million in state and federal tax dollars through June, with nearly 80% going toward administration and consulting fees rather than paying for medical care, according to data the state Medicaid agency shared with KFF Health News.

Enrollment advisers, consumer advocates, and policy researchers largely blame a cumbersome enrollment process, complicated program design, and back-end technology flaws for Pathways’ flagging enrollment. They say that the online application is challenging to navigate and understand and lacks a way for people to receive immediate support, and that state staffers don’t respond to applicants in a timely manner.

“It’s just an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, who helps Pathways applicants appeal denials.

Administrative challenges have also undermined a key part of the program’s philosophy: that people maintain employment to keep coverage. As of July, the state was not removing enrollees for not meeting Pathways’ work requirement, according to Fiona Roberts, a spokesperson for Georgia’s Medicaid agency.

“We understand that people need to be held accountable to those 80 hours for the spirit of the program, and we intend to do that,” said Russel Carlson, the agency’s commissioner.

Pathways is set to expire Sept. 30, 2025, unless the state asks the Centers for Medicare & Medicaid Services for an extension. Georgia officials say they won’t have to make that request until next spring, well after November’s election. So the state could be asking for an extension from the Trump administration, which approved the program in the first place.

Georgia officials sued the Biden administration this year to keep Pathways running without going through the official extension process, which requires the state to conduct public comment sessions, gather extensive financial data, and prove that Pathways has met its goals. A federal judge ruled against Georgia.

A CMS spokesperson said the agency wouldn’t comment on the program.

During the August press event, Kemp said the Biden administration’s attempt to stop the program in 2021 delayed its rollout and stymied enrollment. A federal court blocked the administration and allowed Georgia to proceed.

People familiar with the enrollment process said Pathways has been mired in design flaws and system failures. As of the end of May, 13,702 applications were waiting to be processed, according to state documents.

The program’s lengthy questionnaires and technical language are confusing, guidance is opaque, and tools to upload documents are tricky to navigate, according to interviews with health insurance enrollment specialists conducted for the Georgia Budget and Policy Institute.

“It’s not an easy, ‘Oh, I want to apply for Pathways,’” said Deanna Williams, who helps people enroll in insurance plans at Georgians for a Healthy Future, a consumer advocacy group. People generally learn about the program after being denied other Medicaid coverage, she said.

In the online application, people click through pages of questions before they’re shown a screen with information about Pathways, Williams said. Then they must check a box and sign a form saying they understand the program’s requirements.

Sometimes the Pathways application doesn’t pop up, and she must start over. The process to apply is “not smooth,” she said.

Data shows that people who don’t earn enough to qualify for free ACA plans but also make too much for Medicaid are disproportionately people of color. Pathways offers Medicaid coverage to adults earning up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.

Some people eligible for Pathways who work in retail or restaurants with fluctuating hours are nervous they can’t meet requirements every month, Williams said.

Many current enrollees don’t know how to upload documents, and the website sometimes stops working, said Jahan Becham, an employment specialist for Pathways at Amerigroup Community Care. Or people just forget.

Every month Becham gets a list of 200 to 300 enrollees who haven’t submitted their hours. “It is something new, and not many people are used to this,” Becham said.

“I would get reminders,” said Taylor, who attended the event for enrollees in August. “I just didn’t know how.”

In a June 2023 meeting with Georgia Medicaid staffers weeks before the program launched, federal officials questioned why the state wasn’t automatically verifying eligibility with existing data sources, according to meeting minutes KFF Health News obtained through a state open-records request. Georgia officials said they were unsure when they’d be able to simplify the verification process.

Many potential participants face improper denials, advocates said. Gibson, at the Georgia Legal Services Program, said not enough workers are trained to properly evaluate applications.

Fewer than 1 in 5 people who have their Pathways applications processed had been accepted into the program as of May, according to a KFF Health News analysis of state data. Roberts, with the state, said people were denied because they earned too much, didn’t meet requirements, or didn’t complete the paperwork.

A full-time graduate student was wrongly blocked from the program, and in February a state administrative judge ordered her case be reconsidered. In another case, a different judge ruled a 64-year-old woman who couldn’t work because she was her disabled husband’s full-time caregiver would not qualify for Pathways.

Despite the challenges, state records from May show no individuals were removed from the program since it launched for failing to meet work requirements.

Georgia’s experiment comes after a 2018 effort in Arkansas to implement work requirements on an existing Medicaid expansion population led to 18,000 people losing coverage, many of whom either met requirements or would have been exempted.

Taylor found out about Pathways when she applied for food stamps last year. It wasn’t until August that she learned she could submit her school schedule to meet the qualifying hours requirement. With a full Medicaid expansion, Taylor would have been eligible for health coverage without the extra effort. But, for her, it’s still worth it.

“It’s important to have health insurance,” said Taylor, who has been to the dentist several times and plans to visit a doctor. “I’m glad I have it.”

WINDER, Ga. — About an hour after gunfire erupted at Apalachee High School, ambulances started arriving at nearby Northeast Georgia Medical Center Barrow with two students and two adults suffering from panic attacks and extreme anxiety, not bullet wounds.

A fifth patient with similar symptoms later arrived at another local facility, according to a health system spokesperson.

The day after the Sept. 4 school shooting that killed two students and two teachers, some 80 families showed up in a county office to receive counseling from volunteer therapists who converged from across the Atlanta metro area, according to one medical provider. That Sunday, nine people received free treatment at a local church for post-traumatic stress disorder from volunteering Atlanta-area providers. On Monday, the state opened a temporary recovery center to help locals find counseling, faith-based support, or other aid. The needs are still great.

“We don’t really know how we’re doing,” Amanda McKee — whose son, Asa Deslonde, is a senior at Apalachee — said two days after the shooting. “It’s second by second. It’s minute by minute. The last couple days have been unimaginable.”

When shootings of any magnitude occur, they often leave the survivors with invisible injuries that can create life-changing symptoms that sometimes paralyze them.But such problems can take time to emerge. Panic attacks and anxiety can spike across a community after a shooting and can be most intense when people return to the scene, said Howard Liu, chair of the Council on Communications for the American Psychiatric Association.

So health providers worry that in the coming days, months, and years the community will struggle to find help for their mental health needs. Barrow County, along a highway that connects Atlanta to the college town of Athens, is a community where agriculture is steadily giving way to development.

Prior to the shooting, the area had one stand-alone inpatient mental health facility, located in Gainesville, about 30 miles away from where the shooting occurred in Barrow County, that was “constantly overwhelmed,” said Sean Couch, a spokesperson for Northeast Georgia Health System. And, the latest federal data shows, Barrow would need to add at least 13 full-time providers to no longer be considered a mental health workforce shortage area.

“We put a band-aid on a chronic situation and that band-aid isn’t going to last,” said Roland Behm, a co-founder of the Georgia Mental Health Policy Partnership, an advocacy group that represents mental health organizations in the state. “What happens three months from now?”

The scarcity of mental health providers in Barrow County is emblematic of the state as a whole. Georgia ranks nearly last among states in access to mental health care resources, according to Mental Health America, a nonprofit that advocates for increased mental health spending. More than 5 million Georgians live in mental health care professional shortage areas like Barrow County.

Paying for mental health care to treat such trauma is difficult nationwide. But Georgia is one of the 10 states that have not fully expanded eligibility for Medicaid, the nation’s safety net insurance for those with low incomes and also the largest payer for mental health services. The state has an uninsured rate of 13.6%, which is 4.1 percentage points higher than the country as a whole, according to 2022 data from the U.S Census Bureau.

Even people with private health plans have trouble finding affordable, in-network mental health care because of a lack of providers willing to accept low insurance reimbursement rates, Behm said.

Tamara Conlin, CEO of Advantage Behavioral Health Systems, said the people who came to the initial counseling sessions that her group helped arrange in a county office showed a lot of sadness and anxiety.

“Some of them are still in shock and trying to wrap their heads around what happened,” she said.

Even before the shooting, students at Apalachee High School reported significant mental health challenges.

Nearly 200 of 1,725 student respondents reported that they had seriously considered attempting suicide one or more times in the prior year, according to the latest Georgia Student Health Survey. Top motivators included problems with peers, friends, or family. About half of the students from the school who answered said they felt sad, depressed, or withdrawn at least once in the prior 30 days.

County residents complained about having to travel for psychiatric care and said the “shortage of psychologists and counseling services led to untreated high anxiety and depression rates,” during a 2019 focus group about health care access.

The lack of mental health care remained a top concern in the region during a follow-up assessment in 2022. That year, the opioid overdose death rate in Barrow County was among the highest in Georgia, according to state data, and the five-year suicide rate was above the state average.

The Barrow County School System, which includes Apalachee High School, received a $1.8 million federal grant to boost mental health resources in schools from 2023 through 2028.

But immediately following the shooting, mental health providers across the region still had to cobble together free resources for area residents. Three volunteers helped with last Wednesday’s response at Northeast Georgia Medical Center Barrow. Advantage Behavioral Health Systems kept its Barrow clinic open on Sunday and is providing counselors to community events and local schools as they reopen.

William Smith, who heads the Atlanta Center for EMDR, is planning sessions using eye movement desensitization and reprocessing therapy to address PTSD — at least one for first responders and another for residents.

Over the weekend, Lutheran Church Charities brought nine golden retrievers as “comfort dogs” to help the grieving. The group’s dogs have been deployed in the wake of other school shootings, including the Uvalde, Texas, massacre.

“We can’t fix what they’re feeling,” said volunteer Paul Soost, as people gathered around a campus flagpole where they delivered flowers and messages. “We can provide comfort.”

Many health care providers expect the community’s needs to spike when students return to Apalachee High School and as the national attention on the shooting recedes.

“That’s when people start experiencing the trauma,” said Conlin, with Advantage Behavioral Health Systems, who compared the current crisis to the surge of patients she saw after the immediate threat of the covid-19 pandemic passed.

Her clinic in Barrow County already had about 750 active clients before the shooting, with about 120 under the age of 18.

McKee said she knows healing will be a long process for her son, Asa. One of his football coaches, Richard Aspinwall, was among the four killed. A key step came the day after the shooting, she said, when the school’s head football coach convened the team to share how much he was hurting.

“The coach validated that they were hurt, and encouraged them to embrace that they were injured,” McKee said. “They’re not the physical injuries that were incurred by the senseless act, but they are injuries nonetheless.”

If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Cuando la vicepresidenta Kamala Harris cruzó el escenario del debate el martes 10 por la noche para darle la mano al ex presidente Donald Trump, fue la primera vez que los dos se conocían en persona. Fue un breve y raro momento de cordialidad en un enfrentamiento marcado por declaraciones falsas y, a veces, bizarras del ex presidente.

La cadena ABC organizó el debate, moderado por David Muir y Linsey Davis, quienes ocasionalmente revisaron las afirmaciones de Trump. A la mañana siguiente, en el programa “Fox & Friends” de Fox News, Trump dijo que había sido un “debate de tres contra uno”.

Los dos candidatos presidenciales abordaron una amplia gama de temas, desde cifras de empleo e inflación hasta el aborto y la inmigración, en intercambios marcados por ataques personales.

Como señaló PolitiFact, Harris a menudo se dirigía directamente a Trump mientras respondía a las preguntas de los moderadores. Trump en su mayoría miraba al frente. En respuesta a las afirmaciones de Trump sobre el historial del gobierno de Biden en materia de crimen, Harris mencionó la condena penal de Trump en Nueva York, y otras acusaciones.

Los moderadores le preguntaron a Trump sobre si intentaría desmantelar la Ley de Cuidado de Salud a Bajo Precio (ACA, también conocida como Obamacare), el programa de seguro médico que prometió derogar y reemplazar durante su administración, algo que no logró.

Dijo que, si volviera a ser presidente, “solo lo cambiaría si encontráramos algo que fuera mejor y menos costoso”. Y agregó: “Hay conceptos y opciones para hacerlo, y los escucharán en un futuro no muy lejano”.

Trump ha estado prometiendo que reemplazaría el Obamacare desde su campaña de 2015. Durante el debate afirmó que “salvó” a ACA al emitir regulaciones destinadas a reducir las primas de los seguros.

El anterior apoyo de Harris al “Medicare para Todos”, una propuesta para reemplazar el seguro de salud privado por un sistema de salud administrado por el gobierno, generó preguntas de los moderadores y ataques por parte de Trump.

El aborto fue un claro punto de conflicto. Harris definió a las restricciones estatales impuestas al procedimiento, promulgadas desde 2022, como “las prohibiciones de Trump al aborto”, y dijo que era inmoral quitarle a una mujer la capacidad de tomar decisiones sobre su propio cuerpo. También prometió firmar cualquier ley que restableciera las protecciones descritas en Roe vs. Wade, que la Corte Suprema revocó en 2022.

Trump dijo que, como presidente, nunca enfrentaría la cuestión de firmar una prohibición nacional del aborto porque el tema ahora se está resolviendo en los estados. “No voy a firmar una prohibición”, dijo. “No hay razón para firmar una prohibición”.

Trump también sacó de nuevo a la luz afirmaciones, repetidamente consideradas falsas por PolitiFact y otras organizaciones de verificación de datos, de que los demócratas apoyan los abortos hasta el momento del nacimiento y la “ejecución” de bebés después del nacimiento.

Momentos después de terminar el debate, la super estrella del pop Taylor Swift publicó en Instagram que votaría por Harris “porque lucha por los derechos y causas que creo que necesitan a un guerrero que las defienda”. La publicación de Swift incluyó una foto de ella con su gato y estaba firmada como “Childless Cat Lady” (“Dama de gatos sin hijos”), una referencia a los comentarios de JD Vance, el candidato republicano a la vicepresidencia.

PolitiFact verificó lo dicho en el debate en tiempo real en un blog en vivo, mientras Harris y Trump chocaban sobre economía, inmigración y aborto.

A continuación, extractos que detallan afirmaciones específicas relacionadas con la salud:

Trump: “Pero el gobernador antes, dijo: ‘El bebé nacerá, y decidiremos qué hacer con el bebé’”.

Falso.

Trump inicialmente mencionó a “un gobernador de West Virginia”. Se refería a Virginia y se corrigió más tarde en el debate.

El ex gobernador de Virginia, Ralph Northam, demócrata y médico, nunca dijo que sancionaría la ejecución de recién nacidos. Lo que dijo en una entrevista de radio en 2019 es que, en raros casos de embarazo avanzado cuando los fetos no son viables, los médicos entregan al bebé, lo mantienen cómodo, lo reaniman si la familia lo desea y luego tienen una “discusión” con la madre.

El problema es que Northam se negó a decir en qué consistiría esa discusión. Trump pone palabras en la boca del entonces gobernador, diciendo que los médicos instarían a la madre a que permitiera que mataran al bebé, lo cual es un delito grave en Virginia (y en todos los demás estados) castigado con una larga condena de prisión o la pena de muerte.

Trump: “Todos los estudiosos del derecho, todos los demócratas, todos los republicanos, liberales, conservadores, todos querían que [el aborto] volviera a los estados donde la gente pudiera votar”.

Falso.

La decisión Roe vs. Wade de 1973 inspiró legiones de partidarios y opositores. Antes de que la Corte Suprema de Estados Unidos la anulara en 2022, numerosos estudiosos del derecho escribieron informes instando a la corte a mantener el fallo.

Algunos académicos que apoyan el derecho al aborto han criticado los fundamentos legales de la decisión de 1973, diciendo que otros argumentos constitucionales, basados en la protección igualitaria, habrían proporcionado un caso más sólido. Pero los expertos legales, incluidos algunos que sostenían esta opinión, dijeron que esos académicos nunca habrían abogado por anular Roe sobre esta base.

Trump: Sobre la Ley de Cuidado de Salud a Bajo Precio, “Yo la salvé”.

Falso.

Durante 2016, Trump hizo campaña para derogar y reemplazar ACA. Mientras fue presidente, intentó derogarla y fracasó.

Pero su administración impulsó varias políticas que obstaculizaron su alcance y efectividad, incluido el recorte de millones de dólares en publicidad y financiación de divulgación. Cortó los subsidios a las compañías de seguros que ofrecían cobertura en los intercambios. También tomó medidas regulatorias para permitir planes de salud menos costosos y menos completos, por ejemplo, planes de salud de corto plazo que no cumplían con los requerimientos de ACA.

Durante la administración Trump, la inscripción en ACA bajó y el número de estadounidenses sin seguro aumentó en 2.3 millones de 2016 a 2019, incluidos 726,000 niños, según la Oficina del Censo.

Trump: Harris “quiere que todos estén en un seguro gubernamental” para la atención médica.

Esto es engañoso.

Harris una vez copatrocinó un proyecto de ley para expandir Medicare a estadounidenses de todas las edades, pero actualmente no apoya esta propuesta.

En abril de 2019, Harris se convirtió en uno de los 14 copatrocinadores originales de la Ley Medicare para Todos de 2019 patrocinada por el senador Bernie Sanders (independiente de Vermont). La legislación habría establecido un programa nacional de seguro de salud administrado por el Departamento de Salud y Servicios Humanos (HHS) federal.

El proyecto de ley habría creado un programa de seguro de salud federal automático para todos los estadounidenses, que reflejaría los sistemas de medicina socializada en países como el Reino Unido.

Harris respaldó el proyecto de ley cuando se preparaba para postularse en las primarias presidenciales de 2020 y muchos candidatos creían que los votantes de la base demócrata querían las posiciones más liberales posibles.

Sin embargo, Medicare para Todos no logró avanzar a una votación en el Senado. Después de que su candidatura en 2020 terminara, Harris se centró en fortalecer ACA en lugar de impulsar Medicare para Todos.

Forget repeal and replace. Critics of the Affordable Care Act, a.k.a. Obamacare, have a new target: key parts of the law that they say are too costly and provide incentive for fraud.

Topping that list are the ACA’s enhanced subsidies, put in place during the coronavirus pandemic as part of economic recovery legislation and set to expire next year unless Congress acts. The subsidies are credited with enabling more low-income people to qualify for zero-premium coverage and helping boost enrollment to record levels.

If the subsidies expire, millions of Americans will probably see premiums go up, according to a report from KFF. And the Congressional Budget Office (CBO) says the end of the enhanced subsidies could cause ACA enrollment to fall from a projected 22.8 million in 2025 to 18.9 million in 2026.

But the subsidies cost a lot. The CBO recently estimated that making them permanent would add $335 billion to the budget deficit over 10 years, and some Republicans have said that’s simply too much.

Now the subsidies are part of a larger debate about ACA fraud and enrollment schemes.

At issue is whether people are over- or understating their incomes to qualify for the subsidies. In addition, some lawmakers are concerned about reports that consumers are being enrolled in ACA plans or their coverage is being switched — without their consent — by a subset of unscrupulous brokers eager to gain commissions.

House GOP leaders have called on two watchdog agencies to investigate, while Sen. Chuck Grassley (R-Iowa) fired off accountability questions in a recent letter to the Centers for Medicare and Medicaid Services.

The Republican outcry — particularly aimed at the subsidies — goes hand in hand with a controversial recent report from a conservative think tank estimating that millions of people or their brokers may be misstating their incomes to qualify for ACA subsidies.

Still, the enhanced subsidies are unlikely to become talking points in either party’s presidential campaigns.

“It’s too complicated,” said Debbie Curtis, a vice president at consultancy McDermott+. “I see what’s happening right now as laying the groundwork for the big fight next year.”

Any debate about the enhanced subsidies is likely to draw in other issues — including the Trump-era tax cuts, whose extension would add an estimated $4.6 trillion to the deficit over 10 years — and must be addressed next year. Other aspects of the ACA are also potentially in play, including a special year-round enrollment period for low-income consumers and whether zero-premium plans will still be available for that group.

“The fate of the enhanced tax credits is dependent on the Democrats holding some majority in Congress and/or winning the presidency and is also tied inextricably to the Trump tax cut expiration,” said Dean Rosen, a partner at Mehlman Consulting and a former senior Republican congressional staffer. That’s because both sides have incentive to extend all or part of the tax cuts, but each will want some kind of compromise on other issues as well.

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When Vice President Kamala Harris walked across the debate stage Tuesday night to shake the hand of former President Donald Trump, it was the first time the two had met in person. But that was the rare collegial moment in a face-off otherwise marked by false and sometimes bizarre statements by the former president.

The debate was hosted by ABC with moderators David Muir and Linsey Davis, who occasionally fact-checked Trump. He complained on the Fox News show “Fox & Friends” on Wednesday morning that it was a “three-to-one” contest.

The two presidential candidates covered a wide range of issues — from job and inflation numbers to abortion and immigration — in exchanges marked by personal attacks. As our PolitiFact partners noted, Harris often directly addressed Trump while answering the moderators’ questions. Trump mostly stared straight ahead. In response to Trump’s claims about the Biden administration’s record on crime, Harris cited Trump’s criminal conviction in New York and other indictments.

The moderators questioned Trump about whether he would attempt to dismantle the Affordable Care Act, also known as Obamacare — the health insurance program he pledged and failed to repeal and replace during his previous administration.

He said, if president, he would “only change it if we come up with something that’s better and less expensive.” He went on to say, “There are concepts and options we have to do that, and you’ll be hearing about it in the not-too-distant future.”

Trump has promised an Obamacare replacement since he was on the campaign trail in 2015. He claimed during the debate that he “saved” the ACA by issuing regulations aimed at lowering insurance premiums.

Harris’ previous support for “Medicare for All,” a proposal to replace private health insurance with a government-run health system, drew questions from the moderators and attacks by Trump.

Abortion was a clear flash point. Harris called state restrictions on the procedure enacted since 2022 “Trump abortion bans” and said it was immoral to take away a woman’s ability to make decisions about her own body. She also pledged to sign any bill that would reinstate the protections outlined in Roe v. Wade, which the Supreme Court overturned in 2022.

Trump said that as president he would never face the question of signing a national abortion ban because the issue is now being settled in states. “I’m not signing a ban,” he said. “There’s no reason to sign a ban.”

Trump also resurfaced claims — repeatedly judged false by PolitiFact and other fact-checking organizations — that Democrats support abortions up to the moment of birth and the “execution” of babies after birth. ABC’s Davis flagged Trump’s statement, saying that willfully terminating a newborn’s life is illegal in every state. In addition, the majority of Democrats support abortion access up to fetal viability, when the fetus is able to survive outside the womb, typically around 24 weeks of pregnancy.

Harris brought up Project 2025, a policy blueprint created by the conservative Heritage Foundation from which Trump has sought to distance himself.

Moments after the debate ended, pop superstar Taylor Swift posted on Instagram that she would be voting for Harris “because she fights for the rights and causes I believe need a warrior to champion them.” Swift’s post featured a photo of her with her cat and was signed “Childless Cat Lady” — a reference to comments made by JD Vance, the Republican vice presidential candidate.

Our PolitiFact partners fact-checked the debate in real time on a live blog, with more coverage here, as Harris and Trump clashed on the economy, immigration, and abortion.

Excerpts detailing specific health-related claims follow.

Trump: “But the governor before, he said, ‘The baby will be born, and we will decide what to do with the baby.’”

False.

Trump initially referenced a West Virginia governor. He meant Virginia, and corrected himself later in the debate.

Former Virginia Gov. Ralph Northam, a Democrat and a physician, never said he would sanction the execution of newborns. What he did say during a 2019 radio interview is that in rare, late-pregnancy cases when fetuses are nonviable, doctors deliver the baby, keep it comfortable, resuscitate it if the family wishes, and then have a “discussion” with the mother.

The issue is that Northam declined to say what that discussion would entail. Trump puts words in the then-governor’s mouth, saying doctors would urge the mother to let them forcibly kill the newborn, which is a felony in Virginia (and all other states) punishable by a long prison sentence or death.

Trump: “Every legal scholar, every Democrat, every Republican, liberal, conservative, they all wanted [abortion] to be brought back to the states where the people could vote.”

False. 

The 1973 Roe v. Wade decision inspired legions of supporters and opponents. Before the U.S. Supreme Court overturned it in 2022, numerous legal scholars wrote briefs urging the court to uphold the ruling.

Some legal scholars who favor abortion rights have criticized the 1973 ruling’s legal underpinnings, saying that different constitutional arguments, based on equal protection, would have provided a stronger case. But legal experts, including some who held this view, said those scholars would not have advocated for overturning Roe on this basis.

Trump: On the Affordable Care Act, “I saved it.”

False. 

During 2016, Trump campaigned on repealing and replacing the Affordable Care Act. While president, he sought to repeal the measure — and failed.

But his administration pursued various policies that hindered its reach and effectiveness, including cutting millions of dollars in advertising and outreach funding. He cut subsidies to insurance companies that offered coverage on the exchanges. He also took regulatory steps to permit less expensive and less comprehensive health coverage — for example, short-term health plans that didn’t comply with the ACA.

During the Trump administration, ACA enrollment declined, and the number of uninsured Americans rose by 2.3 million from 2016 to 2019, including 726,000 children, according to the U.S. Census Bureau.

Trump: Harris “wants everybody to be on government insurance” for health care.

This is misleading.

Harris once co-sponsored a bill to expand Medicare to Americans of all ages, but she does not currently support this proposal.

In April 2019, Harris became one of 14 original co-sponsors of the Medicare for All Act of 2019 sponsored by Sen. Bernie Sanders (I-Vt.). The legislation would have established a national health insurance program administered by the federal Department of Health and Human Services.

The bill would have created an automatic, federally run health insurance program for all Americans, which would mirror the socialized medicine systems in such countries as the United Kingdom.

Harris backed the bill when she was preparing to run in the 2020 presidential primaries and many candidates believed that Democratic base voters wanted the most liberal positions possible.

However, Medicare for All failed to advance to a vote in the Senate. After her 2020 candidacy ended, Harris focused instead on bolstering the ACA as opposed to pushing for Medicare for All.

LOS ANGELES — For nearly a decade, John Baackes has led L.A. Care Health Plan, a publicly run insurer primarily serving low-income Los Angeles County residents on Medi-Cal. It is by far the largest Medi-Cal plan in the state.

Baackes, 78, who will retire after the end of the year, helped transform L.A. Care into a major market player following its expansion under the Affordable Care Act. He implemented a new administrative structure and promoted a new internal culture. The insurer generated $11.3 billion in revenue last year, with membership close to 2.6 million people — nearly 900,000 more than when Baackes took the reins in March 2015.

“I recognized when I got here that L.A. Care was a big frog in a big pond,” he said in an interview with KFF Health News on the 10th floor of L.A. Care’s downtown headquarters. But the organization still had a small-plan mentality, he said, until he convinced his staff “that we had an opportunity to really be leaders.”

Baackes moved to Los Angeles from Philadelphia, where he had headed the Medicare Advantage business of AmeriHealth Caritas VIP Care. He started at L.A. Care 15 months after the implementation of the ACA, which expanded Medicaid eligibility and created insurance exchanges where uninsured people could buy federally subsidized coverage.

L.A. Care’s Medi-Cal rolls swelled, and it offered a new health plan sold on the state’s ACA exchange, Covered California, as well as one for medically vulnerable seniors who are eligible both for Medi-Cal and Medicare.

But Baackes saw that L.A. Care didn’t have the right structure to manage the bigger organization it had become. So, he hired directors to oversee each of the health plans and revamped the chain of command.

The changes required a long period of reorientation, Baackes recalled. Then, “one of the officers came up to me one day and said, ‘Well, before I had to talk to everybody, but now I know who to talk to.’ I thought, ‘OK, phew, now we’re making progress.’”

Baackes has sometimes butted heads with state regulators, including when L.A. Care was fined $55 million in 2022 for “deep-rooted, systemic failures that threaten the health and safety of its members.” Baackes thought the fine was not justified. L.A. Care contested it and still has not paid it.

Baackes, who will retain his position as chair of Charles R. Drew University of Medicine and Science, a medical school that trains health professionals to work in underserved areas, expounded on the shortcomings and successes of the U.S. health system and Medi-Cal, which covers well over a third of California’s population.

Like many of his colleagues, he believes Medi-Cal’s principal flaw is low payments to providers, which is exacerbated by a shortage of labor in health care. That discourages doctors and other providers from taking Medi-Cal patients, limiting their choices and extending their wait times for care. He supports Proposition 35, a measure on the ballot this November that would secure a permanent revenue stream to increase Medi-Cal payments.

L.A. Care tackled the labor shortage by creating a $205 million fund to pay for medical school scholarships, help clinics hire doctors, and offer educational debt relief to doctors who work in safety-net settings. Jennifer Kent, former director of the California Department of Health Care Services, which oversees the Medi-Cal program, said she was impressed when Baackes used money from a rate settlement with her agency to help fund those initiatives.

“John very clearly has an appreciation and a passion for the program and what it represents in terms of the power to change people’s lives,” Kent said.

This interview with Baackes has been edited for length and clarity:

Q: Voters will decide, with their vote on Proposition 35, whether money from an industry tax will be locked into Medi-Cal permanently, curbing Gov. Gavin Newsom’s plan to tap the revenue for the state’s budget shortfall. Where do you stand on this?

I understand they’ve got a budget deficit, and they’ve got to do something about it. But we have to have security of the funding, and if it’s going to be decided in every budget, there’s going to be politics and other priorities. This is the same way education runs. They went to a ballot initiative to lock in their portion of the budget, and I think the health of over one-third of the population is as important as education.

Q: Medi-Cal has embarked on an ambitious expansion, including full coverage for all immigrants, a push to increase the amount of primary care provided, the elimination of an asset test, and continuous coverage for children up to age 5, among other things. Does the provider shortage in Medi-Cal dampen the prospects of these efforts?

Absolutely. If we are giving people expansion in access, then we have to have the resources for them to take advantage of it — unless we’re going to say, “Yeah, you have access, but figure it out on your own.” If we look at Los Angeles County, we’ve got plenty of doctors bumping into each other in places like Beverly Hills and Santa Monica. But if you go to South L.A., the Antelope Valley, it’s a different story.

Q: What do you think of the Office of Health Care Affordability’s goal of limiting annual health care spending increases to 3.5% at first, and ultimately to 3%?

Well-intended, but I do not see how it can be effective without causing a lot of damage along the way. You can restrict the amount of money that can be spent, but it doesn’t fix the underlying drivers of why it costs so much.

Q: So it could ultimately reduce care for patients?

Yeah. I think so. Because if doctors and nurses demand higher salaries and can command them because there aren’t enough people, then having an administrative hammer that you can’t spend more isn’t going to work.

Q: A lot of people would say the whole U.S. health care system, not just Medicaid, is failing patients. Access to care, and the cost of it, is difficult for a lot of people. How do we fix the system?

We need to simplify the regulatory environment. Regardless of whether it’s commercial insurance, Medicare, or Medicaid, the regulations are piling up and they cost money. The second thing: I think particularly the safety-net providers might have to say there can be no for-profit or private equity investors in that area. I’m not against capitalism. I just think if you’re going to make that money on a system that’s underfunded in the first place, something is being lost.

Q: What are your thoughts about the California Advancing and Innovating Medi-Cal program (CalAIM), especially the community supports such as meals designed for specific medical conditions, home modifications, and help finding housing?

CalAIM is a wonderful program in the sense that it begins to recognize that social determinants do influence your health. So we’re finally saying, “OK, we’ll put some money toward paying for those.” But the trade-off is that they want to reduce the medical costs by making these investments. The problem is we are trying to save dollars that are already deeply discounted. Of the 14 community supports they have, the one that is in my mind a slam dunk is the medically tailored meals.

Q: How has your thinking about health care evolved?

What I’ve learned and experienced is that health care is part of social justice, and we have to think of it that way. Any other way of thinking of it is going to create winners and losers.

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

The proportion of Americans without health insurance remained stable in 2023, the Census Bureau reported Tuesday, close to the record low the Biden administration achieved in 2022 through expansions of public programs, including the Affordable Care Act.

About 8% of Americans were uninsured, a statistically insignificant increase of just 0.1 percentage point from a year earlier. But because of the Census survey’s methodology, the findings likely don’t capture the experience of tens of millions of Americans purged from Medicaid rolls after pandemic-era protections expired in spring 2023.

Enrollment in Medicaid, the government health program for people with low incomes and disabilities, reached its highest level in April 2023. That was just before what’s called the “unwinding,” the process states have used to disenroll people from the program after the federal government lifted a prohibition on culling enrollment.

It isn’t yet clear what effect the unwinding has had on insurance coverage, but the Census Bureau will release additional data on Thursday from a different survey that may refine the numbers.

“We are likely at a turning point,” said Leighton Ku, director of the Center for Health Policy Research at George Washington University. “We are about to change to a new season where things will be a little worse off from Medicaid unwinding.”

The Medicaid unwinding has been completed in most states, and more than 25 million people have been disenrolled, according to KFF, a health information nonprofit that includes KFF Health News. The Census report, based on surveys conducted early this year, counts people as uninsured only if they lacked insurance for all of 2023. So, for example, a person who was on Medicaid in April 2023 before the unwinding began then lost coverage and never regained it would nonetheless be counted as insured for the entire year.

Many people purged from Medicaid were successfully reenrolled in or obtained other insurance, such as Affordable Care Act marketplace or job-based coverage. Others remained uninsured.

Advocates have feared the unwinding would trigger a rise in the uninsured rate as people struggled to find alternative coverage.

But states, private health insurers, and advocates launched intense efforts to contact enrollees by phone, email, and social media to ensure they did not experience gaps in coverage.

Still, because of the way the Census Bureau reports the uninsured rate, the full impact of the unwinding won’t be known until the 2026 report.

Beyond Medicaid, several other factors boosted the number of Americans with health insurance last year, including a strong economy and near-record-low unemployment. Most Americans obtain insurance through their jobs, according to the Census, meaning that higher employment typically results in broader health coverage.

Another key factor: enhanced federal subsidies that since 2021 helped lower the cost of private coverage through Obamacare. Sign-ups on Affordable Care Act marketplaces hit a record high of 20.8 million in 2024, according to a Treasury report released Tuesday.

But that extra financial assistance is slated to expire at the end of 2025, setting up a flashpoint for whichever party controls power in Washington after the November elections. Democrats want to extend the subsidies introduced during the pandemic, while many Republicans wish to let them end.

Before Congress passed the ACA in 2010, the uninsured rate had been in double digits for decades. The rate fell steadily under President Barack Obama but reversed under President Donald Trump, only to come down again under President Joe Biden.

In addition to expanding subsidies, the Biden administration increased advertising and the number of counselors who help people sign up for plans during the open enrollment season, which Trump greatly curtailed.

Also contributing to the reduction in the number of uninsured Americans are state efforts to expand coverage to mostly low-income residents. North Carolina, for example, expanded Medicaid eligibility in December 2023, resulting in more than 500,000 additional enrollees.

Decades of research shows that expanded health coverage helps people individually and the public overall. Health insurance pays for routine care and can protect people from financial calamity because of severe injuries or illness.

People who are uninsured are more likely to delay or avoid getting health care, which can lead to relatively minor problems becoming more severe and costly to treat. Having more people covered also means more patients can pay their bills, which can improve the financial condition of hospitals and other providers.

The health insurance data released annually by the Census Bureau is considered the most accurate picture of health coverage in the United States. The state-level uninsured data it plans to release Thursday, based on a larger survey, counts people as uninsured if they say they don’t have coverage at the time they’re contacted. Thus, it likely will provide more insight into the effects of the unwinding.

Suspicions that U.S. consumers’ personal information could be accessed from India led regulators to abruptly bar two large private sector enrollment websites from accessing the Affordable Care Act marketplace in August.

New details about the suspensions come in legal filings made late Friday stemming from an effort by the two to regain access to the Obamacare marketplace before the upcoming ACA open enrollment period, which starts Nov. 1.

The Centers for Medicare & Medicaid Services wrote in a Sept. 2 letter to the companies that they were suspended after the agency identified “a serious lapse in the security posture” that could have led to marketplace data, including consumers’ personal information, being accessed from overseas.

The letter, included in the court filings, also noted that regulators will audit the two companies because they have “reasonable suspicion” that they are players in a separate problem: signing people up for Obamacare coverage — or changing their policies — without the consumers’ permission.

Whether those legal issues will be resolved before the upcoming enrollment period is an open question. Currently, the concerns raised about the companies remain allegations, with none of the legal challenges or the audit close to a ruling or conclusion.

Still, the larger issue of fraudulent ACA enrollment by rogue insurance agents seeking commissions will continue to pose a headache for regulators, with more than 200,000 complaints filed by consumers in the first six months of 2024. And it has become a political problem for the Biden administration. GOP lawmakers blamed the schemes partly on Biden-backed expanded Obamacare premium subsidies.

President Joe Biden has claimed record-breaking enrollment under the ACA as one of his administration’s major accomplishments, and regulators are looking to thwart deceptive enrollment schemes without slowing legitimate sign-ups. In recent weeks they’ve removed at least 200 agents’ access to the federal ACA marketplace, and in July began requiring, in many circumstances, that brokers participate in three-way calls with their clients and the healthcare.gov help center before changes can be finalized.

The CMS letter now adds another layer. It is the first time this year the agency has called out a company over questionable enrollments, saying it suspects “the Speridian Companies” might have “directed its employees and other agents to change Marketplace enrollees’ coverage and enroll insured and uninsured consumers without the enrollees’ consent.”

California-based Speridian Global Holdings owns the companies in question, which include enrollment platform Benefitalign and TrueCoverage, doing business as the Inshura enrollment site. It has a data center in India.

The now-suspended Benefitalign site handled at least 1.2 million applications for ACA coverage during the last open enrollment period, according to court documents, which would rank it among the largest of the private enrollment sites allowed to integrate with healthcare.gov, the federal marketplace.

Previously, CMS had said publicly only that it suspended the websites for “anomalous activity.”

The suspended companies deny any wrongdoing related to enrollment schemes. Spokesperson Catherine Riedel declined comment beyond their court filings.

In late August they filed a complaint against CMS over the suspensions in U.S. District Court for the District of Columbia, seeking a restraining order. They added to that complaint on Sept. 6, calling CMS’ suspension action “lawless.”

On Aug. 8, CMS suspended the two websites from accessing healthcare.gov information.

It did so, according to the Sept. 2 letter, over concerns that some consumer information “is processed and/or stored” in India, citing “suspicions” that the data is “being accessed from outside of the United States.”

That’s a problem, the letter says, because marketplace data must stay in the U.S. to “eliminate the possibility that foreign powers might obtain access.” Additionally, websites approved by CMS to integrate with the federal marketplace cannot transmit data outside of the U.S. or allow access from outside the country, under the terms of agreements such companies sign to get CMS approval to operate.

CMS did not spell out what consumer information might have been included, but ACA applications can contain information including a person’s name, date of birth, address, and detailed household income information.

Speridian companies were suspended, then reinstated, from the marketplace in prior years over other concerns, including problems with false Social Security Numbers submitted with some TrueCoverage ACA applications in 2018, and for a 2023 effort by Benefitalign to access the federal marketplace’s “software testing environment” from India, according to the CMS letter.

In seeking a restraining order against CMS, the companies argue that the agency’s action to suspend them now is arbitrary and capricious and violates its own regulations as well as the due process clause of the Constitution.

The filing calls the Sept. 2 CMS letter explaining the reasons for the suspensions “a post hoc justification” that includes a litany of “‘concerns,’ suspicions,’ ‘allegations.’” The filing also asserts “these intimations of violations are made without evidence of any actual violation.”

The court documents say the suspensions will prevent the companies from participating in the upcoming open enrollment period, harming them and “the thousands of brokers” and “millions of consumers who count on brokers” using those websites to sign up for ACA coverage.

The suspension remains in place, the CMS letter says, partly because its concerns have not been allayed by information provided by the companies, but also while the audit is conducted.

CMS has “reasonable suspicion, based on credible evidence it has considered,” that the companies were involved in enrolling consumers or changing their coverage without specific permission, the letter stated, noting that such allegations are included in a civil lawsuit filed by private sector lawyers in U.S. District Court for the Southern District of Florida.

The firms have previously said the allegations in the civil lawsuit are without merit.

Brokers who have used the suspended websites in the past have other options to enroll clients, including several other websites currently approved to integrate with the federal Obamacare marketplace. Consumers can also go directly to the federal or state ACA websites and enroll themselves or get assistance from call centers associated with those marketplaces.

A principios de 2022, Ashley y Kyle estaban recién casados, y emocionados porque esperaban su primer hijo. Pero desde el comienzo de su embarazo, Ashley había tenido hemorragias, y en julio, a las siete semanas, comenzó a tener un aborto espontáneo.

Esto ocurrió unas semanas después que la Corte Suprema de Estados Unidos anulara el derecho federal al aborto. En Wisconsin, su estado natal, volvió a entrar en vigencia una ley de 1849, que permite el procedimiento solo cuando la embarazada corre peligro de muerte.

En el país, la cobertura para la atención del aborto es laberíntica. A menudo, los pacientes no saben cuándo un procedimiento, o las píldoras abortivas, están cubiertas, si es que lo están; y la proliferación de prohibiciones ha exacerbado la confusión.

Ashley dijo que se encontró atrapada en esa maraña de incertidumbres.

La vida de Ashley no estuvo en peligro durante el aborto espontáneo, pero la prohibición del aborto en el estado significaba que los médicos en Wisconsin no podían realizar un D&E —dilatación y evacuación— incluso durante un aborto espontáneo hasta que el embrión no muriera. Condujo ida y vuelta del hospital, sangrando y tomando días por enfermedad en el trabajo, hasta que los médicos pudieron confirmar que el embarazo había terminado.

Solo entonces los médicos eliminaron el tejido del embarazo.

“Con el primer embarazo fue la primera vez que me di cuenta de que algo así podría afectarme”, dijo Ashley, quien pidió ser identificada por su segundo nombre y que su esposo solo fuera mencionado por su primer nombre. Ella trabaja en una agencia gubernamental con compañeros conservadores, y teme represalias por hablar sobre su atención de aborto.

Un año después, con la prohibición del aborto de 1849 aún vigente en Wisconsin, Ashley quedó embarazada de nuevo.

“Todo era perfecto. Empecé a sentir pataditas y movimientos”, dijo. “Fue el día en que cumplí 20 semanas, un lunes. Fui a trabajar, luego recogí a Kyle en el trabajo, y cuando me levanté del asiento del conductor, había líquido en el asiento”.

El saco amniótico se había roto, una condición llamada PPROM no viable. La pareja condujo directamente al triaje obstétrico en UnityPoint Health-Meriter Hospital, conocido como el hospital de maternidad más grande de Wisconsin. Se consideró que el feto estaba demasiado subdesarrollado para sobrevivir, y las membranas rotas representaban una grave amenaza de infección.

Los obstetras y ginecólogos de todo Wisconsin habían decidido que “en casos de PPROM no viable, se debería ofrecer a cada paciente la terminación del embarazo debido al riesgo significativo de infección creciente, y la posible sepsis y muerte”, dijo Eliza Bennett, la gineco-obstetra que trató a Ashley.

Ashley necesitaba un aborto para salvar su vida.

La pareja llamó a sus padres; la madre de Ashley llegó al hospital para consolarlos. Bajo la prohibición del aborto de 1849 en Wisconsin, Bennett, profesora clínica asociada en la Facultad de Medicina de la Universidad de Wisconsin, necesitaba que otros dos médicos atestiguaran que Ashley corría peligro de muerte.

Pero incluso con un arsenal de documentación médica, el seguro de salud de Ashley, el Programa de Beneficios de Salud para Empleados Federales (FEP), no cubría el procedimiento de aborto. Meses después, Ashley entró al portal de facturación médica y se sorprendió al ver que la aseguradora había pagado su estadía de tres noches en el hospital, pero no el aborto.

“Cada vez que llamaba al seguro sobre mi factura, estaba llorando por teléfono porque era muy frustrante tener que explicar la situación y porque creo que debería estar cubierto”, dijo. “Me hacía sentir que era mi culpa, y que debería sentir vergüenza”, dijo Ashley.

Finalmente, habló con una mujer del departamento de facturación del hospital que le transmitió lo que la compañía de seguros había dicho.

“Ella me dijo, textual, ‘FEP Blue no cubre ningún aborto, en absoluto. Punto. No importa lo que sea. No cubrimos abortos’”.

University of Wisconsin Health, que administra la facturación para el hospital UnityPoint Health-Meriter, confirmó este diálogo.

El Programa de Beneficios de Salud para Empleados Federales contrata a FEP Blue, o FEP de BlueCross BlueShield, para proporcionar planes de salud a empleados federales. En respuesta a una solicitud de entrevista, FEP Blue envió un comunicado diciendo que “está obligado a cumplir con la legislación federal que prohíbe a los planes de Beneficios de Salud para Empleados Federales cubrir procedimientos, servicios, medicamentos y suministros relacionados con abortos, excepto cuando la vida de la madre esté en peligro si se lleva el feto a término, o cuando el embarazo sea el resultado de un acto de violación o incesto”.

Desde 1976, el Congreso aprueba cada año esas restricciones, conocidas como la Enmienda Hyde, que prohíben que los fondos federales cubran servicios de aborto.

En el caso de Ashley, los médicos habían dicho que su vida estaba en peligro, y su factura debería haber sido pagada de inmediato, dijo Alina Salganicoff, directora de Políticas de Salud para la Mujer en KFF, una organización sin fines de lucro de información de salud que incluye la redacción de KFF Health News.

Lo que hizo trastabillar la factura de Ashley fue la palabra “aborto” y un código de facturación que es criptonita para los seguros, dijo Salganicoff.

“En este momento, estamos en una situación donde hay una sensibilidad muy alta sobre lo que es una emergencia que amenaza la vida, y cuándo es una emergencia que amenaza la vida”, dijo Salganicoff. El mismo efecto paralizante que ha asustado a médicos y hospitales para no proporcionar atención de aborto legal también puede estar afectando la cobertura, agregó.

En Wisconsin, la falta de cobertura para la atención del aborto es generalizada, dijo Bennett.

“Muchos pacientes que atiendo y que tienen una complicación del embarazo o, más comúnmente, una anomalía fetal grave, no tienen ninguna cobertura”, expresó Bennett.

Recientemente, la factura de $1,700 desapareció del portal de facturación de Ashley. El hospital confirmó que ocho meses después, tras múltiples apelaciones, la aseguradora pagó el reclamo. Cuando se le contactó nuevamente el 7 de agosto, FEP Blue respondió que “no comentará sobre los detalles de la atención médica recibida por miembros individuales”.

Ashley dijo que enfrentarse a su aseguradora y experimentar el impacto de las restricciones al aborto en su atención médica, similar a otras mujeres en todo el país, la ha fortalecido.

“Estoy en esto ahora con todas estas personas”, dijo. “Me siento mucho más conectada con ellas, de una manera que no lo estaba tanto antes”.

Ashley está embarazada de nuevo, y ella y su esposo esperan que esta vez su seguro cubra cualquier atención médica que su médico diga que necesita.

The computer systems run by the consulting giant Deloitte that millions of Americans rely on for Medicaid and other government benefits are prone to errors that can take years and hundreds of millions of dollars to update. While states wait for fixes from Deloitte, beneficiaries risk losing access to health care and food.

Changes needed to fix Deloitte-run eligibility systems often pile on costs to the government that are much higher than the original contracts, which can slow the process of fixing errors.

It has become a big problem across the country. Twenty-five states have awarded Deloitte contracts for eligibility systems, giving the company a stronghold in a lucrative segment of the government benefits business. The agreements, in which the company commits to design, develop, implement, or operate state-owned systems, are worth at least $6 billion, dwarfing any of its competitors, a KFF Health News investigation found.

Problems and delays can extend beyond Medicaid — which provides health coverage to roughly 75 million low-income people — because some state systems assess eligibility for other safety-net programs. Whether a person gets the benefits they are entitled to depends on what the computer says.

There is no automatic switch to stop errors in the system, said Elizabeth Edwards, a senior attorney with the National Health Law Program, a nonprofit that advocates for people with low incomes and medically underserved populations. The group in January filed a complaint urging the Federal Trade Commission to investigate Deloitte, alleging “ongoing and nationwide” errors and “unfair and deceptive trade practices.”

“People will go without care,” Edwards said, and until there’s a fix or a workaround, “you will continue to have the harm over and over again.”

Kenneth Smith, a Deloitte executive who leads its national human services division, previously told KFF Health News that Medicaid eligibility technology is state-owned and agencies “direct their operation” and “make decisions about the policies and processes that they implement.” Smith has called the legal nonprofit’s allegations “without merit.”

States set aside millions of dollars to cover the cost of changes, but systems may require fixes beyond the agreed-upon work. The number of hours or updates is capped each year, so states are left to prioritize certain fixes over others. And even though Deloitte isn’t reinventing the wheel for each eligibility system it builds or runs, the company addresses problems state by state rather than patching through fixes for systems across states, Smith said — a change request in one state “likely has absolutely nothing to do with another state.”

“Because of the custom nature of these systems, it’s never quite that simplistic as, ‘Hey, a particular issue that’s arisen in state of A is directly applicable to state of B,’” Smith said.

Speaking generally, Smith said, “I’m unaware of any circumstance in which a client has needed to get something done that we haven’t found a way to get it done.”

The work is lucrative for Deloitte, which reported global revenue of $65 billion in fiscal year 2023.

Deloitte’s estimates show that 35 change requests for Georgia’s eligibility system in 2023 would take more than 104,000 hours of work, according to a list of change requests that KFF Health News obtained in response to a public records request. That’s the equivalent of 50 years of work, if someone worked 52 weeks a year at 40 hours a week.

“System changes were made to align with changing federal and state policies, as well as to meet evolving business needs,” said Ellen Brown, a spokesperson for the Georgia Department of Human Services. Brown earlier said changes also were made to “improve functionality.”

The federal government — that is, its taxpayers — covers 90% of states’ costs to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

Eligibility systems for years have posed problems for states because of the dynamic between contractors and government officials, said Matt Salo, CEO of consulting firm Salo Health Strategies. The companies hold the expertise “and, quite frankly, they’re kind of running circles around the state capacity,” said Salo, a former executive director of the National Association of Medicaid Directors.

“For decades all I’ve heard from states in this arena is: We know that when we go out to contract it’s going to cost us a lot of money and it is going to run over, it is going to deliver years late, it is going to deliver millions if not hundreds of millions of dollars over budget,” Salo said, and “by the time it’s delivered, our needs have changed and so it’s just this constant process of change orders and going back and fixing.”

Going to Court in Florida

Two advocacy groups last August sued Florida in federal court, alleging tens of thousands of people were losing coverage without proper warning. And Florida’s eligibility system was cutting off Medicaid coverage for some moms after giving birth, William Roberts, a state employee who reviews Medicaid eligibility decisions, testified when the case went to trial in July.

Florida previously gave moms two months of Medicaid coverage after giving birth. Federal regulators in 2022 approved Florida’s proposal to grant Medicaid benefits for 12 months. But in April 2023 state officials discovered a “glitch,” Roberts said, and “the system had reverted back to only giving mothers two months instead of giving them the 12 months that they were entitled to.”

What became clear in the testimony is that the state and Deloitte take different views on what constitutes a “defect” in a Deloitte-run system. Deloitte said it would fix defects without billing any additional hours for the work. Although Deloitte is not a named defendant in the lawsuit, the company was called to testify about its role in operating Florida’s eligibility system.

Harikumar Kallumkal, a Deloitte managing director who oversees the Florida system, initially testified that, in this case, there was no problem and “the computer system was providing 12 months” of postpartum coverage.

Then Kallumkal said, “Even in this case, I do not believe it was a defect.” Even so, “we did fix that.” And for the fix, he said, Deloitte “did not charge” the state.

Rather, a separate defect may have resulted in coverage losses for mothers after childbirth, Kallumkal testified.

Some historical data “required to determine postpartum coverage” was not loading into the system, Kallumkal said. “I don’t know how many cases it impacted,” he said, but Deloitte fixed the problem.

The courtroom revelation confirmed what Florida advocates already knew: an eligibility system issue prevented some of the state’s most vulnerable from getting care. Florida denied allegations that it terminated Medicaid coverage without providing adequate notice. The case is ongoing.

When Michigan resumed regular Medicaid eligibility checks following the covid-19 pandemic, advocates saw a concerning trend.

The computer system routinely fails to recognize when certain adults with disabilities should receive Medicaid benefits, said Dawn Calnen, executive director of The Arc of Oakland County, which provides support for those with intellectual and developmental disabilities.

Often a person who qualifies for Medicaid initially for one reason could remain eligible even when life circumstances change. Calnen said there’s no question that the people her group assisted are still eligible, just in a different way than during the pandemic.

The problem is frequent enough that Calnen’s group felt compelled to notify others. “We kind of shout it from the rooftop for people: Know that this is going to happen.”

When asked about the problem, Chelsea Wuth, a spokesperson for Michigan’s Department of Health and Human Services, said there were “no issues” with the system. Deloitte operates Michigan’s eligibility system. The company said it does not comment on state-specific issues.

Tennessee hired Deloitte in 2016 to build an eligibility system after the state canceled a contract with Northrop Grumman due to chronic delays. Deloitte didn’t create the Tennessee system, known as TEDS, from scratch. It built on components from Georgia’s system, according to a legal declaration and a deposition of Kimberly Hagan, Tennessee Medicaid’s director of member services, that were part of a class-action lawsuit that Medicaid beneficiaries filed against the state in 2020.

The lawsuit, which is ongoing and does not name Deloitte as a defendant, seeks to order Tennessee to restore coverage under its Medicaid program, known as TennCare, for those who wrongly lost it. Hagan, in a court filing, said many problems “reflect some unforeseen flaws or gaps” with the Tennessee eligibility system and “some design errors.”

A federal judge on Aug. 26 sided with the Medicaid beneficiaries, ruling that Tennessee violated federal law and the U.S. Constitution. “Poor, disabled, and otherwise disadvantaged Tennesseans should not require luck, perseverance, or zealous lawyering to receive healthcare benefits they are entitled to under the law,” wrote U.S. District Court Judge Waverly D. Crenshaw Jr., adding, “TEDS is flawed, and TennCare knows that it is flawed.”

Tennessee Medicaid spokesperson Amy Lawrence said the state is “determining what our next steps will be.”

Tennessee’s $823 million contract with Deloitte shows that the budget for changes outside the contract’s original scope increased by hundreds of millions of dollars. Deloitte’s maximum compensation for such change orders rose to $417 million under a 2023 contract amendment, up from $103.6 million four years earlier.

Lawrence said state officials “do not and would not pay to fix vendor errors.” Lawrence attributed the cost increases to “system modernization” in “an effort to enhance our citizens’ interactions with the state Medicaid program.” Additional funding was also needed to comply with new federal requirements related to the covid-19 pandemic, she said.

Waiting on Fixes

States sometimes wait so long for Deloitte’s fixes that the staffers who worked on the problems don’t see the results. Jamie Perkins was responsible for making letters easier for Colorado Medicaid enrollees to understand. The letters are generated by Colorado’s Deloitte-run eligibility system. State audits have found that the notices confuse enrollees and contain errors. Perkins said she left her job in 2021, frustrated that many of her fixes hadn’t been implemented.

“It feels like a really perverse reward system, frankly, for Deloitte,” Perkins said. “When Deloitte is themselves making a problem that did not originate with the department, the department is still paying them to fix those problems.”

The state’s contract with Deloitte now outlines “protocols to address issues that are the result of the contractor,” said Trish Grodzicki, a spokesperson for Colorado’s Medicaid agency. As of June 30, Colorado “has made substantial improvements” and a “majority of the letters have been rewritten” and updated in the system, she said.

Deloitte spokesperson Karen Walsh said “a change request can represent a number of different things,” including when states make policy decisions that would warrant system updates. Smith said Deloitte views change requests and system issues, or defects, as different things.

“We have a responsibility when there’s a system issue to fix that,” Walsh said. “We don’t get a change request to fix an issue.”

Yet in Kentucky and other places, states have submitted change orders to resolve issues. Government officials and Deloitte sometimes negotiate fixes for months before they’re implemented.

Kentucky resident Beverly Likens lost Medicaid coverage in June 2023 partly due to an error with the state’s Deloitte-run system. State health officials told a legal aid group in September 2023 that a “change order has been submitted” to fix the glitch, which blocked her new coverage application from getting through online.

Likens, with the help of a lawyer, had her Medicaid benefits quickly reinstated, but that was far from the end of the saga. The problem that caused her benefits to lapse was resolved in April — 10 months later — when Kentucky implemented the first phase of a change request, Kentucky’s Cabinet for Health and Family Services told KFF Health News.

Agency spokesperson Brice Mitchell said the change request was designed to address a “limitation of the system rather than technical issues.” The request, for which a second phase was implemented in July, cost $522,455 and took more than 3,500 hours of work, according to Mitchell and documents obtained in response to a public records request. All such requests “are thoroughly vetted, negotiated and approved by several areas within the Cabinet,” Mitchell said in an emailed statement.

“These are large, complex system implementations,” Walsh, of Deloitte, said. “So in all of them, you’re going to be able to find a point in time where there was an issue that needed to be fixed. And you can also find millions of people every day who are getting benefits through these systems.”

In February, Georgia officials were discussing a high-priority change request to resolve an ongoing problem: A defect affected potentially tens of thousands of “cases/claims” for families in the Supplemental Nutrition Assistance Program, known as SNAP, and the Temporary Assistance for Needy Families program that, among other problems, led the state to recoup some residents’ entire benefit, according to state documents KFF Health News obtained from a public records request. The programs provide monthly cash assistance to low-income people for food and housing. Georgia in 2014 inked a contract with Deloitte to build and maintain its eligibility system, known as Georgia Gateway.

Federal regulations cap how much money the government can recoup if a SNAP recipient was overpaid at 20% or $20, whichever is higher, according to legal aid attorneys and SNAP experts.

“We have plenty of clients who, that is their entire grocery budget,” said Adrianne Freeman, deputy director for litigation and advocacy at the Georgia Legal Services Program.

The defect — which Georgia DHS’ Brown said was identified on April 29, 2022 — created several problems, including incorrect calculations of how much to recoup and clawbacks not occurring on the correct start dates. “The Gateway system did not consistently adjust or apply the recoupment amount correctly,” Brown said.

A fix was deployed the weekend of Feb. 17, the documents state, but a formal change request was needed to “allow the State Agency (SA) to correctly apply allotment reductions to all SNAP and TANF cases impacted by Defect 21068,” the documents state. The change order would allow state officials to run an automated one-time mass update to fully resolve the problem.

The target date for doing so: March 1. That was nearly two years after officials were provided an “original report” noting that more than 25,000 cases may have been affected, the documents state.

Relying on Workarounds

States often face constraints on how many changes can be made in a year. In Texas, there is a years-long waitlist for changes, according to advocates, state documents, and the state health agency. “The system isn’t nimble enough to meet the needs and often relies really heavily on manual workarounds,” said Stacey Pogue, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms with expertise on Medicaid in Texas.

Texas eligibility workers use workarounds to process applications while awaiting permanent fixes. Deloitte said in its $295 million Texas contract that “there is a real need” for workarounds, which allow operations to continue “without affecting client benefits.”

Many of these “temporary” fixes were implemented years ago and were still in use in 2023, according to records obtained by KFF Health News that found 45 active workarounds in Texas last year. In one instance, a workaround was implemented nearly 14 years ago. Deloitte acknowledged in its Texas contract that reducing workarounds “is one of the top priorities.”

Smith of Deloitte said it doesn’t always take months to fix a problem: “We have changes that get implemented in a day and changes that get implemented in a month.”

Further, Smith said, Deloitte “is one part of implementing a change,” noting “we’re often not necessarily the constraint.”

The state considers several factors when assessing which fixes to tackle first, including how many beneficiaries are affected. The more complex the workaround, “the longer it may take for staff to process eligibility,” said Jennifer Ruffcorn, a spokesperson for Texas Health and Human Services.

In Florida — in addition to the lapses in coverage for maternal care — the National Health Law Program and the Florida Health Justice Project alleged in their lawsuit in federal court that notices to Medicaid beneficiaries alerting them their benefits would be terminated did not explain the basis for the decision.

In October, about a month after the lawsuit was filed, the state asked Deloitte to provide an estimate to alter the notices, Kallumkal of Deloitte testified at trial in August.

Deloitte estimated it would need roughly 28,000 hours, he said. That’s more than twice the 12,600 hours the state sets aside each year to pay Deloitte for revisions. The extra hours would require an amended contract in which the state would have to agree to pay more. Florida’s Department of Children and Families did not respond to requests for comment.

For Deloitte, extra hours mean more revenue, Kallumkal acknowledged during his testimony while under cross-examination. Deloitte subsequently provided the state with a new estimate for a narrower scope of work that would take 12,000 hours, he 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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En medio de una amarga y divisiva contienda, el ex presidente Donald Trump y la vicepresidenta Kamala Harris solo parecen coincidir en una cosa: es tarea del gobierno reducir los altos precios de los medicamentos en el país.

En 2022, Harris emitió el voto de desempate en el Senado para aprobar una ley que permite a Medicare negociar los precios de los medicamentos para sus más de 60 millones de beneficiarios. Antes, como fiscal general de California, fue una reguladora agresiva de la industria farmacéutica.

Como presidente, Trump probablemente mantendría las negociaciones de precios de Medicare a menos que la industria farmacéutica pudiera ofrecer algo más convincente. Según personas de su círculo, en su primer mandato propuso varias políticas destinadas a reducir los costos de los medicamentos recetados, pero tuvo un éxito limitado en su implementación.

La industria farmacéutica podría beneficiarse si Trump sigue sin poder avanzar con tales propuestas.

“Sus esfuerzos fueron en gran parte fragmentados y enfrentaron resistencia tanto de la industria como de los legisladores”, dijo Sergio José Gutiérrez, estratega político que ha trabajado principalmente con demócratas. “La falta de una estrategia consolidada y la capacidad limitada para implementar cambios significativos hizo que su enfoque fuera menos efectivo en comparación con lo que una administración Harris-Walz podría ofrecer”.

Legisladores de ambos partidos atacan cada vez más a la industria, por los precios de los medicamentos que la mayoría de los estadounidenses consideran irrazonables, según encuestas de KFF. El resultado de la elección podría ser crucial para la suerte de las farmacéuticas.

La situación actual de la industria contrasta fuertemente con años anteriores, cuando gozaban de una reputación de ser casi intocables. Durante más de una década, rechazaron propuestas para permitir que Medicare negociara precios más bajos de medicamentos antes de perder la batalla hace dos años.

El cambio en su posición política se refleja en las contribuciones de las compañías farmacéuticas a los candidatos. Una industria que en los años 90 y principios de los 2000 daba tres o cuatro veces más a los candidatos republicanos que a los demócratas, ahora está repartiendo de forma distinta sus apuestas. Hasta ahora, en el ciclo de 2024, las compañías farmacéuticas han dado $4,89 millones a los demócratas y $4,35 millones a los republicanos, según OpenSecrets, un grupo de investigación no partidista.

Harris ha recibido $518.571 de la industria, y Trump $204.748.

En la Convención Nacional Demócrata en Chicago, Harris y otros promocionaron sus antecedentes en la reducción de los precios de los medicamentos. Los partidarios de Harris señalan su pasado y presente.

Mientras fue fiscal general de California, Harris tuvo causas que resultaron en casi $7.200 millones (alrededor de $22 por persona en Estados Unidos) en multas para las farmacéuticas.

Su voto para aprobar la Ley de Reducción de la Inflación del presidente Joe Biden allanó el camino no solo para la negociación de precios de Medicare, sino también para un límite anual de $2.000 en el gasto total en medicamentos de los beneficiarios de Medicare y un límite de $35 en sus suministros mensuales de insulina.

“En los Estados Unidos de América, ningún adulto mayor debería tener que elegir entre llenar su receta o pagar su alquiler”, dijo Harris el 15 de agosto en su primera aparición conjunta con Biden desde que el presidente  abandonara la carrera por la reelección.

Si es elegida presidenta, ha prometido extender tanto el límite anual de gastos en medicamentos como el límite del precio de la insulina a todos los estadounidenses con seguro, no solo a aquellos con Medicare.

Harris también respaldó una política polémica que, en algunos casos, permitiría al gobierno federal inyectar más competencia en el mercado al incautar las patentes de algunos medicamentos costosos desarrollados con fondos federales.

Doug Hart, de 77 años, de Tempe, Arizona, ha estado gastando alrededor de $7.000 anuales en medicamentos recetados. Un medicamento que toma para prevenir coágulos de sangre costará menos bajo las negociaciones de precios de Medicare. El presidente retirado de un sindicato dijo que la disminución será considerable y es una de las razones por las que apoya a Harris.

“Los republicanos votaron en contra de la negociación de precios de Medicare. Harris rompió el empate en el Senado para permitirlo”, dijo Hart, quien es miembro de la junta de la Alianza de Jubilados de Arizona, que trabaja para movilizar a miembros y sindicalistas retirados en temas progresistas.

Si bien como partido los republicanos siguen siendo más favorables a la industria farmacéutica, Trump ha estado dispuesto a desafiar la ortodoxia del GOP tomando medidas para combatir los altos costos de los medicamentos.

Durante su administración, trató de vincular los precios de los medicamentos en Medicare con los precios internacionales más bajos, una propuesta que el instituto de investigación de salud de PricewaterhouseCoopers estimó que costaría a cinco fabricantes de medicamentos hasta $500 millones de dólares al año.

Lo que se conocía como la regla final interina de “nación más favorecida” fue bloqueada debido a desafíos legales y luego fue rescindida por la administración de Biden.

Trump emitió una regla que establecía un camino para importar medicamentos de Canadá y otros países, con Florida convirtiéndose este año en el primer estado en obtener la aprobación federal para importar algunas recetas de Canadá. Pero las acciones del estado se frustraron por la resistencia de Health Canada, el departamento del gobierno canadiense responsable de la política de salud nacional.

Y en su sitio web de campaña, Trump publicó un video en el que cuestionaba si los problemas de salud infantil son el resultado de la “sobre recetar” medicamentos.

“Con demasiada frecuencia, nuestro establishment de salud pública está demasiado cerca de Big Pharma; ganan mucho dinero, Big Pharma, las grandes corporaciones y otros intereses especiales, y no quieren hacer las preguntas difíciles sobre lo que está sucediendo con la salud de nuestros hijos”, dijo. “Si Big Pharma engaña a los pacientes y contribuyentes estadounidenses o antepone las ganancias a las personas, se los debe investigar y responsabilizar”, agregó.

Trump no ha dicho mucho sobre los precios de los medicamentos en su campaña de 2024, pero sus aliados y ex asesores dicen que sigue comprometido a reducir los precios de las recetas, si es reelegido.

Probablemente, Trump se enfocaría en aumentar la competencia de genéricos y biosimilares, importar medicamentos fabricados, pero que en la actualidad se venden en el extranjero, y limitar los costos de bolsillo de la insulina, según ex funcionarios de su administración.

Otros objetivos podrían ser reducir los precios de los medicamentos en el programa 340B de Medicare, que requiere que los fabricantes proporcionen fármacos para pacientes ambulatorios a precios reducidos a organizaciones de salud elegibles que atienden a pacientes de bajos ingresos y sin seguro.

“El tema número 1 que le importaba mientras estaba en la Casa Blanca, y sigo escuchándolo hablar, es reducir los precios de los medicamentos”, dijo Theo Merkel, investigador senior en los think tanks conservadores Paragon Health Institute y Manhattan Institute. Merkel también fue asistente especial de Trump en la Casa Blanca. “Estoy seguro de que estará arriba en la agenda”, agregó.

Catherine Hill, vocera de la Asociación de Investigación y Fabricantes Farmacéuticos de América, o PhRMA, dijo que el grupo comercial de la industria espera colaborar con cualquier futura administración presidencial.

Criticó el plan de negociación de precios de Medicare de la administración Biden, así como el plan de Trump de alinear los precios con los de otros países. Este mes, la administración anunció nuevos precios reducidos para 10 medicamentos en el programa tras negociaciones entre el gobierno federal y las farmacéuticas. Los costos más bajos entrarán en vigencia en 2026.

“Los controles de precios anteriores adoptados por la administración Biden amenazan con frenar esa innovación”, dijo Hill. “Socavar las protecciones de la propiedad intelectual y tomar ‘prestados’ los controles de precios de otros países subestimará aún más la innovación y amenazará el acceso de los pacientes a los medicamentos”.

Ashley and Kyle were newlyweds in early 2022 and thrilled to be expecting their first child. But bleeding had plagued Ashley from the beginning of her pregnancy, and in July, at seven weeks, she began miscarrying.

The couple’s heartbreak came a few weeks after the U.S. Supreme Court overturned the federal right to abortion. In Wisconsin, their home state, an 1849 law had sprung back into effect, halting abortion care except when a pregnant woman faced death.

Insurance coverage for abortion care in the U.S. is a hodgepodge. Patients often don’t know when or if a procedure or abortion pills are covered, and the proliferation of abortion bans has exacerbated the confusion. Ashley said she got caught in that tangle of uncertainties.

Ashley’s life wasn’t in danger during the miscarriage, but the state’s abortion ban meant doctors in Wisconsin could not perform a D&E — dilation and evacuation — even during a miscarriage until the embryo died. She drove back and forth to the hospital, bleeding and taking sick time from work, until doctors could confirm that the pregnancy had ended. Only then did doctors remove the pregnancy tissue.

“The first pregnancy was the first time I had realized that something like that could affect me,” said Ashley, who asked to be identified by her middle name and her husband by his first name only. She works in a government agency alongside conservative co-workers and fears retribution for discussing her abortion care.

A year later, the 1849 abortion ban still in place in Wisconsin, Ashley was pregnant again.

“Everything was perfect. I was starting to feel kicking and movement,” she said. “It was the day I turned 20 weeks, which was a Monday. I went to work, and then I picked Kyle up from work, and I got up off the driver’s seat and there was fluid on the seat.”

The amniotic sac had broken, a condition called previable PPROM. The couple drove straight to the obstetrics triage at UnityPoint Health-Meriter Hospital, billed as the largest birthing hospital in Wisconsin. The fetus was deemed too underdeveloped to survive, and the ruptured membranes posed a serious threat of infection.

Obstetrician-gynecologists from across Wisconsin had decided that “in cases of previable PPROM, every patient should be offered termination of pregnancy due to the significant risk of ascending infection and potential sepsis and death,” said Eliza Bennett, the OB-GYN who treated Ashley.

Ashley needed an abortion to save her life.

The couple called their parents; Ashley’s mom arrived at the hospital to console them. Under the 1849 Wisconsin abortion ban, Bennett, an associate clinical professor at the University of Wisconsin School of Medicine, needed two other physicians to attest that Ashley was facing death.

But even with an arsenal of medical documentation, Ashley’s health insurer, the Federal Employees Health Benefits Program, did not cover the abortion procedure. Months later, Ashley logged in to her medical billing portal and was surprised to see that the insurer had paid for her three-night hospital stay but not the abortion.

“Every time I called insurance about my bill, I was sobbing on the phone because it was so frustrating to have to explain the situation and why I think it should be covered,” she said. “It’s making me feel like it was my fault, and I should be ashamed of it,” Ashley said.

Eventually, Ashley talked to a woman in the hospital billing department who relayed what the insurance company had said.

“She told me,” Ashley said, “quote, ‘FEP Blue does not cover any abortions whatsoever. Period. Doesn’t matter what it is. We don’t cover abortions.’”

University of Wisconsin Health, which administers billing for UnityPoint Health-Meriter hospital, confirmed this exchange.

The Federal Employees Health Benefits Program contracts with FEP Blue, or the BlueCross BlueShield Federal Employee Program, to provide health plans to federal employees. In response to an interview request, FEP Blue emailed a statement saying it “is required to comply with federal legislation which prohibits Federal Employees Health Benefits Plans from covering procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.”

Those restrictions, known as the Hyde Amendment, have been passed each year since 1976 by Congress and prohibit federal funds from covering abortion services.

In Ashley’s case, physicians had said her life was in danger, and her bill should have immediately been paid, said Alina Salganicoff, director of Women’s Health Policy at KFF, a health information nonprofit that includes KFF Health News.

What tripped up Ashley’s bill was the word “abortion” and a billing code that is insurance kryptonite, said Salganicoff.

“Right now, we’re in a situation where there is really heightened sensitivity about what is a life-threatening emergency, and when is it a life-threatening emergency,” Salganicoff said. The same chilling effect that has spooked doctors and hospitals from providing legal abortion care, she said, may also be affecting insurance coverage.

In Wisconsin, Bennett said, lack of coverage for abortion care is widespread.

“Many patients I take care of who have a pregnancy complication or, more commonly, a severe fetal anomaly, they don’t have any coverage,” Bennett said.

Recently, the bill for $1,700 disappeared from Ashley’s online bill portal. The hospital confirmed that eight months later, after multiple appeals, the insurer paid the claim. When contacted again on Aug. 7, FEP Blue responded that it would “not comment on the specifics of the health care received by individual members.”

Ashley said tangling with her insurance company and experiencing the impact of abortion restrictions on her health care, similar to other women around the country, has emboldened her.

“I’m in this now with all these people,” she said. “I feel a lot more connected to them, in a way that I didn’t as much before.”

Ashley is pregnant again, and she and her husband hope that this time their insurance will cover whatever medical care her doctor says she needs.

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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A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars — only to abruptly back off amid an “uproar” from the industry, newly released court filings show.

The Centers for Medicare & Medicaid Services published the draft regulation in January 2014. The rule would have required health plans, when examining patient’s medical records, to identify overpayments by CMS and refund them to the government.

But in May 2014, CMS dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.

The Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” DOJ said in a court filing.

Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

In a court filing, UnitedHealth Group denies wrongdoing and argues it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”

This month, the parties in the court case made public thousands of pages of depositions and other records that offer a rare glimpse inside the Medicare agency’s long-running struggle to keep the private health plans from taking taxpayers for a multibillion-dollar ride.

“It’s easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this,” said Richard Lieberman, a Colorado health data analytics expert.

Spokespeople for the Justice Department and CMS declined to comment for this article. In an email, UnitedHealth Group spokesperson Heather Soule said the company’s “business practices have always been transparent, lawful and compliant with CMS regulations.”

Missed Diagnoses

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare. Along the way, the industry has been the target of dozens of whistleblower lawsuits, government audits, and other investigations alleging the health plans often exaggerate how sick patients are to rake in undeserved Medicare payments — including by doing what are called chart reviews, intended to find allegedly missed diagnosis codes.

By 2013, CMS officials knew some Medicare health plans were hiring medical coding and analytics consultants to aggressively mine patient files — but they doubted the agency’s authority to demand that health plans also look for and delete unsupported diagnoses.

The proposed January 2014 regulation mandated that chart reviews “cannot be designed only to identify diagnoses that would trigger additional payments” to health plans.

CMS officials backed down in May 2014 because of “stakeholder concern and pushback,” Cheri Rice, then director of the CMS Medicare plan payment group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the industry’s reaction as an “uproar.”

Exactly who made the call to withdraw the chart review proposal isn’t clear from court filings so far.

“The direction that we received was that the rule, the final rule, needed to include only those provisions that had wide, you know, widespread stakeholder support,” Rice testified.

“So we did not move forward then,” she said. “Not because we didn’t think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders.”

The CMS press office declined to make Rice available for an interview. Hornsby, who has since left the agency, declined to comment.

But Erin Fuse Brown, a professor at the Brown University School of Public Health, said the decision reflects a pattern of timid CMS oversight of the popular health plans for seniors.

“CMS saving money for taxpayers isn’t enough of a reason to face the wrath of very powerful health plans,” Fuse Brown said.

“That is extremely alarming.”

Invalid Codes

The fraud case against UnitedHealth Group, which runs the nation’s largest Medicare Advantage plan, was filed in 2011 by a former company employee. The DOJ took over the whistleblower suit in 2017.

DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government says.

The government argues that UnitedHealth Group knew that many conditions it had billed for were not supported by medical records but chose to pocket the overpayments. For instance, the insurer billed Medicare nearly $28,000 in 2011 to treat a patient for cancer, congestive heart failure, and other serious health problems that weren’t recorded in the person’s medical record, DOJ alleged in a 2017 filing.

In all, DOJ contends that UnitedHealth Group should have deleted more than 2 million invalid codes.

Instead, company executives signed annual statements attesting that the billing data submitted to CMS was “accurate, complete, and truthful.” Those actions violated the False Claims Act, a federal law that makes it illegal to submit bogus bills to the government, DOJ alleges.

The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members — including several who have since departed government for jobs in the industry — against those of UnitedHealthcare executives.

‘Red Herring’

Court filings describe a 45-minute video conference arranged by then-CMS administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she set up the meeting between UnitedHealth and CMS staff at the request of Larry Renfro, a senior UnitedHealth Group executive, to discuss implications of the draft rule. Neither Tavenner nor Renfro attended.

Two UnitedHealth Group executives on the call said in depositions that CMS staffers told them the company had no obligation at the time to uncover erroneous codes. One of the executives, Steve Nelson, called it a “very clear answer” to the question. Nelson has since left the company.

For their part, four of the five CMS staffers on the call said in depositions that they didn’t remember what was said. Unlike the company’s team, none of the government officials took detailed notes.

“All I can tell you is I remember feeling very uncomfortable in the meeting,” Rice said in her 2022 deposition.

Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

DOJ called the flap over the ill-fated regulation a “red herring” in a court filing and alleges that when UnitedHealth asked for the April 2014 meeting, it knew its chart reviews had been under investigation for two years. In addition, the company was “grappling with a projected $500 million budget deficit,” according to DOJ.

Data Miners

Medicare Advantage plans defend chart reviews against criticism that they do little but artificially inflate the government’s costs.

“Chart reviews are one of many tools Medicare Advantage plans use to support patients, identify chronic conditions, and prevent those conditions from becoming more serious,” said Chris Bond, a spokesperson for AHIP, a health insurance trade group.

Whistleblowers have argued that the cottage industry of analytics firms and coders that sprang up to conduct these reviews pitched their services as a huge moneymaking exercise for health plans — and little else.

“It was never legitimate,” said William Hanagami, a California attorney who represented whistleblower James Swoben in a 2009 case that alleged chart reviews improperly inflated Medicare payments. In a 2016 decision, the 9th Circuit Court of Appeals wrote that health plans must exercise “due diligence” to ensure they submit accurate data.

Since then, other insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart reviews. In July 2023, Martin’s Point Health Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for conditions ranging from diabetes with complications to morbid obesity. The plan denied any liability.

A December 2019 report by the Health and Human Services Inspector General found that 99% of chart reviews added new medical diagnoses at a cost to Medicare of an estimated $6.7 billion for 2017 alone.

Caitlyn Mai thought she did everything right. She called ahead to make sure her insurer would cover her cochlear implant surgery. She thought everything went according to plan but she still got a bill for the full cost of the surgery: more than $139,000. 

What Caitlyn did next is a reminder of why a beloved former guest once said you should “never pay the first bill.” This episode of “An Arm and a Leg” is an extended version of the July installment of the “Bill of the Month” series, created in partnership with NPR.

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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Don’t Get ‘Bullied’ Into Paying What You Don’t Owe

Dan: Hey there — 

One morning when she was in eighth grade, Caitlin Mai did what she always did when she woke up. 

Caitlyn Mai: Music has always been a big part of my life. And so I immediately put in my headphones and started putting on music as I was about to get out of bed and get ready. And I noticed my earbud in my right ear wasn’t working. 

Dan: It was obvious, because on this Beatles tune she’d cued up, Eleanor Rigby, the vocals are almost all on the right-hand side, and she couldn’t hear them. 

Caitlyn: I was like, that’s kind of weird. So I switched the earbuds and it worked fine. But then it was, the other one wasn’t working in my right ear. And I was like, what? 

Dan: Yeah, confusing. And then she tried getting out of bed. 

Caitlyn: I was so dizzy. It was my first time experiencing vertigo, and it was so severe, I couldn’t walk across the room without getting severely motion sick. 

Dan: With that vertigo, Caitlin could barely walk at all. She had no sense of balance — that actually relies on a mechanism inside our ears. Later, doctors found she had lost 87 percent of her hearing on the right side. 

Caitlyn: They think I just had some sort of virus that settled in my ear, and it damaged my ear. But I went to bed completely healthy the night before. Woke up, couldn’t hear out of my ear. 

Dan: She had to learn how to walk all over again.

Caitlyn: I have to rely on my eyes. My friends still find it hilarious if I close my eyes, I fall over. 

Dan: That was eighth grade. Caitlyn made it through high school, in Tulsa where she grew up without a lot of accommodations. 

Caitlyn: Cause in middle school, early high school, you don’t want to bring attention to your disability. At least I really didn’t want to at the time. I was super anxious about that. 

Dan: Catilyn’s 27 now, she works as a legal assistant in Oklahoma City. Her husband’s a lawyer. And for the longest time, she couldn’t access a tool that helps restore hearing for lots of people: Cochlear implants — small devices that stimulate nerves inside the ear. 

The FDA didn’t approve them for just one ear until a couple of years ago. Last year, Caitlin got her insurance to approve one for her. She had surgery in December to insert the implant. And in January, an audiologist attached an external component to switch on Caitlin’s right-side hearing. 

Caitlyn: She said, okay, at some point, you’re gonna start hearing some beeps, just say yes when you can hear them. And my husband said my face just, out of nowhere, lit up, and I go, yes! It was streaming directly to my cochlear implant. And I definitely started tearing up. 

Dan: Then, two weeks later, Caitlin got an alert from the hospital on her phone. 

Caitlyn: And I open it up, and I immediately started having a panic attack. 

Dan: It was a bill for a hundred and thirty-nine thousand dollars. The full amount for Caitlin’s surgery. 

Which, given that Caitlyn had gotten her insurance company’s OK for the procedure in advance, was a pretty big surprise. NPR featured Caitlyn’s story recently for a series they do with our pals at KFF Health News. 

NPR HOST: Time now for the latest installment in our bill of the month series, where we dissect and explain confusing or outrageous medical bills.

Dan: I interviewed Caitlyn for that story. And we’re bringing you an expanded version here because Caitlin’s situation — well, it was a good story. And it made me curious about a couple things. 

It also reminded me of some good advice we’ve heard here before — and it reminded me of an important colleague and teacher. And the bottom line to Caitlyn’s story? Stand up for yourself. Don’t cave. Make the next call. 

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 our job 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. 

To get her insurance company’s approval, Caitlyn had already spent a lot of time — and a lot of money — in the months before surgery. For instance … 

Caitlyn: To prove to insurance that a hearing aid wouldn’t work had to be fitted for a hearing aid and then do a couple hours of testing to prove, yep, it doesn’t help. 

Dan: There were reviews with audiologists, with her surgeon, and an MRI to make sure there wasn’t too much scar tissue for an implant to take. 

Caitlyn: That took a long time to get scheduled, get insurance to approve, pay for, then get back for another appointment. I counted up at one point — it’s like around eight or ten appointments that I had before the final, okay, let’s schedule surgery. 

Dan: And — you caught that, right? Where she mentioned she had to get her insurance to approve paying for the MRI? Every one of these preliminary steps cost money, and she had to wrangle with her insurance to get their OK. 

But of course even with her insurance saying yes, there were still copays, and deductibles, and what’s called co-insurance — where you pay a percentage of any bill from a hospital. 

Which meant Caitlyn was chipping away at what’s called her out-of-pocket maximum: The most she could be on the hook for in a given calendar year. The surgery got scheduled for December — the same calendar year as all those tests — and she checked to see what she might have to pay. 

Caitlyn: I looked at my little portal for insurance, I’m showing what’s left on my out-of-pocket max for the year is around 2,000, give or take, 200 dollars. 

Dan: She called the insurance company to confirm that estimate. And then she cranked up her due diligence. 

Caitlyn: I called the hospital, and I asked for the names of the anesthesiologist, the radiologist. I asked for all of the details of who is possibly going to be on my case. And then I turned around and I called insurance and I said, I want to make sure all of these physicians are going to be in network on this date. 

Dan: Caitlyn had done her homework. Probably more than a lot of us would have thought to do. I asked her: How’d you get so diligent? And first, like a lot of folks I’ve talked with, she said: Having a major health issue as a kid — losing her hearing — gave her an early heads-up to watch out. 

Caitlyn: A little bit was, uh, experience of my mom dealing with insurance battles with me growing up. I remember her running into issues with that. 

Can: And she’s got some experts in her life now. Her brother and her sister in law work in health care. One of her best friends is a healthcare lawyer and had some tips. 

Caitlyn: But honestly, I think a lot of it is I have anxiety, and so I was just really paranoid. 

Dan: The surgery went great. And a few weeks later, Caitlyn was in the audiologist’s office, getting that external component attached, and hearing on her right side for the first time in 15 years. Caitlyn says it all took some getting used to. 

Caitlyn: I remember those, like, first few days especially, it wasn’t really like I was hearing full sounds. It was kind of just different pitches. I wasn’t hearing the words and everything, it was just the breakdown of the different pitches. And they also were just so much higher than they should be.

Dan: So interesting. Radiolab may have already done this story — [but] I’m just like, let’s find out what that’s about. 

Caitlyn: I love Radiolab. 

Dan: Me too! Anyway, two weeks after she starts getting used to her new hearing situation, Caitlyn gets that alert on her phone. 

Caitlyn: And it tells me I have a new invoice. And I was like, oh, awesome! I’m not stressed at all, I did my due diligence. I know it’s gonna be expensive, but affordable. 

Dan: Except, right: It’s a hundred and thirty-nine thousand dollars! Six figures. The full amount for her surgery. You might remember, Caitlyn said she had a panic attack. That was literal: Heart palpitations, hyperventilating. 

It took her 20 or 30 minutes to get calm enough to start making calls. And she says her insurance told her they hadn’t paid because the hospital had neglected to send something important. 

Caitlyn: The itemized bill. Which has all the codes and everything, 

Dan: Caitlyn says she immediately asked the hospital, in writing to send her insurance the itemized bill, and she says sent a follow-up a week later. But her phone kept pinging with alerts about owing the hospital a hundred and thirty-nine thousand dollars. 

Caitlyn: The app so conveniently told me that I could sign up for monthly payments of 11,000 dollars a month, which is just so absurd. 

Dan: After two weeks, she asked her insurance: Do you have that itemized bill yet? They didn’t. So she called the hospital again. 

Caitlyn: The girl I spoke with said she was putting in a request to have it faxed to my insurance and that would take two to three weeks. And I said, hold on, it takes you two to three weeks to fax a document?

Dan: Answer: Apparently yes? And Caitlyn says even three weeks later, her insurance company still hadn’t gotten that itemized bill the hospital promised to fax. 

And all this time Caitlyn was still getting notices from the hospital billing department. And the latest one said, “past due.” She tried something new: So she called the hospital and demanded they send the itemized bill directly to her, immediately. Which they did. 

Caitlyn: So I turned around and faxed it to my insurance. 

Dan: Yeah but, this did not end things, not yet. Caitlyn says she got more notices labeled past due. She fought her way to a direct conversation with a supervisor. 

Caitlyn: They kept saying,‘well, a supervisor’s not available right now.’ I said, No, you’re finding a supervisor. I don’t care if they’re cutting their lunch short. I’m talking to a supervisor right now. I don’t care if I sound like a Karen. It’s been a long, long year already. 

Dan: Eventually, Caitlyn got a supervisor on the line and got the supervisor to get permission from a manager to stop sending her bills while the hospital waited for insurance to pay. 

By this time, it was late March, almost two months after that first bill gave Caitlyn that panic attack. Also by this time, Caitlyn had sent her bill to the folks at NPR and KFF Health News for that Bill of the Month feature they do. 

Caitlyn: I was like, I just need to vent. And so I submitted it just to vent it out. Never expecting anyone to reach out. 

Dan: But they did. And on April 9th, Caitlyn got a call from a regional Patient Service Center manager. 

Caitlyn: And she was super nice and tried to be really apologetic, but never actually accepting any blame. Or outright saying,‘we’re so sorry.’ Just said, ‘I’m sorry for your frustration, that sounds awful.’ 

Dan: She DID tell Caitlyn that the hospital had received payment from her insurance. And that Caitlyn could expect a final bill within a week. And that instead of a hundred thirty nine thousand, it was gonna be one thousand, nine hundred eighty-two dollars and twenty-five cents. 

Caitlyn: I said,‘yep, that actually matches what my insurance said,’ and she said,‘oh, you know what was left on your out-of-pocket, most people don’t,’ and I said,‘I’m very well versed in every dollar sign at this point in this entire case.’ 

Dan: Caitlyn says she got that bill four days later and paid it immediately. 

Caitlyn: And I saved the receipt of that, I have saved everything. It feels like it’s resolved, but there’s part of me that’s still waiting for the other shoe to drop 

Dan: So, Caitlyn’s story brings up a LOT. Of course, I loved the way she kept fighting, and ultimately took control of the situation. And I hated how she got trapped between these two big entities and how much time and stress the whole thing cost her. 

Because, you know, the hospital could’ve resolved this so quickly by just sending that itemized bill to Caitlyn’s insurance company. 

Caitlyn: And the hospital did not do that. They just turned around and billed me. Which was a stupid idea, since the insurance company is more likely to have the money. Not the legal assistant in Oklahoma. 

Dan: Caitlyn’s story raised a few questions, and brought back a lot of themes we’ve touched on before. We dug in also found some new tips, and some memories I want to share. That’s coming right up. 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News, a nonprofit newsroom covering healthcare in America. Their senior contributing editor, Elisabeth Rosenthal, reported Caitlyn’s story for KFF and NPR. She wrote a book about U.S. healthcare. It’s called “An American Sickness,” and it was an inspiration for this show. 

One question we ask sometimes on this show when we see a bill that’s so wildly ridiculous and unfair is: Can they freaking DO that?!? Like, is that even legal?

Like in this instance, can they just keep billing you while they’re apparently not even playing ball with your insurance? And: Do we have any legal weapons to fight back with? 

We asked a bunch of legal experts, and they pretty much all said: Yes, they probably can do that, and no, we probably don’t have any easy legal weapons we can fight with. But then I talked with Berneta Haynes. She’s a senior attorney with the National Consumer Law Center. 

And she had some practical thoughts that are super-worth sharing. She used to work for a nonprofit called Georgia Watch — that’s a state-level consumer protection group. They operated a hotline people could call for help. 

Berneta Haynes: Consumers and patients would call us with all kinds of hospital billing issues and medical debt issues. And we’ve had these kinds of weird questions where really, there wasn’t a particular lever at the legal level to actually help them. But if they feel like they’re experiencing what could be considered potentially an unfair business practice, it is totally within their right to file a complaint within their state A. G.’s office. 

Dan: The A.G. The state attorney general. Whoever’s doing you wrong, you can file a complaint. 

Berneta: Whether or not there’s any real hook that your AG could use to hold them accountable is always a question that’s up in the air. But even just the act of filing a complaint is very likely to get that entity, that company, to behave correctly. 

Dan: Basically, go up the chain. Whether to a government watchdog, or in the organization that’s bugging you. We’ve heard this before, but I loved the specifics that Berneta Haynes shared with me about her own experiences. 

Berneta: I will tell you, one of the mechanisms my husband and I have had to utilize repeatedly, not in a hospital context, but in various other service contexts is to reach out or threaten to reach out to the CEO or president. And it gets results every time. It gets results every time! 

Dan: Oh, and here’s the pro tip.

Berneta: My husband has repeatedly, when he’s had to do it, set up a LinkedIn premium account just to find the CEO and message them directly. 

Dan: Ooh, that’s good! 

Berneta: That has been the way we’ve gotten resolution on all kinds of issues related to insurance companies not wanting to do right by us. And so forth. 

Dan: So that was fun. Now, I do want to talk a little bit about what Caitlyn did, and what allowed her to do it. Caitlyn figures she made at least a dozen phone calls. And she says she’s lucky — privileged — to have a job where she could do that. Here’s the first thing she says she did once she got over that panic attack when the bill arrived. 

Caitlyn: I just went to my boss’s office and I said, I’m going to have to make some phone calls. There’s a problem with my hospital bill. She’s like, don’t worry about it. Do what you need to. 

Dan: And she had people in her corner, like the friend who’s a healthcare lawyer. And legal advice wasn’t the big thing that friend gave Caitlyn. 

Caitlyn: Most of the time I was just venting to her, and she was like,‘you need to keep pushing, like, keep going at them. Don’t let them win. Don’t roll over. Just keep pushing. They should be paying.’ 

Dan: And at that point, I told Caitlyn, she and her story were really reminding me of someone. 

Dan: There’s a reporter named Marshall Allen. He worked for ProPublica for a long time. He wrote on healthcare, and he wrote on stuff like this. And eventually he wrote a book, giving advice to people. And the title of the book was, Never Pay the First Bill. 

Caitlyn: Oh! 

Dan: And I told Caitlyn, Marshall was on my mind at the time because when Caitlyn and I talked in May, Marshall had just died, like less than two weeks before. And he was young — 52. He had three kids.

Caitlyn: So sad. 

Dan: Super, super, super sad. 

Dan: And of course the title of Marshall’s book — Never Pay the First Bill — that’s exactly how Caitlyn played things. She wasn’t going to think about paying anything until she got her questions answered. And it is worth remembering. 

When we were talking with legal experts, one thing a few of them said was: If you pay something that insurance was supposed to cover, and then insurance comes through, you’re supposed to get a refund. But who wants to chase that? 

Yeah. Don’t pay that first bill until you’ve made sure this is money you really owe. So, this seems like a good time to memorialize Marshall Allen a little bit. He liked to compare the healthcare system to a schoolyard bully. Here’s what he told me when he was on this show in 2021 when his book had just come out. 

Marshall Allen: What I think we need to do is stand up to the bully. We need to stop being afraid. We need to stop thinking someone else is going to stick up for us. And I wrote the book to equip and empower people to stand up to the bullies. 

And I think it’s tremendously empowering, but it’s hard, and standing up to a bully takes incredible courage. It takes fortitude. It takes persistence. You might get beat up in the process. There’s no guarantee of victory. It’s risky, right? But if we don’t try, we don’t have a chance. 

Dan: Marshall was a Christian minister before he became a reporter. He wrote a thoughtful essay about how his work as an investigative reporter fit with his faith. The gist was: The Bible is pretty clear that cheating people and exploiting them is wrong. 

And to me, it seems like there was an element of ministry– not just evangelism — to what he did after his book came out. Here’s what he told me in 2021: 

Marshall: I’ve started taking calls, and I’m responding to emails that I get from people and I’m saying,‘call me, let’s talk it through, let me help you with this. Let’s work through this together.’ And now I’m helping people work through their bills, work through these situations where they’re being cheated. It’s super satisfying and gratifying, so it’s my new hobby. 

Dan: He kept at it. He left ProPublica and took a job with the Office of the Inspector General at the federal department of Health and Human Services. And he published a newsletter — it was free, but he encouraged people to pay if they could, and he used the money to hire medical-bill advocates to help people with especially tricky cases. 

And Marshall was funny. I want to close out this episode with a story he told me the first time we talked, in 2019. It’s kind of an origin story. 

Marshall: So when I was 16 years old, um, I worked for this dinner theater in Golden, Colorado, where I grew up. One day I show up for work, and they’ve closed down the business. They owed me like three weeks of pay. 

The guy had closed the place without paying us and said,‘there’s no money. We shut down the business. We can’t afford to pay you. You’re out of luck.’ Well, we were all pretty angry about that. We were really angry because they had opened a sister dinner theater under the same company umbrella across town. And we all knew that. And we were like, well, if you can afford to keep your other place open, you can afford to pay us. And they said,‘sorry, kids, you’re out of luck.’ 

Dan: Marshall goes home, tells his mom what’s going on. 

Marshall: And my mom tells me you should sue him. I’m like, mom, what do you mean? I can barely drive. How can I sue the guy? She goes,‘you should take him to small claims court.’ So lo and behold, I go down, I fill out the paperwork. 

It’s a few paragraphs. It’s easy to fill out the paperwork in small claims court. I fill out the paperwork and turn in like 10 bucks at the time or whatever it costs. It’s not that expensive to file one of these cases. And I get a notice in the mail like six weeks later. And I have a court date, and I’m like geared up for this big Perry Mason moment. 

Dan: Perry Mason was a lawyer on this super old TV show — courtroom drama. But this wasn’t a courtroom.

Marshall: It’s more like a conference room and there’s some administrative hearing judge in there. And lo and behold, the owner of the company and his attorney had to show up in court there with me. 

And I thought we’d have a big argument all the administrative judge did is he read my few paragraphs on the little thing I’d written up and he looks over at the owner and he goes,‘is what this kid saying true?’And the owner’s like, ‘well, yeah.’ And the judge is like,‘give this kid his money.’ And I was like, This is amazing. You know what? Maybe the court system does actually work every now and then maybe every now and then the little guy can win. 

Dan: Marshall and I both stayed interested in how people can use the legal system to get our rights. I learned a lot from Marshall, and like a lot of people, I just loved his spirit. Marshall Allen, thank you. And here’s the end of my conversation with Caitlyn. 

Dan: Marshall Allen would have been extremely proud of you. 

Caitlyn: Yeah. 

Dan: Caitlyn has the final word here. 

Caitlyn: I got to the point where I was like, it’s my fight. I’ve got gasoline in the fire. I’m, I’m going for it. 

Dan: We’ll be back with a new episode in a few weeks. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport — and edited by Ellen Weiss. 

KFF senior contributing editor Elisabeth Rosenthal reported Caitlyn’s story for KFF and NPR. She was editor in chief there when she invited me to collaborate with KFF to make this show’s second season, and we’ve been colleagues ever since. I’ve never felt so lucky or so thankful. 

Special thanks to Christopher Robertson at Boston University’s School of Law, Wendy Epstein of the College of Law at DePaul University, Sabrina Corlette at Georgetown University’s Center on Health Insurance Reforms, and Elisabeth Benjamin from the Community Service Society of New York for pitching in with legal expertise here. 

Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Bea Bosco is our consulting director of operations. Sarah Ballama 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 healthcare 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 editorial liaison to this show. 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 https://armandalegshow.com/support/. Thank you so much for pitching in if you can — and, thanks for listening.

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

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. 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.

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Former President Donald Trump and Vice President Kamala Harris have a rare point of agreement in their otherwise bitter and divisive contest: It’s up to the government to cut high U.S. drug prices.

Harris cast the tie-breaking Senate vote in 2022 for legislation that allows Medicare to negotiate drug prices for its more than 60 million beneficiaries. Before that, she was an aggressive regulator of the drug industry as California attorney general.

As president, Trump would likely retain Medicare price negotiations unless the pharmaceutical industry can come up with something more compelling that they’d put on the table, people close to him say. In his first term, he proposed various policies aimed at reducing prescription costs but had limited success with their implementation.

The drug industry could benefit, though, if Trump remains unable to advance such proposals.

“His efforts were largely fragmented and faced resistance from both the industry and lawmakers,” said Sergio Jose Gutierrez, a political strategist who has primarily worked with Democrats in the U.S. “The lack of a cohesive strategy and the limited ability to implement significant changes made his approach less effective compared to what a Harris-Walz administration could offer.”

The industry is increasingly under attack by lawmakers from both parties for drug prices most Americans regard as unreasonable, according to KFF polling, so the election outcome could be pivotal to drug companies’ fortunes. Their predicament is a sharp reversal from years past, when the firms enjoyed a reputation as being almost untouchable. For more than a decade, manufacturers successfully fended off proposals to let Medicare negotiate lower drug prices before losing the battle two years ago.

The shift in their political standing shows up in pharmaceutical companies’ contributions to candidates. An industry that gave three or four times as much to GOP candidates as to Democrats in the 1990s and early 2000s is now hedging its bets. So far in the 2024 cycle, drug companies have given $4.89 million to Democrats and $4.35 million to Republicans, according to OpenSecrets, a nonpartisan research group.

Harris has received $518,571 from the industry and Trump has received $204,748.

At the Democratic National Convention in Chicago last week, Harris and fellow Democrats touted their records on curbing drug prices. Harris supporters point to her past and present.

While she was California’s attorney general, she joined cases that resulted in nearly $7.2 billion (about $22 per person in the U.S.) in fines for drug companies.

Her vote to pass President Joe Biden’s Inflation Reduction Act paved the way not only for Medicare price negotiation but also an annual $2,000 cap on Medicare beneficiaries’ total drug spending and a $35 cap on their monthly insulin supplies.

“In the United States of America, no senior should have to choose between either filling their prescription or paying their rent,” Harris said Aug. 15 in her first joint appearance with Biden since he exited the presidential race.

She has promised to extend both the annual drug spending cap and the insulin price cap to all Americans with insurance, not just those on Medicare, if elected president.

Harris also backed a contentious policy that, in some instances, would empower the federal government to inject more competition into the marketplace by seizing the patents on some high-cost drugs developed with federal funds.

Doug Hart, 77, of Tempe, Arizona, has been spending about $7,000 annually on prescription drugs. A drug he takes to prevent blood clots will cost less under the Medicare price negotiations. The retired labor union president said the decrease will be considerable and it is one reason he backs Harris.

“The Republicans all voted against Medicare negotiation. Harris broke the tie in the Senate to allow it,” said Hart, who is a board member for the Arizona Alliance for Retired Americans, which works to mobilize returned union members and activists on progressive issues.

While Republicans as a party remain more friendly to the pharmaceutical industry, Trump has been willing to challenge GOP orthodoxy by taking action to combat high drug costs.

He sought during his administration to tie drug prices in Medicare to lower international prices, a proposal that the PricewaterhouseCoopers health research institute estimated would cost five drugmakers as much as $500 million a year. What was known as the “most favored nation” interim final rule was blocked because of legal challenges and later rescinded by the Biden administration.

Trump issued a rule setting up a path to import drugs from Canada and other countries, with Florida this year becoming the first state to get federal approval to import some prescriptions from Canada. But the state has been stymied by pushback from Health Canada, the Canadian government department responsible for national health policy.

And on his campaign website, Trump posted a video in which he questioned whether childhood health problems are the result of “overprescription” of medications.

“Too often, our public health establishment is too close to Big Pharma — they make a lot of money, Big Pharma — big corporations, and other special interests, and does not want to ask the tough questions about what is happening to our children’s health,” he said. “If Big Pharma defrauds American patients and taxpayers or puts profits above people, they must be investigated and held accountable.”

Trump hasn’t said much about drug prices in his 2024 campaign, but allies and former advisers say he remains committed to knocking down prescription prices if reelected.

He would likely focus on increasing generic and biosimilar competition, importing drugs made in the U.S. but sold overseas back to the U.S., and capping out-of-pocket insulin costs, according to former Trump administration officials. Other goals may be lowering prices for drugs in the Medicare 340B program, which requires drugmakers to provide outpatient drugs at reduced prices to eligible health organizations that serve lower-income and uninsured patients.

“The No. 1 issue he cared about while I was in the White House, and I continue to hear him talk about, is lowering drug prices,” said Theo Merkel, a senior research fellow at conservative think tanks Paragon Health Institute and the Manhattan Institute. Merkel was also a special assistant in the Trump White House. “I’m confident that will be at the top of the agenda,” he added.

Catherine Hill, a spokesperson for Pharmaceutical Research and Manufacturers of America, or PhRMA, said the industry trade group looks forward to collaborating with any future presidential administration.

She criticized the Biden administration’s plan for Medicare price negotiation as well as Trump’s plan to align U.S. prices with those in foreign countries. This month, the administration announced new, reduced prices for 10 drugs in the program following negotiations between the federal government and drugmakers. The lower costs take effect in 2026.

“Previous price controls adopted by the Biden administration threaten to stifle that innovation,” Hill said. “Undermining intellectual property protections and borrowing other countries’ price controls will further undercut innovation and threaten patients’ access to medicine.”

A hard-won provision of the Affordable Care Act allows young adults to stay on their family’s health insurance until age 26. But after that, those without employer-sponsored insurance face an array of complicated choices, including whether to shop on the insurance plan exchange, apply for Medicaid, or roll the dice and go uninsured.

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Federal regulators have blocked two private sector enrollment websites from accessing consumer information through the federal Obamacare marketplace, citing “anomalous activity.”

The unusual step comes as the Centers for Medicare & Medicaid Services is under the gun to curb unauthorized enrollment and switching of Affordable Care Act plans by rogue agents. The agency received more than 200,000 complaints in the first six months of the year about such actions.

CMS said in a written statement that it had suspended the two sites — Benefitalign and Inshura — “while the anomalous activity is researched to ensure the EDE partners are in compliance with CMS data standards.” EDE stands for “enhanced direct enrollment” and refers to websites approved to integrate with healthcare.gov.

In a separate development, the two websites, which insurance brokers use instead of the federal healthcare.gov site to enroll clients in Affordable Care Act plans, are mentioned in an ongoing civil lawsuit filed by attorneys representing consumers and agents who claim they’ve been harmed by enrollment schemes.

CMS posted on Aug. 9 an updated list of websites approved to integrate with the federal Obamacare marketplace that no longer included Benefitalign and Inshura. As a result, insurance agents can’t use the websites to enroll customers in or make changes to their Obamacare plans.

Private sector enrollment sites were first allowed to integrate with healthcare.gov data under the Trump administration. About a dozen such sites are now approved to connect with the federal system.

Thwarting enrollment schemes and rogue insurance agents without making it too difficult for consumers and legitimate agents to enroll in health plans has become a political problem for the Biden administration. President Joe Biden has claimed record-breaking enrollment under the ACA as one of his administration’s major accomplishments.

In recent weeks, lawmakers have called on CMS to do more and introduced legislation to increase penalties for agents who enroll people in plans without authorization. The large number of complaints from victims of the schemes have caught the attention of House Republicans, who on June 28 requested investigations by the Government Accountability Office and the Office of Inspector General at the Department of Health and Human Services.

KFF Health News began reporting on ACA enrollment schemes early this year.

CMS has since taken actions to short-circuit unscrupulous agents and call centers.

Until last month, agents using the approved private sector enrollment sites could access consumer information via healthcare.gov with only a name, birth date, and state of residence. CMS now requires three-way calls among agents, consumers, and the healthcare.gov helpline when agents new to a policy try to make a change. Many legitimate insurance agents are urging an additional fix used widely by state Obamacare enrollment systems: requiring two-factor authentication before consumer information can be accessed or changed by agents.

Meanwhile, the move to suspend the two enrollment websites baffled the companies, said Catherine Riedel, a spokesperson for TrueCoverage, an insurance call center that also does business as Inshura. TrueCoverage and Benefitalign are subsidiaries of Speridian Global Holdings of California.

“We don’t know what they want us to do differently,” she said.

The websites, she said, are cooperating with CMS, and they conducted an internal review that found no security issues. Very few details, other than “it is related to a potential technical anomaly reported by an outside party” were given, Riedel wrote, and the firms have not been provided “any specific, actionable information related to the alleged anomaly.”

Both firms are mentioned in the lawsuit first filed in April in the U.S. District Court for the Southern District of Florida. The suit alleges that people and organizations engaged in misleading advertising, or made changes to ACA policies, without the express permission of consumers — all with a goal of racking up commissions.

Late on Aug. 16, that case was amended to add allegations and defendants, including Benefitalign. The other enrollment website, Inshura, is not listed as a defendant, although it is run by TrueCoverage, which is.

Riedel said TrueCoverage disputes the lawsuit’s claims.

The case “is founded on misinformation and technical naivety that seems to have been connected to create a sensational and false narrative,” she said.

The Aug. 16 filing alleges that TrueCoverage or Speridian Technologies, another subsidiary of Speridian Global Holdings, used the Benefitalign or Inshura websites to access U.S. consumers’ personal information, then sent it to marketers in India and Pakistan. The allegation, if true, would violate agreements the private sector websites made with the federal government to gain approval to operate, the suit contends.

Riedel said there is no evidence to support the allegations and that it is technically impossible to move “bulk amounts of consumer data” from the Obamacare marketplace.

“Like many technology companies, some of TrueCoverage’s marketing efforts have been based in India. However, as part of that marketing work, TrueCoverage did not move any customer data out of the EDE platform,” she said.

The 185-page amended complaint added as a defendant Bain Capital Insurance Fund, part of one of the world’s leading private investment companies, saying it “aided and abetted” Florida-based Enhance Health, which describes itself as a large broker of ACA plans. Bain helped launch Enhance with a $150 million investment in 2021 and appointed its CEO.

After initially planning to market Medicare Advantage plans, the lawsuit says, Enhance Health and Bain decided to shift to ACA plans, which were seen as more profitable. The suit alleges Enhance Health participated in unauthorized agent changes or switching of ACA policies.

Bain knew “what was going on” at Enhance “and ultimately supported it,” the lawsuit says, noting that Bain executives sat on Enhance’s board, controlled the hiring of executives, and were often at its Sunrise, Florida, offices. The firm hoped to sell the company once it showed how profitable it could be, the suit alleges.

In a written statement, Enhance Health said that “upholding the highest standards of compliance and controls is a core focus in all aspects of our operation and we will vigorously defend against these baseless claims.”

Bain Capital Insurance did not reply to a request for comment.

The additional allegations expand on the initial April filing, which outlined a complex web of activities aimed at capitalizing changes to the ACA under Biden that resulted in broader availability of zero-premium plans for lower-income applicants. In some cases, consumers were lured to call centers through misleading ads touting nonexistent cash cards. Some call centers or agents filed duplicate coverage for the same individuals, without consumer permission, or split family members among multiple policies, the suit alleges.

Because the customers don’t pay monthly premiums for the plans, they may not notice they’ve been enrolled until they try to obtain care.

Some consumers whose plans were switched lost access to their doctors or medications. Some face tax consequences if they were enrolled in duplicative coverage or in subsidized plans for which they did not qualify.

One victim added to the case, Paula Langley of Texas, initially responded to an advertisement promising a cash card. She called the number advertised and was enrolled in ACA coverage in February 2023 but never received the promised incentive, according to the lawsuit.

She and her husband began receiving multiple insurance cards from different insurers, the suit says. She would show up for a doctor’s visit or to pick up a prescription only to find her coverage had been canceled, leaving her with unpaid medical bills.

All in all, she was switched among plans and agents at least 22 times in just over a year, the lawsuit alleges.

Attorneys Jason Kellogg of Miami and Jason Doss of Atlanta said they amended the lawsuit based on dozens of interviews with former employees of the named firms. They’re seeking class-action status on behalf of affected consumers and agents who have lost business to the unauthorized plan-switching, and the suit alleges violations of the federal Racketeer Influenced and Corrupt Organizations — or RICO — Act.

“The scheme is bad enough because it’s so large,” Kellogg said. “But it’s much worse given that it preys upon Americans who are at the lowest levels of the income scale, who may be desperate, are most vulnerable.”

Jamie Holmes says a surgery center tried to make her pay for two operations after she underwent only one. She refused to buckle, even after a collection agency sued her last winter.

Holmes, who lives in northwestern Washington state, had surgery in 2019 to have her fallopian tubes tied, a permanent birth-control procedure that her insurance company agreed ahead of time to cover.

During the operation, while Holmes was under anesthesia, the surgeon noticed early signs of endometriosis, a common condition in which fibrous scar tissue grows around the uterus, Holmes said. She said the surgeon later told her he spent about 15 minutes cauterizing the troublesome tissue as a precaution. She recalls him saying he finished the whole operation within the 60 minutes that had been allotted for the tubal ligation procedure alone.

She said the doctor assured her the extra treatment for endometriosis would cost her little, if anything.

Then the bill came.

The Patient: Jamie Holmes, 38, of Lynden, Washington, who was insured by Premera Blue Cross at the time.

Medical Services: A tubal ligation operation, plus treatment of endometriosis found during the surgery.

Service Provider: Pacific Rim Outpatient Surgery Center of Bellingham, Washington, which has since been purchased, closed, and reopened under a new name.

Total Bill: $9,620. Insurance paid $1,262 to the in-network center. After adjusting for prices allowed under the insurer’s contract, the center billed Holmes $2,605. A collection agency later acquired the debt and sued her for $3,792.19, including interest and fees.

What Gives: The surgery center, which provided the facility and support staff for her operation, sent a bill suggesting that Holmes underwent two separate operations, one to have her tubes tied and one to treat endometriosis. It charged $4,810 for each.

Holmes said there were no such problems with the separate bills from the surgeon and anesthesiologist, which the insurer paid.

Holmes figured someone in the center’s billing department mistakenly thought she’d been on the operating table twice. She said she tried to explain it to the staff, to no avail.

She said it was as if she ordered a meal at a fast-food restaurant, was given extra fries, and then was charged for two whole meals. “I didn’t get the extra burger and drink and a toy,” she joked.

Her insurer, Premera Blue Cross, declined to pay for two operations, she said. The surgery center billed Holmes for much of the difference. She refused to pay.

Holmes said she understands the surgery center could have incurred additional costs for the approximately 15 minutes the surgeon spent cauterizing the spots of endometriosis. About $500 would have seemed like a fair charge to her. “I’m not opposed to paying for that,” she said. “I am opposed to paying for a whole bunch of things I didn’t receive.”

The physician-owned surgery center was later purchased and closed by PeaceHealth, a regional health system. But the debt was turned over to a collection agency, SB&C, which filed suit against Holmes in December 2023, seeking $3,792.19, including interest and fees.

The collection agency asked a judge to grant summary judgment, which could have allowed the company to garnish wages from Holmes’ job as a graphic artist and marketing specialist for real estate agents.

Holmes said she filed a written response, then showed up on Zoom and at the courthouse for two hearings, during which she explained her side, without bringing a lawyer. The judge ruled in February that the collection agency was not entitled to summary judgment, because the facts of the case were in dispute.

Representatives of the collection agency and the defunct surgery center declined to comment for this article.

Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms, said it was absurd for the surgery center to bill for two operations and then refuse to back down when the situation was explained. “It’s like a Kafka novel,” she said.

Corlette said surgery center staffers should be accustomed to such scenarios. “It is quite common, I would think, for a surgeon to look inside somebody and say, ‘Oh, there’s this other thing going on. I’m going to deal with it while I’ve got the patient on the operating table.’”

It wouldn’t have made medical or financial sense for the surgeon to make Holmes undergo a separate operation for the secondary issue, she said.

Corlette said that if the surgery center was still in business, she would advise the patient to file a complaint with state regulators.

The Resolution: So far, the collection agency has not pressed ahead with its lawsuit by seeking a trial after the judge’s ruling. Holmes said that if the agency continues to sue her over the debt, she might hire a lawyer and sue them back, seeking damages and attorney fees.

She could have arranged to pay off the amount in installments. But she’s standing on principle, she said.

“I just got stonewalled so badly. They treated me like an idiot,” she said. “If they’re going to be petty to me, I’m willing to be petty right back.”

The Takeaway: Don’t be afraid to fight a bogus medical bill, even if the dispute goes to court.

Debt collectors often seek summary judgment, which allows them to garnish wages or take other measures to seize money without going to the trouble of proving in a trial that they are entitled to payments. If the consumers being sued don’t show up to tell their side in court hearings, judges often grant summary judgment to the debt collectors.

However, if the facts of a case are in dispute — for example, because the defendant shows up and argues she owes for just one surgery, not two — the judge may deny summary judgment and send the case to trial. That forces the debt collector to choose: spend more time and money pursuing the debt or drop it.

“You know what? It pays to be stubborn in situations like this,” said Berneta Haynes, a senior attorney for the National Consumer Law Center who reviewed Holmes’ bill for KFF Health News.

Many people don’t go to such hearings, sometimes because they didn’t get enough notice, don’t read English, or don’t have time, she said.

“I think a lot of folks just cave” after they’re sued, Haynes said.

Emily Siner reported the audio story.

After six years, we’ll have a final installment with NPR of our Bill of the Month project in the fall. But Bill of the Month will continue at KFF Health News and elsewhere. We still want to hear about your confusing or outrageous medical bills. Visit Bill of the Month to share your story.

“Vice President Kamala Harris cast the tie-breaking vote to cut, as you know, Medicare by $273 billion. She cast a vote to cut Medicare.” 

— Former President Donald Trump at a July 24 campaign rally in Charlotte, North Carolina.

During a July 24 campaign rally in Charlotte, North Carolina, former President Donald Trump claimed that Vice President Kamala Harris was responsible for passing legislation in the U.S. Senate to cut Medicare spending by nearly $300 billion.

“As Vice President, Kamala Harris cast the tie-breaking vote to cut, as you know, Medicare by $273 billion,” Trump told rally attendees. “She cast a vote to cut Medicare.”

Trump gave no further explanation for which vote he was referring to or how he arrived at that figure. A campaign spokesperson told KFF Health News in an email that Trump was referring to a statistic from a Wall Street Journal op-ed by Tomas Philipson, a University of Chicago economist and a former Trump administration official.

Philipson’s op-ed argued that the Inflation Reduction Act — a sweeping climate and health care measure passed in 2022 for which Harris cast the tie-breaking vote — would harm Medicare patients by driving up costs. His article cited a Congressional Budget Office analysis showing that the measure’s health care provisions would reduce the federal deficit by $237 billion over 10 years. “(M)ost of that reduction comes from the program spending less on prescription drugs,” Philipson wrote.

But the government’s spending less on Medicare programs would not amount to the kind of “cut” to Medicare benefits Trump implied, experts told KFF Health News. Several provisions in the law pertaining to prescription drug pricing are widely seen by health policy experts as beneficial to both consumers and the government. Individual patients are expected to spend less out-of-pocket on their prescription drugs, while the government will reduce Medicare spending without any impact to services offered.

We dug into the facts surrounding Trump’s claim and the law’s effect on Medicare. It resurfaces a long-running debate over Medicare savings versus cuts and the question of whether lowered spending automatically leads to a reduction in benefits for Medicare enrollees.

Following the Numbers

The Inflation Reduction Act’s many provisions include some intended to lower prescription drug costs for older Americans and others receiving Medicare insurance coverage. 

The law caps the cost of insulin at $35 per month for most Medicare beneficiaries, establishes out-of-pocket spending limits for Part D drug coverage, and institutes penalties for drug companies that raise prices faster than the inflation rate. The law also authorizes Medicare officials, for the first time, to negotiate drug pricing directly with pharmaceutical manufacturers. 

“The idea behind drug price negotiation is that Medicare can use its buying power to get a better price than what is currently being negotiated for these drugs,” said Juliette Cubanski, deputy director of the program on Medicare policy at KFF, a health information nonprofit that includes KFF Health News.

According to an analysis by the Congressional Budget Office, the nonpartisan federal agency that calculates the financial impact of new legislation, the Inflation Reduction Act’s health care measures will have a mixed effect on spending. Some steps, such as the cap on beneficiaries’ out-of-pocket prescription drug spending, will likely cost the government more. But others, including the drug price negotiations, are projected to save the government money. All told, the Inflation Reduction Act’s health care measures are expected to save taxpayers $237 billion over 10 years.

On the numbers, Trump said the law would “cut Medicare” by $273 billion; he likely meant $237 billion.

Despite the government being expected to spend less overall, beneficiaries’ services would not necessarily be cut, as Trump claimed. In fact, most Medicare recipients would likely see their costs decrease, too, while keeping the same level of benefits.

“There are big shifts in who’s paying for what,” said Andrew Mulcahy, a senior health economist who researches prescription drug markets at the Rand Corp., a nonpartisan think tank. “But that doesn’t mean they’re getting any less. If anything, they’ll have better access to drugs.”

Cubanski, echoing Mulcahy, said: “When you’re reducing Medicare spending, that’s not the same thing as a cut to Medicare or cutting Medicare benefits. If you buy eggs every week and now you’re getting them cheaper, you’re still getting the eggs, you’re just getting them for a lower price.”

A year ago, the Centers for Medicare & Medicaid Services named the first 10 drugs on which it will focus, though the exact savings from the drug pricing negotiations process will be known only when the government and drug manufacturers reach agreements. The new pricing for this first batch of medications is set to take effect in 2026.

Whether the government can negotiate meaningfully lower costs versus current prices is unclear, especially since pharmacy benefit managers, or PBMs — middlemen in the negotiations among drug companies, insurers and pharmacies — are tasked with doing that.

“I think for many of the drugs selected in the first year, my expectation is that the government won’t be able to do much better than the PBMs,” Mulcahy told KFF Health News. 

The Medicare drug pricing program could have negative side effects. Philipson, for example, argued in his op-ed that the negotiations will “deter companies from developing new medicines” and threaten older Americans’ access to doctors, as manufacturers and hospitals would likely be reimbursed less for their drugs and services.

Cubanski brushed off such concerns.

“The drug industry certainly has a vested interest, you know, in raising alarm bells,” she said. “I think it’s just still too early to talk about ‘the sky is falling’ with regard to pharmaceutical innovation. Time will tell, but it certainly is the case right now that the law includes a lot of provisions that will be very helpful for Medicare beneficiaries.”

On Aug. 15, CMS announced the results of its negotiation over the first round of drugs. The new prices represent discounts ranging from 38% to 79% of the original costs. White House officials said the negotiations will lead to $6 billion in savings for Medicare the first year, while Medicare recipients are expected to save an additional $1.5 billion in out-of-pocket costs.

Our Ruling

Trump’s statement is wrong both on the hard numbers and his interpretation of what they mean.

The analysis Trump cited, per his campaign, said the Inflation Reduction Act’s health care provisions would lower the deficit by $237 billion — not $273 billion, as the former president claimed. Moreover, whatever the exact number is, multiple experts pushed back against the notion that the savings equated to a “cut” to Medicare, as Trump claimed.

We rate Trump’s claim False.

Our Sources

Centers for Medicare & Medicaid Services, Fact Sheet: Medicare Drug Price Negotiation Program Revised Guidance, June 2023.

Centers for Medicare & Medicaid Services, Medicare Drug Price Negotiation.

Program: Selected Drugs for Initial Price Applicability Year 2026, August 2023.

The Wall Street Journal, “This Is How President Biden ‘Beat Medicare,’” July 9, 2024.

Congressional Budget Office, Estimated Budgetary Effects of Public Law 117-169, to Provide for Reconciliation Pursuant to Title II of S. Con. Res. 14, Sept. 7, 2022.

Congressional Budget Office, How CBO Estimated the Budgetary Impact of Key Prescription Drug Provisions in the 2022 Reconciliation Act, February 2023.

C-SPAN, “Former President Trump Campaigns in Charlotte, North Carolina,” July 24, 2024.

Email exchange with Karoline Leavitt, national press secretary for Donald J. Trump for President, July 29, 2024.

KFF Health News, “Trump Is Wrong in Claiming Full Credit for Lowering Insulin Prices,” July 18, 2024.

Phone interview with Andrew Mulcahy, senior health economist at Rand Corp., July 26, 2024.

Phone interview with Juliette Cubanski, deputy director of the program on Medicare policy at KFF, July 29, 2024.

United States Senate, Roll Call Vote 117th Congress-2nd Session, Aug. 7, 2022.

Trisha Byers left behind one crucial item when she moved to North Carolina last year to be closer to her family after suffering a brain injury: health insurance.

In Massachusetts, Byers, 39, was enrolled in Medicaid, the government health program that covers low-income people. But she was ineligible in North Carolina, which had not yet expanded Medicaid coverage under the Affordable Care Act. She said she racked up thousands of dollars in unpaid emergency room bills while uninsured for several months after her move.

Then in December, North Carolina joined 39 other states and Washington, D.C., in widening Medicaid eligibility to include adults with incomes up to 138% of the federal poverty level, or $20,783 for an individual.

“I could finally get all the doctor appointments I needed,” said Byers, one of more than 500,000 North Carolinians who gained coverage.

The North Carolina expansion came amid the biggest upheaval in Medicaid’s nearly six-decade history. Since April 2023 — when protections that had blocked states from disenrolling Medicaid beneficiaries during the pandemic expired — states have disenrolled more than 24 million people whom they said no longer qualified or had failed to renew coverage.

This Medicaid “unwinding” led to fears that the number of people without insurance would spike. But it also coincided with moves in more than a dozen states to expand health coverage for lower-income people, including children, pregnant women, and the incarcerated.

These expansions will mitigate the effects of the unwinding to some degree, though it’s still unclear how much. Five states have not finished culling their rolls, and the effect on the uninsured rate won’t be clear until the U.S. Census Bureau releases official figures in September of next year.

“The pandemic was destructive and concerning and clearly demonstrated that Medicaid is so crucially important for our national safety net,” said Jennifer Babcock, senior vice president for Medicaid policy at the Association for Community Affiliated Plans, a trade group representing nonprofit health insurers that cover people on Medicaid. “These expansions are incredibly meaningful.”

Unwinding-era expansions include:

• South Dakota, like North Carolina, expanded Medicaid coverage under the Affordable Care Act last year. About 22,000 people enrolled in the first eight months.
• In July, Oregon launched a Medicaid-like coverage option for those who earn too much to qualify for Medicaid under federal limits. The plan is available to all adults with incomes between 138% and 200% — up to $30,120 for an individual — of the federal poverty level. More than 50,000 people have enrolled so far, Oregon officials say.
• In January, a new federal law required states to allow children to stay covered under Medicaid for at least a year after signing up. Several states are going beyond that: Oregon, New Mexico, and Washington, for example, allow children to stay covered up to age 6. California passed legislation to expand continuous eligibility for children up to age 4 but has not yet implemented the policy.
• Three states widened income eligibility for children to qualify for Medicaid: Arizona, Maine, and North Dakota.

• This year, Utah began offering a Medicaid-like coverage option for children regardless of immigration status, though the program is capped at about 2,000 children.
• Several states expanded coverage for pregnant women. Nevada, North Dakota, and Tennessee widened income eligibility to make it easier for pregnant women to qualify for Medicaid. Alabama and Maryland expanded eligibility to cover those who are pregnant regardless of immigration status. And Maine, Oregon, and Vermont extended postpartum coverage to 12 months, up from two. With those changes, 47 states now offer one year of postpartum coverage.
• In June, five states — Illinois, Kentucky, Oregon, Utah, and Vermont — received approval from the Biden administration to extend Medicaid coverage to incarcerated people up to 90 days before their release. Those states will join several states, including California, Massachusetts, Montana, and Washington, in offering that coverage.

States, which split funding of Medicaid with the federal government, typically expand Medicaid eligibility during times of economic growth when they have more revenue. But several other factors have contributed to the expansion trend. These include heightened awareness over rising maternal mortality rates and new restrictions on abortion, which have reinforced the need for expansions for pregnant women, said Allison Orris, a senior fellow with the left-leaning Center on Budget and Policy Priorities.

In particular, the pandemic showed how important health coverage is to ensure people’s health and communities’ safety from infectious diseases, Orris said. “It is not surprising to see states look at their Medicaid programs and find ways to strengthen in the midst of the unwinding,” she said.

For example, while federal Medicaid funding cannot be used for people living in the country unlawfully, a small but growing number of states have used their money to expand coverage to residents lacking legal status.

During the pandemic, as a requirement to gain extra federal funding, states were prohibited from cutting off Medicaid coverage even for those no longer eligible. The experience showed states the benefits of keeping people enrolled, rather than churning them in and out as their income fluctuates, Orris said. It also brought the nation’s uninsured rate to a record-low 7.7%.

Some advocates fear the unwinding of that pandemic-era policy will reverse key gains. A KFF survey published in April found 23% of adults reported being uninsured after they were disenrolled from Medicaid in 2023. A Centers for Disease Control and Prevention report released Aug. 6 found the uninsured rate rose to 8.2% in the first quarter of 2024, from 7.7% in the same quarter in 2023.

Enrollment increased by about 23 million people during the pandemic. As of Aug. 1, with about 85% of the unwinding completed, roughly 14.8 million people have been removed from Medicaid rolls. As a result, it’s unlikely the uninsured rate will rise as sharply as some advocates feared a year ago, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News.

“We have seen some amazing coverage expansion in places like Oregon and California,” said Ben Anderson, deputy senior director of health policy at Families USA, a consumer advocacy group. “But if you live in Texas, Florida, and Georgia, since the pandemic your health coverage has been disrupted in ways that were preventable by state leaders.” Those three states are among the 10 that have chosen not to expand Medicaid under the ACA.

Still, Anderson said, the effect of the expansions, even in a limited number of states, will ensure some people can better afford health care and avoid medical debt.

The unwinding process has been rife with fumbling, particularly in states that didn’t steer enough resources to connect people with coverage. A study by the federal Government Accountability Office released in July revealed a Centers for Medicare & Medicaid Services’ finding that almost all states made mistakes that led to eligible individuals losing Medicaid coverage.

The recent Medicaid expansions provide examples of how some states prioritize health coverage, particularly for certain vulnerable groups.

Tricia Brooks, a Medicaid expert at Georgetown University, noted that some states are “targeting little pockets of coverage and doing it for a variety of reasons.”

Getting and keeping children insured means they are more likely to have a regular health provider and be ready to learn in school, she said. “There is no doubt there is a return on investment,” she said.

Medicaid advocates wonder, though, whether a second Trump administration would curtail coverage expansions. Republicans have signaled they do not want to extend the federal subsidies that reduce what lower-income people pay for ACA marketplace plans and that are scheduled to expire in 2025.

“We are bracing for that potential impact,” said Erin Delaney, director of health care policy at the Progressive Policy Institute.

The Host

Julie Rovner
KFF Health News

@jrovner

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.

On September 2, 1974, President Gerald Ford signed into law the Employee Retirement Income Security Act, better known as ERISA. While the law was primarily intended to regulate and protect worker pensions, it also fundamentally changed how health insurance is provided and regulated in the United States. Fifty years on, ERISA plays a role in nearly every detail of health insurance and has had a profound impact on the entire health care sector.

To note this anniversary, in this week’s special episode of KFF Health News’ “What the Health?”, host and KFF Health News chief Washington correspondent Julie Rovner discusses the law’s past, present, and future with three experts on ERISA: Larry Levitt of KFF, a health information nonprofit that includes KFF Health News; Paul Fronstin of the Employee Benefit Research Institute, a nonprofit; and Ilyse Schuman of the American Benefits Council, a trade group advocating for employers that sponsor worker benefit plans.

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Transcript: Happy 50th, ERISA

KFF Health News’ ‘What the Health?’ Episode Title: ‘Happy 50th, ERISA’ Episode Number: 360Published: Thursday, Aug. 15, 2024

[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. Usually, I’m joined by some of the best and smartest health reporters in Washington, but today, we have a special episode for you. We’re taping this week on Monday, Aug. 12th, at 2 p.m. As always, news happens fast, and things might’ve changed by the time you hear this — although this time, I hope not. So here we go.

So if you follow health policy, you’re likely familiar with the big federal laws that have shaped how health care in the U.S. is organized and delivered and paid for. Medicare and Medicaid in 1965, HIPAA in 1996, and the Affordable Care Act in 2010, just to name a few.

One you may not have heard as much about is ERISA, the Employee Retirement Income Security Act, which was signed in 1974 by then-President Gerald Ford. This fall marks 50 years since ERISA became law. ERISA, as its name suggests, is mostly about protecting pension benefits for workers. It was inspired, at least in part, by the collapse of a pension fund when a plant that built Studebaker cars in Ohio shut down in 1963. But, at least as legend has it, at the very last minute in the House-Senate Conference in 1974, someone decided to add health benefits to ERISA’s scope, and that literally changed the entirety of how health benefits are regulated in the U.S.

I am pleased to have an all-star panel here to join us to talk about what ERISA has meant to health policy and what it’s likely to mean going forward as it begins its second half-century. Larry Levitt is executive vice president for policy here at KFF and one of only a few people in the organization even nerdier than I am about things like ERISA. Paul Fronstin is director of health benefits research at the Employee Benefit Research Institute, a nonpartisan think tank that does research and education. Paul has also taught me more about ERISA over the years than probably any other single person.

Finally, Ilyse Schuman is senior vice president of the American Benefits Council, which represents large employers and other providers of health and retirement benefits through employer-sponsored plans. Ilyse also spent several years on Capitol Hill working on the Senate committee that oversees ERISA policy. So, a lot of knowledge here in our podcast box. Thanks for all of you for being here.

Ilyse Schuman: Thank you

Larry Levitt: Great to be here.

Rovner: So let’s start at the beginning. How did health benefits wind up being covered in a law that was aimed at retiree pensions?

Paul Fronstin: None of us were here or there at the time, so I think anything we know is second- or third-hand information. And like you said, the provision was inserted at the last minute, but I think there were a lot of conversations about it leading up to it being inserted at the last minute. I think a lot of it had to do with some tensions between state regulation and federal regulation, because there were self-insured health plans in existence and self-insured benefits more generally in existence before ERISA passed.

And clearly those plans wanted some federal protection regarding what they were doing, and the states wanted more regulation. And I’ve read a little bit about this over the years, and there was certainly some lobbying for and against having a provision in there to protect self-insured plans from state regulation. So the conversations were happening. It just … the language probably just didn’t make it into the legislation till the last minute.

Schuman: And I think certainly the landscape back in 1974, as Paul talked about, was that more and more states were creating, with respect to health care, their own versions of various laws. And so self-funded plans, large employers like our members — a number of them were back in existence 50 years ago, some weren’t — were finding it increasingly difficult to be able to administer their self-funded plans on a uniform basis nationwide.

So it wasn’t in the backrooms when they were actually drafting the legislation, but certainly note that the nationwide landscape in this growing patchwork of state health laws was becoming increasingly problematical for self-funded health plans.

Levitt: Yeah. I mean, this was also a period when health insurance was changing quite dramatically. I mean, before this time health insurance was pretty simple. It was called indemnity insurance, right.

You went to the doctor, you went to the hospital, you got a claim, you filed it with your insurance company, and they paid 80% of it. This was a time when PPOs [preferred provider organizations] were starting, managed care, HMOs were really just getting their start. So there was a need for much more regulation because insurance was getting more complicated.

Fronstin: Yeah. To some degree, the HMO Act of, what, 1973, right, just the year before. So HMOs were just coming on the scene, and that may have played into this as well.

Rovner: So back in 1945, when really none of us were in the room, Congress passed something called the McCarran-Ferguson Act, which was supposed to ensure that states rather than the federal government retained the authority to regulate insurance. What happened in ERISA to change that? Ilyse, I think you were already sort of referring to this. And what do we mean when we talk about ERISA preemption? That’s a phrase that people hear a lot and their eyes glaze over.

Schuman: Sure. Well, their eyes may glaze over but it really is foundational to millions of Americans and their families that are covered by employers who decide that they want to self-fund their plans. That means that they’re the ones that decide that, “Hey, we’re going to take the risk as offering these benefits instead of the carrier.”

Rovner: So they’re not actually buying insurance because …

Schuman: That’s …

Rovner: … they’re paying the bills.

Schuman: They’re doing more than just paying the bill. They’re the ones that are ultimately assuming the risks of those claims, too. And I think the value. So maybe — just to step back before we talk about what a preemption is — is what we talk about employers who decide to self-fund versus those that don’t. Admittedly, many of those that self-fund are larger employers, but again, they say that “We will take the risk of paying for the claims of our health insurance coverage instead of the carrier. But along with that, we get the flexibility and we get the ability to design and implement health coverage that we think meets the needs of our population. That’s enabled us to” — speaking again from self-funded employers — “to implement innovative designs with the assurances that they could implement those, they could administer that on a uniform basis nationwide.” So that’s really what we’re talking about. Preemption is the ability of self-funded employers to administer those benefits on a uniform basis nationwide.

And yes, getting back to McCarran-Ferguson, and if you want to talk through the sort of various layers of ERISA preemption, is there’s something called the savings clause, which is OK. So ERISA says: “First threshold level, we are going to preempt state laws.” But there’s a savings provision that says basically: “If you’re in the business of insurance, states can regulate that.” But then there’s this deemer clause — this is really nerdy now, so some of your audience may be wondering here what we’re talking about …

Rovner: I remember learning this many, many years ago.

Schuman: No. Yeah. So if you’re in law school, take note that the deemer clause means that self-funded group health plan is deemed not to be in the business of insurance; meaning that they don’t have to comply with those state insurance laws.

Levitt: And here’s where this gets really tangible for people, right? So 150 million people have insurance coverage through an employer. It’s the biggest source of health coverage. But 65% of them are in self-insured plans, like Ilyse was talking about. And those self-insured plans are exempt from state regulation.

So if a state is regulating insurance, let’s say mandating benefits, mandating coverage of IVF, mandating coverage of preventive care, mastectomies, whatever — those regulations that states are putting in place do not apply to most people with employer-sponsored insurance because they are in these self-funded plans.

Rovner: And, of course, the continuing complications that a lot of people who are in these self-funded plans don’t know it because they have an insurance card and it says Blue Cross or Aetna or whatever, because, in their case, they have an insurance card, but the insurer is not providing insurance, right?

Levitt: No, it’s remarkable. We did a survey of consumers about their experiences with health insurance. And we asked them, “What government agency do you think you would turn to with a problem with your insurance?” And literally zero people said the Department of Labor, which is the government agency that actually enforces ERISA.

Rovner: But I guess what I was asking about are third-party administrators, which I think most people have never heard of until they discover that they’re not subject to their state’s requirement.

Levitt: Absolutely. I mean, it gets really confusing, right? Because it might be that UnitedHealthcare is administering this self-funded plan, but you, as an employee in this plan, have no way of really understanding is that a self-insured plan administered by UnitedHealthcare? Or is that an insurance plan administered by UnitedHealthcare? And then there are these third-party administrators that you’ve never even heard of that are administering them for many employers.

Rovner: Paul, you wanted to add something.

Fronstin: We need to distinguish between ERISA and self-insured plans, right, because they’re not one and the same. ERISA also covers fully insured plans.

Schuman: Right.

Fronstin: So fully insured plans are regulated both by ERISA and at the state level. And then you’ve got some self-insured plans like government plans that are not covered by ERISA, right? But they’re self-insured. So it’s even more complicated than what we’re making it out to be when we talk about ERISA, preemption, and self-insurance. That’s just one aspect of ERISA.

Schuman: And I think to the point about employees not sure what covers them, what doesn’t cover them. Again, for self-funded large employers, I mean, I think most of the employees understand from their employer, from the group health plan, what the terms of the plan are, and what the benefits are. And I think in some ways, perhaps less complex than, OK, if you’re an employee working in Kentucky, you have one plan. If you’re an employee working in New York, you have another plan. And employees talking to each other and saying, “Hey, how come you have that and I don’t have this?”

So I think that the clarity or the consistency is important not just for employers who are administering the plan, but for employees understanding what the terms of the plans are. And also, two things about sort of the benefits and what’s covered. There’s a difference between a state saying, “OK, you have to cover this benefit and have to cover it in precisely this way” versus employers who say, “Look, it’s really important for our population, to be healthy and productive, to have these benefits, and so we’re going to offer this benefit. We’re just going to do it in the same way nationwide.”

And remember, ERISA, if the federal government, as it has done over the past, wants to make changes to … that are applicable to group health plans, it can amend and has amended ERISA to do that. So the market reforms, for example, in the Affordable Care Act, were applicable, and the Public Health Service Act, were sort of incorporated into ERISA. The Genetic Information Nondiscrimination Act, for example, amended ERISA. So it’s like that’s the lever to make changes to ERISA that will be applicable to self-funded plans as well is at the federal level.

Rovner: When I was first covering Congress in the 19… late-1980s and early-1990s, you didn’t go there. If you wanted to do something about health policy, you didn’t touch ERISA. I think lawmakers were afraid of reopening it and getting into all kinds of fights. Why did that finally change?

Levitt: I mean, I think there was a growing recognition, particularly with the Affordable Care Act, that there were just some minimum thresholds that health coverage had to meet to be legitimate coverage. So if you look at what the ACA did, and as Ilyse said, those applied to all employers, all group health plans through the amendments to ERISA.

And these were things like no preexisting condition exclusions, coverage of preventive services with no patient cost sharing, no annual on lifetime limits, a cap on out-of-pocket costs. And probably the most popular provision of the ACA, coverage of dependents up to age 26. There was no way to reach everyone with insurance without amending ERISA under the Affordable Care Act.

Fronstin: Yeah. But there were examples, pre-ACA, that affected all plans, or most plans, like mental health parity we didn’t mention. Well, there’s been a couple of instances of that. And certainly the Clinton health plan tried this and didn’t succeed in the early 1990s.

Rovner: And HIPAA …

Levitt: I mean …

Rovner: … which was, I guess, the first major walk into ERISA since ERISA had been passed.

Levitt: Right. Or even COBRA. The ability to continue your insurance after you leave an employer was an amendment to ERISA.

Rovner: That’s right. And that was in 1986.

Fronstin: Yeah, and even that could be confusing because it exempts smaller employers, right. But you got the mini-COBRA laws at state level that affect some of those employers, but not every state has one.

Rovner: Yeah. And Paul, you were referring to this. We should probably talk about who’s not subject to ERISA because I don’t think anybody mentioned church plans. There’s a rule, and then there’s all these exceptions.

Fronstin: I think the two major categories are church plans, and I’m not sure we even have a good handle on how many people are covered by church plans because a lot of them tend to be small businesses, and they may not even offer coverage. And federal, state, and local government. I’m not sure if there’s another category in there that’s not covered by ERISA. I believe that the state and local governments have their own law that’s similar to ERISA, but it’s not ERISA.

Schuman: And I think when we talk about covered by ERISA, certainly it’s, What does ERISA afford? It’s not just about self-funded employers being able to offer uniform benefits nationwide. There are important protections. There are important disclosure requirements for employees, for participants that are included in there that are applicable to all ERISA plans, self-funded and insured plans, and obviously on the retirement plans, too.

But I just think it’s really important that we look to see the idea behind ERISA was that, yes, there will be this uniformity for self-funded plans. But for all ERISA plans, there are these protections and safeguards in there that are embedded in the law for the benefit of participants.

Rovner: And that’s why you used to get a phone-book-thick, “This is your plan documentation.” Now, it’s all online, and it’s all in 4-point type. But that’s where that comes from, right? At the requirement that you be told everything that your plan covers.

Schuman: Right. Correct.

Rovner: So, Larry, you kind of referred to this earlier. Self-funded ERISA plans are regulated not by the states but by the Department of Labor, which most people don’t know. And for a long time, if you were injured or someone died as a result of being denied care, the only thing that they could recover was the cost of the care that was denied. Not any damages for what happened. When did that finally change? And has it finally changed? What do you do now if you’re injured — you can’t go to your state regulatory agency?

Levitt: No, there have been some changes to that, but enforcement of ERISA is still relatively light at the administrative level compared to what state insurance departments do. And the Department of Labor just seems very far away to people compared to a state insurance department.

I think it’s really this structure of ERISA that, Julie, you said people were always resistant to amending in Congress, that has been resistant to amendment, right? I mean, this idea that states regulate insurance directly but that states cannot regulate group health plans under ERISA. And that’s had far-reaching health policy implications. So states looking to do employer mandates or anything that directly affects those group health plans, employer health plans, and that’s maybe …

Rovner: Also, states looking to do single-payer plans, right?

Levitt: Yeah. No, I mean, single-payer there might be some ways around ERISA through single-payer and taxation, but ERISA has been a barrier to state health reform efforts, for better or for worse.

Schuman: If maybe we can just step back 50 years, I think it’s … I wrote down this quote from one of the authors of ERISA, specifically on the ERISA preemption, and that was by Rep. John Dent, who was a Democrat from Pennsylvania who identified the ERISA preemption as the law’s crowning achievement.

And he said it was the crowning achievement because, without it, the legislation would not have enjoyed the support of both labor and management since it’s so fundamental for the ability of multistate employers to sponsor benefit plans to workers nationwide. So I think just kind of getting back into the minds of the drafters of ERISA, that bargain, if you will, that became ERISA preemption was really foundational to the law passing.

Rovner: And you could see why it would make sense. If you work for a national company and you get transferred from one state to another, your insurance shouldn’t change dramatically.

Schuman: Yeah. And I think fast-forward 50 years, and we’ve got, certainly, post-pandemic or after the pandemic, an increasingly mobile and remote workforce. And we have heard repeatedly about how ERISA preemption really promotes that worker mobility and the ability to work out of your house in another state or to be able to transfer from one location to another.

So think a little bit if we just see how the workforce itself has evolved, I think that ERISA preemption provision may become even more important. And I think increasingly, it’s not just large employers that find themselves — like nationwide or multistate employers — but because the workforce is more remote and mobile, and wants to be, that more and more employers of multistate employers, too.

Levitt: I would say we have increasingly seen smaller employers self-funding, and there are some advantages to that, right? They don’t necessarily have to pay premium taxes to states, and they are exempt from state benefit mandates that apply over and above beyond the Affordable Care Act. I mean, insurers have come up with very creative ways of allowing smaller businesses to self-fund and avoiding some of the risk by layering lots of reinsurance on top of that.

Fronstin: I was going to say, along with self-funding comes ease of administration here. Ilyse, you call it uniformity of benefits. But I think of employers, they don’t want to be offering 50 different health plans in 50 different states. And to the degree you’ve got the states doing something — whether it’s a single-payer or something short of that — employers, they just want to offer everyone the same benefit and make it as easy as possible to do so.

And my concern is if they had to comply with 50 different state laws to do so or create 50 different benefit plans, especially today with the ACA guaranteed issue and subsidized coverage, you’ll get to the point where if employers didn’t have the ability to provide one benefit plan across all 50 states, they’re not going to do it anymore, right? They’ve got … pre-ACA might’ve been different, but now they’ve got an alternative where their employees could get coverage if they didn’t offer coverage themselves.

Rovner: So that was all predicted. This huge movement away from employer-provided coverage after the ACA passed was predicted, and it didn’t happen.

Fronstin: I was one of those people predicting it. Yeah. Before the ACA passed, I was one of those people predicting it. And I think what happened is: One, being employers, they still value the benefit. They still understand there are business reasons to offer it, and they haven’t had a good excuse to get rid of it.

We haven’t had — other than the recession tied to covid — we haven’t had a recession. Our unemployment rate has been at historically low rates. And I think employers, they don’t want to mess with something that’s working for the most part because they use it to recruit and retain employees for the same thing they were doing back in the 1940s and ’50s when they first started offering it.

Schuman: I think it’s important to delineate the employer voice in here. And I think maybe there’s a perception that employers are just writing the checks or employers and health plans are kind of conflated. But employers are doing a lot more than just writing a check. And I think those, again, that have decided to self-fund want to be able to have control over how they’re spending their health care dollars. So again, they can try to drive more affordable, higher-value, higher-quality health care.

And so it’s not just about who writes the check, but the reasons behind employers saying, “Hey, we’re going to be spending … we spend a whole lot of money on our health benefits because we recognize that it’s good business. It’s good for employees. But we want to be able to have the ability to try to drive improvements in that to drive higher-value care.” And so that’s enabled by ERISA. So the health reforms and the health innovation, certainly there’s a lot coming from the states, but there’s a lot coming from employers, too.

Rovner: So what are the big issues going forward for ERISA? I mean, obviously, there’s still, if you Google ERISA, you get all kinds of lawsuits and challenges. And I mean, it’s still a very lively part of the law 50 years on.

Levitt: I mean, I think, Julie, you mentioned these lawsuits, and that is potentially a big issue going forward. Something called the Consolidated Appropriations Act added some transparency in fees that self-insured employer plans paid to providers. And that’s opened the door to some lawsuits challenging whether group health plans, ERISA plans, are acting as appropriate fiduciaries in trying to get the lowest costs, particularly for prescription drugs. And these started out as kind of a fringe movement, but I think pose some potential risks for group health plans.

Rovner: Ilyse, what are employers most concerned about?

Schuman: Well, I think that employers seeing the growing number of states that are trying to chip away, if not erode in a fundamental way, ERISA preemption is really alarming. A lot of these efforts have come up around pharmacy benefit managers and efforts to regulate pharmacy benefit managers at the state level.

But the way that they’ve done it, the states have really taken direct aim at ERISA preemption and self-funded plans and, I think, has much broader implications for self-funded group health plans beyond just the PBM context. And so I think that they’re looking at the growing number of states that are interested in passing laws that really erode ERISA preemption as very alarming.

Rovner: So I want to go around the table before we end. Sort of what do you think has been the biggest impact on the health system of ERISA, both for good and for not so good? I mean, it’s certainly one of the things that makes it so confusing to understand and explain. Larry, you want to go first?

Levitt: I think the biggest impact of ERISA has been putting the brakes on some state health reform efforts. States have found ways to get around it. Some raise some issues for employers, like Ilyse was saying, but it has really circumscribed what states can do around health reform. That said, ERISA has provided a very stable regulatory environment for employers and likely allowed employer coverage to grow over time in that environment.

Rovner: Paul?

Fronstin: Yeah, I’d say, in addition to that, it’s allowed employers to be innovative. Not every self-insured employer has been innovative, right? And there’s something like a million employers out there with a thousand or more employees. And the smaller of those are not necessarily being innovative, but they’re learning from the largest ones, right? The jumbo employers, who are trying to do different things when it comes to engaging the health system, right? Engaging hospitals and physicians and pharmaceutical managers.

And I think that that … the lessons learned from what they’re doing trickles down to the smaller self-insured employers, and it trickles out to the health insurers that are offering fully insured plans to small employers.

Rovner: Ilyse.

Schuman: I think ERISA has allowed employers to provide value-driven, comprehensive, affordable, higher-quality health coverage to working families across the country — 150 million, 180 million, guess it depends what stats you’re looking at, and that it’s withstood the test of time.

And I think that probably no stressor, like the pandemic, where many wondered what would emerge from that, and with some dents, but also with a lot of silver linings in terms of employers offering benefits to help their employees navigate through the pandemic. And so I think there’s a resiliency to the employer-sponsored system coupled with the innovation that Paul has mentioned.

Rovner: Last question. Yes or no? Is ERISA going to be around in another 50 years? In other words, are we still going to have this system of health coverage? I promise I will not hold you to it. Just best guess. Larry.

Levitt: I say no.

Rovner: Paul.

Fronstin: I answer “don’t know.”

Rovner:: That’s OK. Ilyse.

Schuman: Well, I will say that I just recently got a tortoise for my family that I’ve found will live 50 or 100 years, so beyond me. So will ERISA be around as long as Veggie, the tortoise? I don’t know.

I think that there’s really an important inflection point. And I think if addressing some of the underlying drivers of rising health care costs and consolidation, I think that if those are addressed, I think employer-provided coverage certainly has the ability to withstand the test of time over the next 50 years.

Rovner: Good. Thank you all so much. This has been great.

Schuman: Thanks a lot.

Levitt: Great. Thanks, Julie.

Schuman: Thank your team.

Levitt: Thanks all.

Schuman: Bye-bye.

Fronstin: Take care, everybody.

Levitt: Bye.

Rovner: Bye. OK, that’s our ERISA anniversary show. Big thanks to our guests, Larry Levitt of KFF, Paul Fronstin of EBRI, and Ilyse Schuman of the American Benefits Council. And before we go this week, we’re looking for your help on a project here at KFF Health News. Are you a young adult confused about navigating the exchanges used to pick plans? Have you bought a plan on an ACA exchange and found that it didn’t cover care you needed? Have you married or taken a job just to get insurance? Did you decide to go without coverage?

Whatever your story, KFF Health News and The New York Times want to hear it. Email your experience to Elisabeth Rosenthal — that’s elisabethr with an S, not a Z — @kff.org. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks, as usual, to our technical guru, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth, all one word, @kff.org, where you can still find me. I’m @jrovner on X. We’ll be back in your feed next week. Until then, be healthy.

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The Affordable Care Act is back under attack. Not as in the repeal-and-replace debates of yore, but in a fresher take from Republican lawmakers who say key parts of the ACA cost taxpayers too much and provide incentive for fraud.

Several House Republican leaders have called on two watchdog agencies to investigate, while Sen. Charles Grassley (R-Iowa) fired off more than half a dozen questions in a recent letter to the Centers for Medicare & Medicaid Services.

At issue are the ACA’s enhanced subsidies, put in place during the covid-19 pandemic as part of economic recovery legislation. Grassley said in a recent news release that the subsidies “left Obamacare, a program already riddled with problems, wide open to new waste, fraud and abuse.”

While potential fraud in government programs has always been a rallying cry for conservatives, the recent criticisms are a renewed line of attack on the ACA because repealing it is unlikely, given that more than 21 million people enrolled in marketplace plans for this year.

“I see what’s happening right now as laying the groundwork for the big fight next year,” said Debbie Curtis, a vice president at consulting firm McDermott+.

The enhanced subsidies are set to expire in late 2025. Without them, millions of Americans would likely see their premiums go up.

But the debate will also likely draw in other issues, including Trump-era tax cuts, which also must be addressed next year. Also potentially in play are other aspects of the ACA, including a special year-round enrollment period and zero-premium plans for low-income consumers.

Much of what eventually happens will depend on the makeup of the Senate and House, as well as control of the White House, after the November elections.

“The fate of the enhanced tax credits is dependent on the Democrats holding some majority in Congress and/or winning the presidency and is also tied inextricably to the Trump tax cut expiration,” said Dean Rosen, a partner at Mehlman Consulting and a former senior Republican congressional staffer. That’s because both sides have incentive to extend all or part of the tax cuts, but each will want some kind of compromise on other issues as well.

The growing outcry by Republicans about the subsidies goes hand in hand with a controversial recent report from a conservative think tank that estimates millions of people — or their brokers — may be misstating their incomes and getting the most generous ACA subsidies.

The Paragon Health Institute report estimates that the number of people who enrolled in ACA coverage for this year who projected they would earn between 100% of the federal poverty level and 150% — amounts that qualify them for zero-premium plans and smaller deductibles — likely exceeds the number of people with that level of income, particularly in nine states.

It recommends several changes to the ACA, including letting the enhanced subsidies expire, increasing repayment amounts for people who fail to project their incomes correctly, and ending the Biden-backed initiative that allows very low-income people to enroll in ACA coverage year-round rather than having to wait for the once-a-year general open enrollment period.

The Paragon report was cited by both Grassley and the House GOP lawmakers in their letters to government overseers. It also notes what they consider a related concern: ongoing problems of unscrupulous, commission-seeking agents enrolling people in ACA coverage or switching their plans without their permission, often into highly subsidized plans. KFF Health News uncovered the enrollment and switching schemes in the spring.

Some critics, though, question how the Paragon analysis was done.

For instance, Paragon’s findings rely on two unrelated data sets from different years. Combining them makes many people who are eligible for subsidies appear to be ineligible, said Gideon Lukens, a senior fellow and director of research at the Center on Budget and Policy Priorities. “The analytic approach is not careful or sophisticated enough to provide accurate or even meaningful results.”

Paragon President Brian Blase, a former senior Trump administration official and a co-author of the report, said it used publicly available data that others could use to confirm its results.

Paragon’s recommendations also drew mixed reactions.

Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University, said they “would make coverage less affordable, disproportionately affecting low-income people, and that’s the opposite of the goals of the ACA.”

Another ACA expert, Joseph Antos of the conservative American Enterprise Institute, agrees with one of the recommended fixes: changing the structure of the subsidies to limit zero-premium plans.

“Giving health insurance away is the problem,” said Antos, who said it is probably contributing to the unauthorized switching by some rogue brokers, who know if they sign someone up for a free plan without their permission, they’re unlikely to get caught for a while because the person won’t get monthly bills.

Another potential solution to people misstating their income is that “the seven or eight states that still haven’t expanded Medicaid should do that,” Antos said. The expansion would open Medicaid eligibility to more people who earn less than the poverty level, reducing the incentive to overestimate their income to qualify for ACA subsidies.

Among other things, the subsidies are larger now for low-income enrollees. For example, families at the poverty level or just above it ($30,000 to $45,000 for a family of four) can currently qualify for coverage with no monthly premium, whereas before they would have had to pay 2% to 4% of their annual income toward such a plan.

President Joe Biden has pushed to make the subsidies permanent and has often touted the record enrollment in ACA plans under his watch. Across all income groups, nearly 20 million people out of 21 million ACA enrollees this year got at least some subsidy, according to a KFF report.

Subsidies, also called premium tax credits, are generally paid directly to health insurers, and applicants must estimate their income for the coming year to qualify.

Those who incorrectly project their incomes — possibly because they work irregular retail hours, are self-employed and give a best guess of business, or get an unexpected raise or a new job — must pay back all or part of the subsidy, on a sliding scale linked to income.

The cost of the enhanced subsidies has been sharply criticized by some GOP leaders after the Congressional Budget Office recently estimated that making them permanent would add $335 billion to the federal budget deficit over 10 years.

Democrats have pointed to another recent CBO report estimating extending the Trump-era tax cuts would add $4.6 trillion to the deficit over 10 years.

The enhanced subsidies “cost a lot less than that and it’s actually helping people,” Curtis said.

Ultimately, “every health care debate comes down to money,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “There is a trade-off here. Millions of people have gotten coverage and more affordable premiums due to these enhanced subsidies, but extending them would cost the government a lot of money.”

Despite the attention paid by some GOP lawmakers to the fraud concerns, many political observers say they don’t think they will play a direct role during the election campaigns of either party.

“For Republicans, they’ll stay away from health care period. It is not a winning campaign issue for them,” Curtis said. “With Harris’ campaign, we will see a continued drive for affordable coverage being key, particularly drug costs. In neither party will you hear much about the importance of extending the enhanced subsidies. It’s too complicated.”

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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SAN RAFAEL, Calif. — When Bobby Moske went to a community clinic a few years ago with a toothache, he couldn’t find a dentist in Marin County willing to take Medicaid to do a root canal.

Marin Community Clinics referred the 75-year-old to a dentist about 20 miles away in San Francisco, but his tooth decayed while he waited months for authorization to cover the procedure. In the end, his tooth was pulled.

It was the sixth time in a decade Moske had lost a tooth for lack of dental care, he said. The behavioral health peer specialist wears a denture that must be removed at mealtime, making eating a chore. He often struggles to mash food between his gums, and he limits his diet to things he can easily chew. Nuts and steak, for instance, are off the table. It can be embarrassing to sit down for a meal with clients or colleagues.

“I feel like I give off the impression of somebody who doesn’t take care of himself, and I do take care of myself,” Moske said. “I try very hard. So, when I go out, I try not to smile.”

California is among a growing number of states that provide comprehensive dental benefits to adults enrolled in Medicaid, and some lawmakers want to add more dental cleanings, examinations, and implants to the safety-net program. Yet many dentists don’t accept Medi-Cal, the state’s Medicaid program, so new benefits would offer no guarantee that patients could get care.

The UCLA Center for Health Policy Research found that 21% of California dentists saw Medi-Cal patients of all ages, according to data from 2019 to 2021. Often those dentists limit the number of Medi-Cal patients they will see, meaning only 15% of adults might get dental care in any given year, said Elizabeth Mertz, a dentistry professor and medical sociologist at the University of California-San Francisco.

“The issue is you have coverage that is useless,” Mertz said. “The state does provide coverage, but almost no dentist will accept it.”

One of the bills moving through the California Legislature would expand Medi-Cal coverage of dental implants — artificial tooth roots implanted into the jawbone that support artificial teeth — and crowns, giving patients with broken or missing teeth more options.

Currently, Medi-Cal covers implants only when “exceptional medical conditions are documented,” according to the state’s 2024 benefits guide. It’s unclear how many private dental plans cover implants, but preliminary research has shown about half of individuals enrolled in a PPO plan nationwide have some type of coverage, said Mike Adelberg, executive director at the National Association of Dental Plans.

Under the bill, introduced by Democratic Sen. Aisha Wahab, Medi-Cal patients could qualify for an implant if their dentist determines it is the best option to replace a missing tooth.

“If you need an implant, you should be able to get it, especially our most vulnerable,” Wahab said. “The poorest of the poor in California deserve this.”

The Senate passed the bill unanimously in May, and a vote is pending in the Assembly Appropriations Committee. Elana Ross, a spokesperson for Democratic Gov. Gavin Newsom, declined to comment on the bill.

Four in 10 U.S. adults have had permanent teeth pulled, according to an analysis by the Centers for Disease Control and Prevention. The CDC also reports that low-income older adults are at higher risk for tooth loss, which can cause discomfort and affect eating and speaking. The fix can be prosthetic devices, such as bridges and dentures, or replacement teeth, but they can be costly, especially for those without insurance or on government programs with limited benefits.

While the alternatives might be a better fit for some patients, implants are “the standard of care,” said Sohail Saghezchi, director of UCSF’s oral surgery residency program.

“They’re not able to eat everything that they want, and, a lot of times, foods like vegetables and fruits are harder to eat,” he said.

The Department of Health Care Services, which oversees Medi-Cal, estimates it would cost between $4 billion and $7 billion a year for about 1.5 million implants — a price tag Wahab fears could be problematic since Newsom in June signed a state budget closing an estimated $46.8 billion deficit.

The cost of an implant varies widely. DHCS estimates it would reimburse dentists between $3,000 and $4,500 for each implant surgery. FAIR Health, a national nonprofit that estimates health costs, reported a median charge for a typical implant in California between October 2022 and September 2023 ranged from about $4,000 to $4,800. Location matters, too. In San Franciso, for example, an implant is closer to $8,000, Saghezchi said.

“Reimbursement rates need to cover the costs of providing the service,” said Alicia Malaby, a spokesperson at the California Dental Association. “As with any Medi-Cal benefit, coverage is not meaningful unless the state is willing to fully invest in it to ensure people can actually access the care they need.”

The California Dental Association, which does not support the current bill, has raised concerns about the invasiveness of implant surgery, which requires regular follow-up appointments. It’s sponsoring legislation to require Medi-Cal to cover a standard two teeth cleanings and examinations a year for people 21 and older, as opposed to one.

DHCS spokesperson Leah Myers said the state has increased Medi-Cal reimbursements to dentists since the passage of Proposition 56 in 2016 and created a web-based app to enlist more dentists. More than 14,000 dentists — about 40% — were enrolled in the Medi-Cal program, as of July, according to the latest numbers published by the Dental Board.

But for people such as Moske, finding a dentist and getting needed care feels impossible. In most of California, 3 in 4 Medi-Cal patients 21 and up didn’t have a dental appointment in 2023, according to DHCS.

When Moske testified in support of the implant bill in June, he took out his denture, held it up to show lawmakers, and opened his mouth.

“I’m here to show you something,” Moske said. “Please don’t be offended. These are the teeth I lost.”

After Moske had finished speaking, Assembly member Reggie Jones-Sawyer (D-Los Angeles) turned to his fellow members and removed his own denture.

“I know exactly what you went through,” he said. “I have dental insurance from the city of Los Angeles and the state of California and still had problems getting things covered. I thank you for being brave enough to let people know.”

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

For Roderick Givens, a radiation oncologist, the expansion of Medicaid isn’t just a policy issue. He practices medicine in a rural area in the Mississippi Delta and he sees daily how Medicaid coverage could help his uninsured patients.

“I can’t tell you the number of patients who I see who come in with advanced disease, who have full-time jobs,” Givens said. “They haven’t seen a physician in years. They can’t afford it. They don’t have coverage.”

This spring, the Mississippi Legislature considered but ultimately failed to expand Medicaid, which would have extended coverage to around 200,000 low-income residents. Mississippi is one of 10 states that haven’t expanded Medicaid, the state and federal health insurance program for people with low incomes or disabilities.

Seven of those states are in the South. But as more conservative-leaning states like North Carolina adopt it, the drumbeat of support, as one Southern state lawmaker put it, grows louder.

Advocates for expanding Medicaid say opposition is largely being driven by political polarization, rather than cost concerns.

Givens, who is also chair of the board of trustees for the Mississippi State Medical Association, which supports Medicaid expansion, said the federal government would pay for the vast majority of it and that most Mississippians support it. “Why does that not translate when it comes to policy?” Givens asked. “It’s called the stupidity of politics. Period.”

Givens pointed to Arkansas as a potential model for Mississippi because the state has similar demographics and expansion has been in place there for a decade. “Look at what has worked for them and what needs to be tweaked,” he said. “For me, that’s just common sense.”

In states that have not expanded Medicaid, hundreds of thousands of people fall into the “coverage gap,” meaning they earn too much to qualify for Medicaid but are not eligible for subsidies to help pay for private insurance. Those in the coverage gap also can’t afford premiums and other out-of-pocket expenses on employer-sponsored insurance even if they are eligible.

The coverage gap is not an issue in states that have expanded Medicaid. In those states, a single person making up to 138% of the poverty level, or about $20,000 a year, can get on Medicaid. Someone making more than that can get subsidies for private health insurance.

For the first time in Mississippi, both the state Senate and House of Representatives proposed expanding Medicaid during the legislative session that ended in May. In the end, the efforts fizzled at the last minute.

Had the proposed bills succeeded, some 74,000 Mississippians who are stuck in the coverage gap would have gained access to Medicaid.

The House speaker, Jason White, a Republican who supports expansion, acknowledged the political hurdles. “It’s President Obama’s signature piece of legislation. It’s known as Obamacare,” White said. “So, there are a lot of political dynamics centered around it that probably never allowed it to get off the ground.”

White said this year was different because of increased support from the business community.

“I kidded some of my fellow Republicans. I said, ‘Come for the savings, if you will, and then you can stay for the salvation and the good things that it does to improve people’s lives,’” White said. “If you can’t get there because it’s the right or compassionate thing to do to help these individuals, get there because it makes sense from a business standpoint.”

In neighboring Alabama, politics also thwarted attempts to provide more health care this year. Although the state legislature didn’t vote on any direct expansion bills, there was an attempt to include expansion language in a bill about casino gambling — specifically, a provision to allocate some gambling profits to rural health systems.

Ultimately, the Alabama bill was stripped down, and the funding for rural health was removed.

If Alabama expanded Medicaid, at least 174,000 more people would be covered, according to KFF. But the connection to Obamacare remains a stumbling block in Alabama’s Republican-dominated state legislature.

“Just the partisan nature of this is definitely a problem,” said Regina Wagner, an assistant professor of political science at the University of Alabama. Wagner said that most Alabama voters support expansion and that other states have adopted the programs after mounting public pressure.

“A lot of rural voters are Republicans. And so your own constituents are being hit by this and you’re not addressing it,” she said. “If the pressure gets high enough and sentiment shifts, maybe that’s going to be enough to push them.”

The main disagreement in the Mississippi Legislature revolved around work requirements — recipients would have to show they were working part-time or in school.

White said many of his Republican colleagues view extending health coverage through Medicaid as “some form of welfare, some form of giveaway, some form of expanding government.”

Opponents of Medicaid expansion in Alabama are also concerned about potential impacts on the workforce of what they call free health care.

“If you open up this federal subsidized program for hundreds of thousands of people, then it could actually hurt that labor participation rate, give them another reason not to go to work, to stay at home,” said Justin Bogie, senior director of fiscal policy at the Alabama Policy Institute, a research group that says it is committed to limited government.

The federal Centers for Medicare & Medicaid Services, or CMS, would have to issue a waiver to allow an expansion plan with a work requirement — something the Biden administration hasn’t done for any state.

This spring, Mississippi came close to a compromise bill that included a work requirement, something that needs a CMS waiver. Had the bill passed and CMS denied the waiver, expansion still would not have taken effect, and the state would have had to apply for the waiver from CMS every year, hoping for approval under a future — potentially more conservative — presidential administration.

That’s what happened in Georgia. In 2020, the Trump administration approved a waiver for a work requirement as part of a limited expansion effort. CMS later rescinded the waiver under the Biden administration, leading to a lawsuit. A federal judge ruled in favor of Georgia, reinstating the work requirement provisions.

However, only about 2,300 people are enrolled — which is fewer than half of 1% of the more than 430,000 uninsured Georgia adults who could gain access if Medicaid were fully expanded, according to KFF. The state’s alternative expansion plan has cost taxpayers at least $26 million, according to KFF, with nearly all of it going to administrative and consulting fees, not medical care for low-income residents.

As public support for expansion continues to grow in holdout states, North Carolina, the most recent Southern state to pass Medicaid expansion, may offer a glimpse of the future. Since its adoption last year, more than 600,000 people have become eligible.

“But it still took a long time,” said Robin Rudowitz, a vice president and director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News. “It took the governor who continually supported expansion, and the legislature finally came to endorse and pass the expansion.”

Rudowitz said the fiscal incentive under the American Rescue Plan Act played a role in moving the needle in North Carolina and could help ignite debate in other holdout states. But ultimately, she said, the reasons the Affordable Care Act was established continue to be the strongest motivators.

“Without expansion, there are more people who are uninsured. Hospitals and other providers are not able to get reimbursement because individuals are uninsured,” Rudowitz said. “Those are the underlying issues that existed pre-ACA and continue to exist, particularly in states that haven’t adopted expansion.”

This article is from a partnership that includes the Gulf States Newsroom, NPR, and KFF Health News.

Vice President Kamala Harris “endorsed free taxpayer-funded government health care for all illegal aliens.”

Former President Donald Trump, July 24, in a speech at a rally in Charlotte, North Carolina.

Attacking Vice President Kamala Harris on immigration, Republicans and allies of former Donald President Trump’s are saying the presumptive Democratic presidential candidate supported using taxpayer dollars to provide free health coverage to immigrants who are in the country without legal permission.

Senate and House candidates, an American political action committee supporting Trump, and the Republican National Committee have made similar assertions in recent days.

We contacted the Trump and Harris campaigns for comment about Trump’s statement, but neither responded.

The claims are misleading. It’s true that Harris supported allowing immigrants residing in the U.S. to obtain public health insurance regardless of legal status. During the first 2019 Democratic presidential primary debate in Miami, Kamala Harris raised her hand when a moderator asked candidates to raise their hands if their administration’s health plan would cover immigrants who are in the country illegally.

But that doesn’t mean Harris specifically said she supported taxpayer funding for the benefits or that the health coverage would be free.

PolitiFact has checked similar claims Republicans and Trump made in 2019 and found them Mostly False. The moderator didn’t ask Harris and the other candidates directly whether their plans would provide the coverage free of charge or with taxpayer money, so the claim is unsubstantiated.

Recently, Republicans have pointed to statements Harris made in 2019 while running for president to portray her as supporting giving public benefits to immigrants living in the country illegally. Specifically, CNN’s Jake Tapper asked Harris whether her “Medicare for All” plan would cover such immigrants.

The National Republican Senatorial Committee on July 23 posted on the social platform X a clip of the interview with the message: “FLASHBACK: Kamala Harris tells Jake Tapper she endorses universal healthcare and Medicare-for-all for illegal immigrants.”

But that clip doesn’t show her saying that. Instead, in response to a question about whether Medicare for All should apply to people in the country illegally, she said, “I am opposed to any policy that would deny in our country any human being from access to public safety, public education, or public health, period.” Tapper didn’t ask anything else about this.

Medicare for All is a system, promoted by some Democrats, in which all Americans would get their health insurance from a government program modeled after the one that currently covers people 65 and older and people with disabilities.

Under the Emergency Medical Treatment and Labor Act, which became law in 1986, all patients regardless of citizenship or immigration status are already entitled to treatment in hospital emergency rooms. 

Some anti-immigration groups say they still believe Harris supports taxpayer-paid health benefits for immigrants lacking legal residency.

“Instead of pushing back, she at the very least implicitly endorses Medicare for illegal aliens,” said Joey Chester, a spokesperson for Federation for American Immigration Reform, a group that seeks to reduce overall immigration. That she raised her hand during the 2019 debate means her position is to give taxpayer-funded health care benefits to people who are in the country illegally, he added.

Harris’ proposal would have provided comprehensive health insurance to all Americans. But it was not all free. She would have allowed Americans to immediately buy into the program while expanding it over 10 years. The plan she produced was similar to current Medicare, in which people can buy plans that the federal government or private insurers administer.

A 10-year phase-in would automatically enroll newborns and uninsured people. But her proposal didn’t break down how it would pay for coverage of recipients living in the U.S. without authorization.

Harris wrote in a 2019 article on Medium that “good options” to pay for Medicare for All plans include an income-based premium by employers, higher taxes on the wealthiest 1% of Americans, taxing Wall Street trades, and savings from accelerating health care-delivery system reforms and changes in the way providers are paid.

California, where Harris served as attorney general from 2011 to 2017, was the first state this year to expand Medicaid eligibility to all qualified immigrants regardless of legal status, phasing it in over several years. Medicaid is a federal-state health program that provides health coverage to low-income and disabled adults.

The California program for immigrants is funded almost entirely by state dollars, according to the Public Policy Institute of California, a nonprofit research institution. Federal law generally bans states from using federal money to pay for health coverage for immigrants living in the country without legal permission.

However, taxpayers can bear the brunt of uncompensated care, when people without insurance — including immigrants lacking legal residency — seek care at hospitals or from other providers. The costs are passed on to other consumers in the form of higher prices and are considered a drain on state and local government budgets.

“Government payments are the main source for helping to defray providers’ costs for care to the uninsured, and those government payments are ultimately funded by taxpayers,” said Laurel Lucia, health care program director at the University of California-Berkeley Center for Labor Research and Education Center, which provides research and policy information.

Immigrants who are in the country illegally also pay billions of dollars in taxes.

“If she does support subsidized coverage for noncitizens, I’d see that as a good thing, not a bad thing,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy. “Many recent immigrants are taking care of our children, our elderly, working in hospitality, food service, and food production. Isn’t it in our best interests for these folks to have access to good health care?”

Our Ruling

Republicans have sought to portray Harris as extreme on immigration and assert that she supports free, taxpayer-funded health benefits for immigrants who are in the country illegally.

Harris signaled in 2019 that her Medicare for All proposal would cover all immigrants regardless of status. She has also said that she would oppose any policy that would deny anyone in the country access to “public health.” However, health policy and immigration experts say there’s no evidence she would provide the coverage free, paid for by other taxpayers. Immigrants lacking legal residency also pay taxes.

Harris has not expressly said she supports free, taxpayer-supported health coverage for immigrants living in the U.S. illegally.

Trump’s statement contains an element of truth but ignores critical facts that would give a different impression. We rate this claim Mostly False.

Sources

YouTube, former President Donald Trump rally in Charlotte, North Carolina, July 24, 2024.

YouTube, Democratic presidential primary debate in Miami, June 27, 2019.

X, Republican National Committee post of Jake Tapper’s State of the Union interview with Kamala Harris, remarking on immigrant health care, July 23, 2024.

Email interview with Edwin Park, research professor at the McCourt School of Public Policy at Georgetown University, July 24 and July 25, 2024.

Email interview with Sabrina Corlette, research professor, founder, and co-director of the Center on Health Insurance Reforms at Georgetown University’s McCourt School of Public Policy, July 25, 2024.

Email interview with Laurel Lucia, health care program director at the University of California-Berkeley Labor Center, July 24 and 25, 2024.

Email interview with Joey Chester, spokesperson, Federation for American Immigration Reform, July 25, 2024.

PolitiFact, “Fact-Checking Trump Ad on Democrats, Health Care for Immigrants Illegally in the Country,” Aug. 1, 2019.

PolitiFact, “Florida GOP Chair Twists’ Response by Democrats at Debate on Health Care for Undocumented Immigrants,” Nov. 8, 2019.

Medium, “Kamala Harris: My Plan for Medicare for All,” July 29, 2019.

American Immigration Council, “Adding Up the Billions in Tax Dollars Paid by Undocumented Immigrants,” April 4, 2016.

NOTE: On Friday, hours after KFF Health News reported that the National Education Association had threatened to cut off striking workers’ health benefits, the union reversed course and said it would continue providing coverage. This story has been updated to reflect that decision.

The National Education Association, the nation’s largest union, reversed course Friday on its threat to cut off health insurance to about 300 Washington, D.C.-based workers in an effort to end a bitter contract dispute.

“The NEA is not discontinuing its unionized staff’s health insurance and will continue to pay insurance premiums as we bargain a new contract,” Kim Anderson, NEA’s executive director, said in a statement to KFF Health News. “Both parties have mutually agreed to mediation and we are making every effort to reach an agreement as quickly as possible.”

The NEA’s decision came just hours after KFF Health News reported on the union’s warning that it would cancel health benefits on Aug. 1 for striking workers, including some with ongoing medical issues. Reached Friday, officials at the NEA staff union confirmed they had been notified by the NEA.

Some private employers have used the threat of cutting off health benefits as leverage against unionized workers, a tactic that has drawn scrutiny from congressional Democrats and is prohibited for state employers in California. Experts on labor law say they’ve never seen a union make the move against its own workers.

“This is like a man-bites-dog situation where the union is now in a position as the employer,” said Paul Clark, a professor of labor and employment relations at Penn State University. “It’s not a good look for a union.”

NEA workers with pressing health needs were worried but said they wouldn’t fold. Joye Mercer Barksdale, a writer on the NEA’s government relations team, said she needs coverage for a medical procedure to address atrial fibrillation, a cardiac disorder. “This is insane for the NEA to use our health benefits as a bargaining chip,” she said.

But Barksdale had said she was “not ready to give in.” Reached Friday morning, she said she was thrilled by the reversal: “Oh my God, I am so thankful.”

The NEA Staff Organization, the union representing workers at the NEA’s headquarters, launched a strike on July 5 in Philadelphia, during the union’s annual delegate assembly. It was its second walkout this summer as the two parties negotiate a new contract, navigating sticking points such as wages and remote work.

In response, the NEA ended the conference early. President Joe Biden was supposed to speak at the event but withdrew, refusing to cross the picket line. The NEA on July 24 endorsed Kamala Harris for president.

On July 8, the day after the conference had been scheduled to end, the NEA locked out workers. In a letter the day before, the NEA informed its unionized workers that they would not be paid, effective immediately, and their health benefits would expire at the end of July unless a new deal were reached.

“NEA cannot allow NEASO to act again in a way that will bring such lasting harm to our members and our organization,” Anderson, the NEA’s executive director, wrote in the letter, obtained by KFF Health News. “We are, and have always been, committed both to our union values and to the importance of conducting ourselves as a model employer.”

Democrats in Congress, including Sens. Sherrod Brown of Ohio and Bob Casey of Pennsylvania, introduced legislation last year to protect striking workers from losing their health benefits, after several large companies, including General Motors, John Deere, RTX (formerly Raytheon Technologies), and the maker of Kellogg’s cereals, threatened to or did cut off coverage during labor disputes.

“Workers shouldn’t have to choose between their family’s health and a fair contract,” Brown said in a statement to KFF Health News.

The legislation was endorsed by large labor unions including the Service Employees International Union and United Steelworkers, according to a press release from Brown’s office. The NEA wasn’t among them.

“This tactic is immoral, and it should be illegal,” United Steelworkers’ president at the time, Thomas Conway, said in the release.

Officials at the NEA, which represents teachers and other administrators, declined an interview request. In a statement Wednesday, the organization’s president, Becky Pringle, said “we are making every effort to reach an agreement as quickly as possible” with its staff union.

“As union leaders who have been on strike, we recognize the significance and impact of these important decisions on a personal and family level. We truly value our employees and look forward to continued collaboration with NEASO to develop a new contract that benefits us all,” she said.

Kate Hilts, a digital strategist who works for the NEA, said she feared losing her coverage would leave her unable to afford treatment for a rare autoimmune disease that attacks her kidneys. Her next treatment was slated for August.

“I wake up every day and can’t believe this is happening,” she said. “You would expect this from an employer that is antiworker or has a terrible labor record, but I am totally flabbergasted that a labor union would do this that bills itself as pro-worker, pro-family, pro-education, and pro-children.”

The NEA staff union has filed multiple charges with the National Labor Relations Board this year, including allegations that the NEA withheld holiday overtime pay and failed to provide information on the outsourcing of millions of dollars in bargaining unit work.

California is one of the only states that protect striking workers from losing health coverage. The state legislature passed a law in 2021 that blocks the tactic from being used against public employees and another law in 2022 that allows any striking workers who lose their insurance to immediately get heavily discounted coverage through the state’s Affordable Care Act marketplace.

If they had remained locked out, the NEA workers would have been eligible for coverage under COBRA, a federal program that allows people who are fired or laid off to maintain their employer-sponsored insurance for 18 months.

But the coverage can be a financial hardship, as individuals often must pay the entire cost of their insurance premiums, plus a 2% administrative fee.

Another option for workers would have been coverage through the Affordable Care Act marketplace, though that also can be costly. And it may have been unclear how soon that coverage would begin or whether insurers would cover their existing doctors.

“I’m hoping the NEA will be so ashamed of what they are doing that, at the very least, they will not take away our health benefits,” Barksdale said before the NEA’s decision.

Health insurance agents who fraudulently enroll consumers in Affordable Care Act health plans could be subject to criminal charges — and civil penalties of $10,000 to $200,000 — under legislation introduced Wednesday by Sen. Ron Wyden (D-Ore.), chairman of the powerful Senate Finance Committee.

Wyden first promised the bill in May, when he called on federal regulators to do more to combat sketchy Obamacare enrollment schemes. Often, consumers who are targeted don’t know they’ve been enrolled or that their coverage has been switched to a new plan until they lose access to preferred doctors, learn they have different deductibles, or find they owe taxes for ACA insurance premium subsidies.

The schemes exploit the federal health insurance enrollment system, which requires only minimal proof of identity — a name, birth date, and state — for a broker to create or access an account. The lure is monthly commissions paid by insurance companies — amounts that are only about $25 per person but can add up when multiplied across transactions.

“It is critical for these bad actors to be held criminally responsible and implement common sense consumer protections so working families can confidently purchase quality, affordable health insurance that works for them through honest brokers,” Wyden said in a statement.

The Centers for Medicare & Medicaid Services said July 19 that more than 200,000 people have complained about unauthorized Obamacare enrollment or plan switches this year.

KFF Health News began reporting on Affordable Care Act enrollment schemes this spring.

CMS’ directive last week also detailed new rules aimed at thwarting the problem by blocking agents from making changes to consumers’ coverage unless they are already “associated” with that policyholder’s account, or take other steps to verify that they have consumers’ permission.

Wyden’s proposal, co-sponsored by Democratic Sens. Sherrod Brown of Ohio, Tammy Duckworth of Illinois, Patty Murray of Washington, Brian Schatz of Hawaii, and Chris Van Hollen of Maryland, would call on federal regulators to begin verifying that consumers have granted consent to brokers for ACA enrollment or plan switches, and to notify consumers whenever a change is made to their accounts or coverage.

The civil penalties would range from at least $10,000, in cases of straightforward negligence, to as much as $200,000 for agents who “knowingly and willfully” submit fraudulent information.

Wyden’s bill faces a seemingly impossible climb, landing in a very polarized Senate during an election year.

But next year, the ACA will be in the spotlight as Congress must decide whether to extend beyond 2025 enhanced subsidies that help people purchase coverage. Increased subsidies were instituted under the Biden administration at the height of the pandemic and are considered a key factor behind recent record ACA enrollment.

Some Republican lawmakers have demanded investigations of ACA enrollment-switching schemes, which they allege may be part of a larger problem of brokers or consumers misstating their incomes to garner insurance subsidies. Obamacare supporters say the complaint is a partisan effort to stop the enhanced subsidies from becoming permanent.

Sen. Chuck Grassley (R-Iowa) sent a letter July 8 to CMS questioning how federal regulators verify incomes for those who get subsidies and what enforcement efforts are underway related to potential ACA subsidy fraud.

Wyden’s office said his proposal is supported by some insurers and agent groups, including AHIP, the trade association for insurance companies; individual insurers like Centene Corp.; and several disease-specific patient advocacy groups, including the Leukemia & Lymphoma Society, the American Cancer Society Cancer Action Network, and the National Multiple Sclerosis Society.

Health Agents for America, a group that has sought solutions to the issue, supports criminal charges for agents found to be falsely enrolling or switching consumers but stopped short of endorsing Wyden’s bill. Ronnell Nolan, its president and CEO, said her organization would like to see more effort “to hold CMS responsible” for allowing what she views as security loopholes in private sector enrollment websites, and in enforcement actions against bad actors.

“The bottom line is to stop fraud and help the consumer,” she said.

In a July 19 letter to Wyden’s office, CMS Administrator Chiquita Brooks-LaSure outlined steps the agency has taken to increase “oversight of agents and brokers to protect consumers” — including suspending 200 agents in recent weeks from enrolling clients in Obamacare plans.

“The numbers being addressed are very low,” said Nolan, who suspects it isn’t just individual rogue agents seeking commissions by changing ACA enrollments, but a larger effort using automation to rapidly enroll or switch consumer policies.

Nolan and other agents say federal regulators should simply require private Obamacare enrollment sites to add layers of security before agents can access consumer accounts.

Eighteen states and the District of Columbia run their own ACA marketplaces and require additional security measures, including two-factor authentication, before consumer accounts can be accessed. Two-factor authentication, a common internet security feature, requires people to enter a code — usually sent to their phones — before accessing accounts at banks, social media platforms, and many other services.

The state-run enrollment sites report far fewer problems than the federal marketplace, Nolan and others say. If CMS simply added two-factor authentication to healthcare.gov, Nolan said, “all these other shenanigans would not happen.”

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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