That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans.

“Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said.

Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a found that many returning marketplace enrollees reported higher costs this year.

In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage.

Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans.

As of this year, that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan.

Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints.

But because states have passed laws exempting from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans.

Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions.

Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be than unsubsidized marketplace plans, plan managers say.

As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins.

“We’re trying to present another option,” he said.

Sowing Choices

In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to for subsidized enrollees who retained their marketplace plan, according to Â鶹ŮÓÅ.

Last year, was one of four states that passed laws permitting farm bureau health plans. The others were , , and .

Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage . Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them.

In Missouri, the farm bureau offers with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network.

Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said.

It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years.

“People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said , general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.”

Staying Rooted in Coverage

Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said.

“We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said.

And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said , principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network.

Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said.

“We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said.

Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions.

Meanwhile, policy experts share Howard’s concerns.

Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said , vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans.

Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said.

Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans.

“I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said , co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.”

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But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.

“We really want people to factor that in,” said , managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”

There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.

In addition, as Medicare Advantage plan in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a in February.

“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.

For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.

But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:

• People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
• People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “.”
• If a Medicare Advantage plan leaves Medicare or in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
• If an individual and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said , a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.

There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.

Patient advocates emphasize that it’s often useful to work with a counselor at the , or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.

People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.

Beware: More Underwriting

In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.

The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a of leading insurers’ applications.

When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said , a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.

“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.

Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.

“They have access to a Medigap comparison tool in addition to what is existing on that can give you a very good estimate of what you may pay for those Medigap plans,” said , associate director of health coverage and benefits at the National Council on Aging.

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Instead of typing on her computer keyboard during the exam, Urban’s primary care physician at the , AI scribes may help reduce physician burnout and after-hours “pajama time” catching up on work in the evening.

The potential of AI to transform every aspect of the health care system — from patient care to clinical efficiency to medical innovation — is an area of intense focus, including by the Trump administration.

Last January, President Donald Trump issued an to remove barriers to American leadership in AI. Later in the year, a from the federal Department of Health and Human Services invited stakeholders to weigh in on how the department can accelerate the adoption of AI in health care.

Several startup vendors in recent years have introduced ambient AI scribe products that can be integrated into electronic health records. EHR market leader Epic is technology, which it expects to release widely early this year, according to , a family medicine physician who is chief medical officer and vice president of clinical informatics at Epic.

Health tech experts estimate that a third of providers have access to ambient AI scribe technology. As adoption looks likely to grow rapidly over the next few years, many expect it to become more of a recruiting tool, a minimum requirement for incoming clinicians, who are increasingly prioritizing work-life balance.

“It’s part of keeping doctors happy,” said , a professor and the chair of the Department of Medicine at the University of California-San Francisco, whose forthcoming book, , explores how AI is transforming health care. “Health systems that initially might have done a hard-nosed return-on-investment calculation — many are softening on that and realizing that the cost of recruiting and retaining doctors is pretty high.”

But many questions remain. Does the use of ambient AI scribes improve patient care and health outcomes? Will doctors use time they gain by employing an AI scribe to improve the quality of the time they spend with their patients or just boost the number of patients they see? To what extent will expanding the amount of detail available from a patient visit lead to bigger bills if the AI scribe is integrated with a coding app that optimizes provider charges?

For now, these questions remain mostly unanswered.

Urban said that the AI scribe didn’t change her experience as a patient very much. Typically, after a patient gives verbal permission, the AI scribe records the visit on a phone and organizes the conversation into the structure of a clinical note, filtering out small talk that isn’t pertinent to the medical visit but incorporating relevant details about a family member’s recent cancer diagnosis, for example. The scribe’s note is often then integrated into the provider’s EHR. The doctor later reviews the note and signs off on it.

Even though the visit may not feel very different to patients, some clinicians report that ambient AI scribes are changing patient encounters in unanticipated ways.

“Now, when I’m doing a physical exam, I have to say what I’m doing and what I’m finding out loud in order for the AI scribe to document it,” said , Urban’s primary care doctor. “People find that very interesting,” she said.

When Capalongo places her stethoscope over the carotid artery under a patient’s jaw, for example, she might say that she doesn’t hear a “bruit,” or vascular murmur, whose presence could indicate atherosclerosis. Patients have told her, “I never knew why a doctor would listen there,” she said.

Saying things out loud for the AI scribe that would typically appear only in a clinical note can create its own set of challenges, particularly during sensitive physical exams. Doctors may feel it’s important to adjust their conversation accordingly.

“Sometimes patients are anxious and scared and my saying things that they don’t understand or they may worry about during an uncomfortable examination does not help the situation and honestly is insensitive to what the patient is going through,” said , a professor in the Division of Colon and Rectal Surgery at the University of Minnesota, who is also chief health informatics and AI officer at Fairview Health Services in Minneapolis. “I’ll keep that top of mind and make sure I record it” after the visit.

“How we have conversations with patients about these tools is really important, in particular for maintaining trust and ensuring accurate information,” Melton-Meaux said.

Studies have found that, across a range of measures such as completeness, timeliness, and coherence, the notes created by ambient AI scribes are generally at least as good as, and sometimes better than, traditional documentation, said , a pediatrician who is vice president for applied informatics at the University of Pennsylvania Health System.

An ongoing concern is around AI “hallucinations,” in which false, sometimes fabricated information appears in an AI output.

Kaiser Permanente, an of ambient AI scribe technology, provides it to more than 25,000 doctors, advanced practice providers, and pharmacists systemwide. It has found hallucinations to be “quite rare,” said , an internist who is vice president of AI and emerging technologies at KP.

But they happen. An AI-scribe-generated note, for instance, might say that the doctor planned to refer someone to a neurologist or to follow up in two weeks. The problem? The doctor might not have said that.

“The technology is not perfect, and that’s why physicians are reviewing it,” Yang said. It’s learning from regular physician visits as it goes, he said. That’s why having a person check the work product is critical.

Still, even such a “human-in-the loop” system is fraught, Wachter said. “Humans stink at maintaining vigilance over time,” he said.

As the use of ambient AI scribes becomes routine, some clinicians worry that the technology will widen the divide between health care haves and have-nots.

Large health systems are able to move forward with the technology, Melton-Meaux said. But what about critical access hospitals or small private practices? “There need to be more resources,” she said.

Physicians’ enthusiasm for ambient AI scribes stands in sharp contrast to their negative reaction to electronic health record systems that have become widely adopted in recent years to replace paper charts.

“During the last 10 years, when EHRs became a thing, we all became very grumpy, overworked data scribes,” Wachter said.

The introduction of AI scribes makes physicians feel like technology is working for them rather than the other way around, health care AI experts said.

And AI scribes are “training wheels” for more consequential adoption of AI in health care, Wachter said.

To improve health care value and save costs, Wachter said, we need a system that makes it more likely that physicians will practice evidence-based medicine to order the right tests and prescribe the right medications.

“It’s a few years away, but it’s all AI-dependent,” he said.

Epic has introduced roughly 60 AI use cases for patients, clinicians, and administration, with over 100 more in the works.

“It’s so much bigger than a scribe,” said Epic’s Gerhart. “It’s literally listening and acting in a way that tees things up for me so that I can take action.”

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En lugar de teclear en su computadora durante la consulta, la médica de atención primaria de Urban, en la práctica  en Media, Pennsylvania, usó un asistente de inteligencia artificial (IA) conocido como ambiental para tomar notas.

Al final de los 30 minutos de la visita, la doctora le mostró a Urban el resumen que generó el programa: un documento claramente organizado por secciones con su historial médico, los hallazgos del examen físico y un plan de evaluación y tratamiento para su artritis reumatoide y los sofocos, entre otros detalles.

La nota clínica —que Urban también pudo revisar más tarde en el portal para pacientes— fue increíblemente detallada, dijo. Resumía todas sus preguntas y preocupaciones, así como las respuestas de la doctora. El asistente “se aseguró de que no se nos pasara nada”, dijo Urban.

Los médicos están considerando a estos asistentes de IA ambiental como una herramienta revolucionaria que les permite concentrarse en sus pacientes en lugar de en el teclado.

indican que, al liberar a los doctores de la tarea tediosa y que consume tiempo, de documentar cada encuentro con un paciente, estos asistentes podrían ayudar a reducir el agotamiento profesional y el llamado “tiempo en pijama”: horas extra en casa para ponerse al día con el trabajo.

El potencial de la inteligencia artificial para transformar todos los aspectos del sistema de salud —desde la atención directa hasta la eficiencia clínica y la innovación médica— es un tema de gran interés, incluso dentro de la administración Trump.

En enero de 2025, el presidente Donald Trump emitió para eliminar barreras al liderazgo estadounidense en inteligencia artificial. Más tarde ese mismo año, el Departamento de Salud y Servicios Humanos (HHS, por sus siglas en inglés) publicó invitando a distintos sectores a opinar sobre cómo acelerar la adopción de la IA en el sistema de salud.

En los últimos años, varias empresas emergentes han lanzado asistentes de IA ambiental que pueden integrarse a los registros médicos electrónicos (EHR, por sus siglas en inglés). Epic, el proveedor líder del mercado de EHR, está probando , que planea lanzar de forma más amplia a principios de este año, según , médica de medicina familiar, directora médica y vicepresidenta de informática clínica en Epic.

Expertos en tecnología estiman que un tercio de los proveedores ya tiene acceso a esta tecnología. A medida que su adopción se acelera, muchos anticipan que se convertirá en una herramienta de reclutamiento, un requisito básico para nuevos profesionales clínicos, quienes, , cada vez valoran más el equilibrio entre vida laboral y personal.

“Es parte de mantener felices a los médicos”, dijo , profesor y jefe del Departamento de Medicina en la Universidad de California en San Francisco. Su próximo libro, , explora cómo la IA está transformando la atención de salud. “Muchos sistemas de salud que inicialmente hacían cálculos estrictos sobre el retorno de la inversión ahora están flexibilizando su postura y reconociendo que el costo de contratar y retener médicos es bastante alto”.

Pero aún hay muchas preguntas. ¿Mejora la atención médica y los resultados en salud el uso de asistentes de IA ambiental? ¿Usarán los médicos el tiempo que ganan para ofrecer mejor atención o solo para ver a más pacientes? ¿Hasta qué punto podría aumentar el costo de una consulta si el asistente de IA se conecta a un sistema de codificación que optimiza los cobros?

Por ahora, estas preguntas siguen sin respuesta.

El papel del asistente

Urban dijo que la presencia del asistente de IA no cambió mucho su experiencia como paciente.

Normalmente, luego de tener el permiso verbal del paciente, el asistente graba la visita con un teléfono y organiza la conversación en el formato de una nota clínica, omitiendo los comentarios sin relevancia médica, pero incluyendo información importante como el diagnóstico reciente de cáncer de un familiar, por ejemplo. La nota del asistente suele integrarse en la Historia Clínica Electrónica (HCE) del proveedor. Luego, el médico revisa y firma el documento.

Aunque para los pacientes la consulta puede no sentirse muy diferente, algunos profesionales aseguran que los asistentes de IA ambiental están cambiando los encuentros con los pacientes de formas inesperadas.

“Ahora, cuando hago un examen físico, tengo que decir en voz alta lo que estoy haciendo y lo que estoy encontrando para que el asistente lo documente”, dijo , la médica de atención primaria de Urban. “A la gente le parece muy interesante”, añadió.

Por ejemplo, cuando Capalongo coloca su estetoscopio sobre la arteria carótida, debajo de la mandíbula de un paciente, puede decir en voz alta que no escucha un “soplo”, un sonido vascular que puede indicar aterosclerosis. Los pacientes le han dicho: “Nunca supe por qué un médico escuchaba ahí”.

Decir en voz alta cosas que normalmente solo estarían en la nota clínica puede representar un desafío, especialmente durante exámenes físicos delicados. Algunos médicos consideran importante adaptar la conversación según el contexto.

“Hay pacientes que están ansiosos o asustados, y que yo diga cosas que no entienden, o que les pueden preocupar durante un examen incómodo, no ayuda y, la verdad, es insensible frente a lo que están viviendo”, dijo , profesora de la División de Cirugía de Colon y Recto en la Universidad de Minnesota, y directora de informática en salud e inteligencia artificial en Fairview Health Services, en Minneapolis. “Tengo eso muy presente y me aseguro de registrarlo después de la consulta”.

“La manera en que hablamos con los pacientes sobre estas herramientas es muy importante, especialmente para mantener la confianza y asegurar que la información sea precisa”, añadió Melton-Meaux.

Notas más completas, pero con desafíos

Según , pediatra y vicepresidente de informática aplicada en el sistema de salud de la Universidad de Pennsylvania, estudios han encontrado que, en aspectos como integridad, claridad y puntualidad, las notas creadas por asistentes de IA ambiental son generalmente tan buenas como —y a veces mejores que— las notas tradicionales.

Sin embargo, persiste la preocupación por las llamadas “alucinaciones” de la IA, cuando la herramienta genera información falsa o inventada.

Kaiser Permanente, en adoptar esta tecnología, la ha puesto a disposición de más de 25.000 médicos, profesionales avanzados y farmacéuticos en todo su sistema. Según , internista y vicepresidente de IA y tecnologías emergentes en Kaiser, las alucinaciones “son bastante raras”.

Pero ocurren. Por ejemplo, una nota generada por IA podría indicar que el médico planea derivar a un paciente a neurología o hacer un seguimiento en dos semanas, cuando en realidad eso nunca se dijo.

“La tecnología no es perfecta, y por eso los médicos la revisan”, señaló Yang. El sistema aprende de las consultas médicas habituales, agregó. Por eso es clave que una persona verifique el contenido generado.

Aun así, incluso ese modelo de “humano editando” tiene sus limitaciones, dijo Wachter. “Los humanos no somos buenos para mantener la vigilancia constante”, afirmó.

¿Mayor desigualdad tecnológica?

A medida que el uso de estos asistentes se vuelve más común, algunas personas en el sector temen que la tecnología profundice la brecha entre quienes tienen acceso y quienes no.

Los grandes sistemas de salud pueden avanzar con estas tecnologías, dijo Melton-Meaux. “¿Pero qué pasa con los hospitales rurales o los consultorios pequeños? Se necesitan más recursos”.

El entusiasmo por los asistentes de IA contrasta con la frustración generalizada que causaron los registros médicos electrónicos cuando se implementaron hace una década para reemplazar los historiales en papel.

“Durante los últimos 10 años, cuando se adoptaron los HCE, todos nos convertimos en escribas gruñones y sobrecargados”, recordó Wachter.

Con la llegada de los asistentes de IA, los médicos sienten que la tecnología ahora trabaja para ellos, y no al revés, según expertos en IA aplicada a la salud.

Además, estos asistentes funcionan como “entrenamiento” para una adopción más amplia de la inteligencia artificial en la atención médica, señaló Wachter.

Para mejorar el valor del sistema de salud y reducir costos, explicó, necesitamos un sistema que aumente las probabilidades de que los médicos ejerzan una medicina basada en evidencia, ordenando los estudios adecuados y recetando los medicamentos correctos.

“Eso aún está a unos años de distancia, pero dependerá totalmente de la IA”, dijo.

Epic ha desarrollado alrededor de 60 herramientas de IA para pacientes, profesionales clínicos y la administración, y tiene más de 100 en desarrollo.

“Esto es mucho más que un asistente”, dijo Gerhart, de Epic. “Literalmente escucha y actúa de una manera que me prepara todo para que yo pueda tomar decisiones”.

[Aclaración: Este artículo fue revisado a las 11 am ET del 6 de marzo de 2026 para aclarar la ubicación de los agentes del Servicio de Inmigración y Control de Aduanas de Estados Unidos cerca de clínicas y hospitales.]

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Aunque la temporada de inscripciones ya está en marcha, el futuro de los subsidios ampliados —que hacen más accesible el seguro para — sigue siendo incierto, con la posibilidad de que las primas aumenten significativamente.

Aun así, hay medidas que puedes tomar para asegurarte de elegir correctamente tu plan para el próximo año.

1. Entender cómo llegamos hasta aquí

En 2021, como parte de un paquete de ayuda por covid, se ampliaron los subsidios de ACA para reducir los costos de las personas que ya calificaban y extender la elegibilidad a quienes tenían ingresos superiores al 400% del nivel federal de pobreza ( para una sola persona en 2025).

Estas ampliaciones, que fueron renovadas en 2022, al finalizar 2025, a menos que el Congreso actúe.

El debate sobre si renovar los subsidios ha sido el centro de una lucha política entre republicanos y demócratas en el Congreso, conflicto que contribuyó al cierre del gobierno federal que ya lleva más de un mes.

Las implicaciones económicas para muchas personas inscritas en los mercados son enormes.

Según Â鶹ŮÓÅ, una organización sin fines de lucro de información sobre salud que incluye a Â鶹ŮÓÅ Health News, se proyecta que los pagos de bolsillo de las primas (lo que pagas cada mes por tu cobertura) para los inscritos subirán más del doble si expiran los subsidios ampliados.

“Cuanto más tiempo dure esto, mayor será el daño”, dijo , vicepresidenta y directora del Programa sobre ACA en Â鶹ŮÓÅ. “Si alguien entra al sitio web el 1 de noviembre y ve que su prima se duplicó, es posible que se vaya”.

Eso sería un error, según las personas expertas en los mercados. Lo que sí está claro es que quienes buscan seguro deben estar informados y tener precaución.

2. Seguir las noticias

Puede resultar frustrante seguir el día a día las peleas en el Capitolio, pero puede ser la mejor manera de mantenerse al tanto.

El Congreso podría llegar a un acuerdo para renovar los subsidios en cualquier momento durante los próximos meses, o no. En cualquier caso, eso puede afectar tu decisión de inscripción. Así que, mantente atento.

No cuentes con que el mercado o tu aseguradora te informen sobre lo que podrías llegar a pagar. “Muchos mercados estatales han retrasado” el envío de notificaciones a los consumidores con las primas netas (que ya tienen en cuenta los subsidios), dijo , codirectora del Centro sobre Reformas del Seguro de Salud de la Universidad Georgetown.

El gobierno federal no envía notificaciones a las personas inscritas sobre las primas para el próximo año en los . Para 2026, también ha indicado que los planes de salud pueden .

3. Actualizar la información de tu cuenta

Ingresa a tu cuenta del mercado de seguros y actualiza tus ingresos, el tamaño de tu hogar y cualquier otro dato que haya cambiado.

Este año, es particularmente importante proporcionar una estimación precisa de tus ingresos pronosticados para 2026.

Una disposición en la ley HR 1, a veces llamada , sobre lo que muchas personas debían devolver si subestimaban sus ingresos y recibían más ayuda de la que les correspondía.

El próximo año, tendrán que reembolsar la totalidad del monto recibido de más.

Dada la incertidumbre sobre las primas, este probablemente no sea un buen año para permitir que el mercado en tu plan actual o en uno similar, según especialistas.

Esto es especialmente importante para quienes, si no hay un nuevo acuerdo, ya no calificarán para subsidios el próximo año, específicamente quienes tengan ingresos superiores al 400% del nivel federal de pobreza.

4. Elegir el plan según el precio publicado

Si el Congreso no llega a un acuerdo para extender los subsidios ampliados, muchas personas se sorprenderán al ver el costo proyectado de sus primas.

, se espera que las primas de los seguros de salud en los mercados aumenten, en promedio, un 26% el próximo año. Es el mayor incremento desde 2018.

Hasta ahora, las personas han estado protegidas en gran medida de estos aumentos gracias a los subsidios ampliados, que casi todas reciben. Así funciona: la mayoría de las personas con planes de ACA pagan una parte de su prima según una escala progresiva basada en sus ingresos, y el gobierno cubre el resto.

Según un análisis de Â鶹ŮÓÅ, si no se renuevan los subsidios ampliados, una familia de cuatro con ingresos de $75.000 $5.865 anuales por un plan de referencia de nivel plata en 2026: más del doble de los $2.498 que pagaría si se renuevan.

Al evaluar un plan, concéntrate en el precio publicado. Si no es accesible sin los subsidios ampliados, no es una buena opción.

“Las personas deben tomar decisiones basadas en lo que tienen delante”, señaló Cox.

Si no puedes pagar ese precio sin los subsidios ampliados, considera inscribirte en un plan menos generoso con una prima más baja pero un deducible más alto, dijo Cox. Los planes de nivel bronce deben ofrecer cobertura integral, incluyendo atención preventiva gratuita, y pueden cubrir algunas visitas médicas antes de que se alcance el deducible (lo que tú debes pagar antes de que la aseguradora se haga cargo del gasto).

“En la mayoría de los casos, tiene más sentido tener un plan bronce que no tener seguro”, explicó.

La administración Trump ha estado promoviendo los como una opción más accesible para quienes enfrentan dificultades económicas, incluyendo a las personas que no califican para subsidios porque sus ingresos están por debajo del 100% o por encima del 400% del nivel federal de pobreza.

Al igual que los planes bronce, los planes catastróficos cubren un conjunto de beneficios esenciales, ofrecen atención preventiva gratuita y deben cubrir al menos tres visitas al médico antes de alcanzar el deducible. Pero estos planes tienen los deducibles más altos de todos los planes del mercado: $10.600 para individuos y $21.200 para familias en 2026.

“Son caros en relación con lo que cubren”, señaló , directora de acceso a la cobertura médica en el Centro de Prioridades Presupuestarias y Políticas (CBPP), quien advirtió que las primas pueden costar varios cientos de dólares.

5. Revisar más de una vez

Si te desanimas al ver los precios de las primas en tu primera visita, “no apagues la computadora ni llegues a la conclusión de que no hay opciones para ti”, dijo Sullivan. “El Congreso aún podría actuar y las cosas podrían cambiar drásticamente”.

Los legisladores podrían restaurar los subsidios ampliados hasta fin de año que viene, o incluso después.

En la mayoría de los estados, incluyendo los 28 que usan el mercado federal centralizado, el período de inscripción abierta dura hasta el 15 de enero. También hay otras fechas clave que debes tener en cuenta.

En la mayoría de los estados, las personas antes del 15 de diciembre para tener cobertura a partir del 1 de enero, y antes del 15 de enero para comenzar la cobertura el 1 de febrero, aunque algunos estados tienen plazos más extensos.

6. Esperar para pagar la prima

Generalmente, las primas deben pagarse antes de que entre en vigencia el plan, aunque los mercados y las aseguradoras tienen la flexibilidad de extender los plazos, explicó Corlette.

Podrían, por ejemplo, permitir más tiempo para hacer el primer pago. “Ya hemos visto eso en el pasado. Funcionarios estatales y aseguradoras han procurado por todos los medios mantener a las personas con cobertura”, dijo.

Pero si se llega a un acuerdo de último minuto y alguien ya pagó su prima para la cobertura de enero y recibió un subsidio menor al que correspondería con el nuevo acuerdo, aún debería poder recibir el subsidio más alto.

“Existen maneras de compensar a las personas”, aseguró Corlette, aunque no está claro cómo sucederá eso en este periodo de inscripción.

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Even with sign-up season underway, the fate of the enhanced premium tax credits that make coverage more affordable for remains up in the air, with the prospect of significantly higher premiums looming.

But there are steps marketplace shoppers can take to ensure they make the right choices for the upcoming plan year.

1. Understand How We Got Here

In 2021, as part of a covid-era relief package, the ACA premium tax credits were enhanced to lower costs for previously eligible people and expand eligibility to people with incomes over 400% of the federal poverty level (which amounts to for one person in 2025). But those enhancements, which were extended in 2022, at the end of 2025 unless Congress acts.

The debate over whether to extend them again has been at the center of a political battle of wills between Republicans and Democrats in Congress, a fight at the heart of the now month-old government shutdown.

The financial implications for many marketplace enrollees are huge. Average out-of-pocket premium payments for subsidized enrollees are projected to more than double if the enhanced tax credits expire, according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“The longer this goes on, the more damage is done,” said , a vice president and the director of the Program on the ACA at Â鶹ŮÓÅ. “If someone logs on Nov. 1 and sees their premium doubling, they might just walk away.”

That would be a mistake, marketplace experts agree. What is clear, though, is that buyers need to beware and be informed.

2. Follow the News

It can be frustrating to track day-to-day Capitol Hill machinations. But that may be your best source for up-to-date information. Congress could make a deal to extend the enhanced subsidies anytime during the next few days, weeks, or months — or not. Either way, it could affect your enrollment decision. So, pay attention.

Don’t count on the marketplace or your insurer to notify you about what you should expect to pay. “Many state marketplaces have hit delay” on sending consumers notices of net premiums, which take premium tax credits into account, said , a co-director of Georgetown University’s Center on Health Insurance Reforms.

The federal government doesn’t send enrollees notices about plan premiums for the coming year for the marketplaces. For 2026, it has said that health plans can also to.

3. Update Your Account Information

Log in to your marketplace account and update your income, household size, and any other details that have changed.

This year, it’s particularly important to provide an accurate estimate of your anticipated income for 2026.

A provision in HR 1, sometimes called the , on what many people were required to repay if they underestimated their projected income and received more premium assistance than they should have. Next year, people will have to repay the entire excess amount.

In the past few years, it’s been possible to put your ACA insurance “on autopilot,” with in your current or a similar plan. Given the uncertainty around premiums, this is not a good year to do that, enrollment specialists say.

This is especially true for people who, without a deal in Congress, will no longer qualify for subsidies next year, specifically those whose incomes are over 400% of the federal poverty level.

4. Shop Based on Sticker Prices

When people see their projected premiums, assuming Congress hasn’t reached a deal to extend the enhanced credits, many will be shocked.

Health insurance premiums on the marketplaces are expected to increase, on average, 26% next year, . That’s the largest rate increase since 2018.

Until now, people have largely been shielded from those increases by the enhanced premium tax subsidies that nearly all enrollees receive. Here’s how it works: Most people with ACA marketplace plans are responsible for paying a portion of their premium based on a sliding income scale, and the government pays the rest.

According to an analysis by Â鶹ŮÓÅ, if the enhanced credits are not renewed, a family of four with $75,000 in income, for example, for paying $5,865 in annual premiums for a benchmark silver plan in 2026 — more than double the $2,498 it’ll pay if they are renewed.

When evaluating a plan, focus on the listed price. If it’s not affordable without the enhanced tax credits, it’s not a good buy.

“People need to make a decision based on what is in front of them,” Cox said.

If you can’t afford the sticker price without the enhanced credits, consider enrolling in a less generous plan with a lower premium but a higher deductible, Cox said. Bronze plans must provide comprehensive coverage, including covering preventive care at no cost, and may cover some doctor visits before the deductible.

“In most cases, it makes more sense to have a bronze plan than to be uninsured,” she said.

The Trump administration has been promoting as a more affordable option for people who face financial hardship, including those who don’t qualify for subsidies because their incomes are either less than 100% or more than 400% of the federal poverty level.

Similar to bronze plans, catastrophic plans cover a set of essential health benefits, provide free preventive care, and must cover at least three doctor visits before people reach their deductible. But catastrophic plan deductibles are the highest of any type of marketplace plan: $10,600 for individuals and $21,200 for families in 2026.

“They are expensive relative to what they cover,” said , director of health coverage access at the Center on Budget and Policy Priorities, noting premiums can cost several hundred dollars.

5. Come Back, Check, and Recheck

If you’re dismayed at premium prices on your first pass, “don’t slam the computer shut and decide that there are no options for you,” Sullivan said. “Congress might still act and things might change radically.”

Lawmakers could restore the enhanced premium tax credits right up to the end of the year, or later.

In a majority of states, including the 28 that use the federal government’s centralized marketplace, open enrollment lasts until Jan. 15. There are also other key dates to remember.

In most states, people by Dec. 15 for coverage starting Jan. 1, and by Jan. 15 for coverage starting Feb. 1, though some states have later deadlines.

6. Wait To Pay Your Premium

Premium payments are generally due before the plan takes effect, although marketplaces and insurers have flexibility to extend deadlines, Corlette said.

They might allow people extra time to make a first payment, for example. “We’ve seen that in the past. State officials and insurance companies have gotten creative to try and keep people in coverage,” she said.

But if there is a last-minute deal and someone has already paid their premium for January coverage and received a lower tax credit than the deal provides, they should still be able to receive the higher credit.

“There are ways to make people whole,” Corlette said, although how that might happen this enrollment period is unclear.

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Después de un verano confuso, cuando las autoridades federales anunciaron cambios en las recomendaciones sobre la vacuna contra covid, que luego anularon, los Centros para el Control y la Prevención de Enfermedades (CDC) anunciaron a principios de octubre , que no difieren mucho de los del año pasado.

Según expertos en salud pública, eso debería facilitar que la mayoría de las personas que quieren vacunarse puedan hacerlo.

“Desde la experiencia del paciente, no debería haber nada diferente a lo que ya han vivido, salvo quizás que el farmacéutico les dé un poco más de información”, explicó , directora de iniciativas estratégicas en la Asociación Nacional de Farmacéuticos Comunitarios.

Esto es lo que necesitas saber:

VACUNA CONTRA COVID

Este otoño, se recomienda esta vacuna para todas las personas , con una salvedad: se requiere primero una conversación con el proveedor de salud, un modelo llamado “toma de decisiones clínicas compartida”.

El proveedor puede ser tu doctor, un farmacéutico u otro profesional que administre vacunas. En el caso de las personas menores de 65 años, el Comité Asesor sobre Prácticas de Vacunación de los CDC enfatizó que la vacunación suele ser más beneficiosa para quienes tienen mayor riesgo de presentar covid grave.

Aunque las recomendaciones de edad no han cambiado respecto al año pasado, hay algunos matices. Si bien la aprobación de los CDC es amplia —y eso significa que los planes de salud deben cubrir la vacuna sin costo para el paciente—, algunos proveedores podrían mostrarse reacios a administrar la vacuna a personas menores de 65, a menos que tengan una afección médica que las exponga a un mayor riesgo de sufrir covid grave si se infectan. Esa es la recomendación que figura en la etiqueta de la vacuna, aprobada por la (FDA).

“Es un detalle que podría surgir en la interacción entre un proveedor y un paciente”, dijo , vicepresidenta y directora de políticas de salud pública y global en Â鶹ŮÓÅ.

Sin embargo, si un proveedor se niega a vacunar a una persona sana por considerarlo un uso no recomendado en la etiqueta de la vacuna, otro proveedor probablemente sí estaría dispuesto a administrarla, dijeron expertos.

“Podrían ir a otra farmacia”, señaló Kates.

Según , muchos estados han intervenido para garantizar que las personas puedan acceder a las vacunas si así lo desean. Veintiún estados y el Distrito de Columbia han adoptado recomendaciones más amplias que las del gobierno federal, explicó Kates.

Sin embargo, el porcentaje de personas que optan por recibir la vacuna contra covid sigue bajando. A fines de abril, solo 23% de los adultos había recibido la vacuna actualizada, .

Con una aceptación tan baja, es posible que menos farmacias y médicos decidan tener la vacuna disponible este año, comentó , médico de atención primaria, líder de salud poblacional en la consultora WTW y profesor adjunto en la Facultad de Salud Pública Chan de la Universidad de Harvard.

Cadenas grandes como CVS y Walgreens afirman que tienen suficiente suministro para cubrir la demanda.

Aun así, los obstáculos adicionales que las personas podrían enfrentar —como tener que buscar otra farmacia o proveedor— podrían afectar el interés en vacunarse contra covid.

“Para que más personas se vacunen, la clave es que el proceso sea lo más fácil posible y reducir la cantidad de pasos”, dijo Levin-Scherz.

VACUNA CONTRA LA GRIPE

Más personas buscan la vacuna contra la gripe que la de covid, pero aun así, solo el 47% de los adultos se vacunó durante la temporada pasada.

que prácticamente todas las personas de 6 meses en adelante se vacunen contra la gripe cada año. Este año no hay cambios. Las vacunas estarán ampliamente disponibles en farmacias y consultorios médicos, y los planes de salud las cubrirán sin costo para el paciente.

El Departamento de Salud y Servicios Humanos (HHS) que las vacunas contra la gripe no deben contener timerosal, un conservante que evita el crecimiento de bacterias en las vacunas.

Según investigadores especializados en el tema, de que este aditivo, que contiene mercurio y se ha utilizado durante décadas, sea dañino. El año pasado, que solo el 6% de las vacunas contra la gripe contenía timerosal.

VACUNA CONTRA EL VRS

Esta vacuna protege contra el virus respiratorio sincitial (VRS), altamente contagioso que afecta los pulmones y las vías respiratorias. Aunque los síntomas suelen ser leves, el VRS puede causar infecciones pulmonares graves, especialmente en personas mayores.

en 2023. para todas las personas de 75 años o más, y para quienes tienen entre 50 y 74 años con afecciones médicas que las expongan a un mayor riesgo de desarrollar una forma grave de la enfermedad.

Las personas que cumplan con estos criterios deberían poder vacunarse en su farmacia, explicó Fish.

La vacuna contra el VRS no es anual. Según la normativa vigente, si ya la recibiste, no necesitas volver a vacunarte.

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Following several confusing months this summer when federal officials announced and then retreated from changes to covid vaccine recommendations, the Centers for Disease Control and Prevention on Oct. 6 that are not that different from last year’s. That should clear the way for most people who want shots this fall to get them, public health experts say.

“From a patient’s experience, there shouldn’t be anything different from what they’ve experienced in the past, except maybe they’ll get a little more information from the pharmacist,” said , senior director of strategic initiatives at the National Community Pharmacists Association.

Here’s what you need to know:

Covid Vaccine

This fall, the covid vaccine is recommended , with one caveat. People need to have a conversation with their provider first, a model called “shared clinical decision-making.” Providers can be doctors, pharmacists, or the health professionals giving the shots. For people younger than 65, the CDC’s Advisory Committee on Immunization Practices emphasized that vaccination is generally more beneficial for those who are at higher risk for severe covid.

Although the shots are recommended for the same age range as last year, there are a few possible wrinkles. Even though the CDC’s approval is broad and means that health plans have to cover the shot without charging consumers for it, some providers may balk at giving the vaccine to people under 65 unless they have an underlying condition that puts them at risk for severe covid if they get infected. That’s what the for the covid vaccine advises.

“It’s a nuance that could occur in an interaction between a provider and a patient,” said , a senior vice president and the director of global and public health policy at Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

However, if a provider refused to administer the shot to a healthy person because doing so would be “off-label,” another provider would probably be willing to give someone the jab, experts said.

“They could go to a different pharmacy,” Kates said.

Many states have stepped in to ensure that people can get vaccines if they want them, according to . Twenty-one states and the District of Columbia have adopted recommendations that are broader than those of the federal government, Kates said.

However, the percentage of people opting to get the covid vaccine continues to drop. At the end of April, 23% of adults said they had received the current vaccine, .

With uptake so low, fewer pharmacies and doctors may choose to stock the shot this year, said , a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard’s Chan School of Public Health.

Large chains, including CVS and Walgreens, say they have enough supply available to meet demand.

The additional hoops people might have to go through — such as having to find a different pharmacy or physician — could have an impact on uptake of the covid shot, though.

“To get more people to get vaccines, the key is making vaccination really easy and to take steps out,” Levin-Scherz said.

Influenza Vaccine

More people seek out the flu vaccine than the covid vaccine, but even so, only 47% of adults got a shot last flu season.

The that virtually everyone 6 months or older get a flu shot annually. This year is no different. The shots should be widely available at pharmacies and physician offices, and health plans will cover the shots without charging people for them.

The federal Department of Health and Human Services that flu vaccines must not contain thimerosal, a preservative that prevents bacterial growth in vaccines. There is that the mercury-based additive, which has been used for decades, is harmful, according to vaccine researchers. Last year, that only 6% of flu vaccines use thimerosal as a preservative.

RSV Vaccine

This vaccine protects against respiratory syncytial virus, a highly contagious that infects the lungs and respiratory tract. Although symptoms are typically mild, RSV can lead to serious lung infections, particularly in older people.

A vaccine . The for everyone 75 or older and for people 50 to 74 who have medical conditions that put them at risk for severe disease.

People who meet the criteria should be able to get the RSV vaccine at their local pharmacy, Fish said.

The RSV vaccine is not an annual vaccine. If you’ve already received it, you don’t need to get it again, according to current guidelines.

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The two hospitals that treated Cochran-Zipp at the time determined that she qualified for 100% financial assistance, since her income as a college student was extremely low. Not having to worry about the roughly $100,000 in bills she racked up for her care was an enormous relief, she said.

Then she started receiving unexpected bills from doctors who worked at the hospitals but, because they weren’t on staff there, didn’t have to abide by the facilities’ financial assistance policies.

Those bills, which came from specialists in emergency medicine, anesthesiology, and radiology who treated her, totaled more than $5,000. Although it was a fraction of the total cost of her care, to Cochran-Zipp it was an enormous amount. She went on payment plans and used scholarship and covid stimulus money to help cover the bills.

Cochran-Zipp, now 25 and working at a community health center, is applying to medical schools and hopes to enroll next fall. Her experience as a patient has shaped how she thinks about becoming a doctor.

“I don’t think that I could be a provider that, in good conscience, charges patients money in addition to the hospital fees,” she said.

Hospital financial assistance programs are commonplace, and many patients rely on them. Most offer varying amounts of financial help to uninsured and lower-income people. Eligibility is typically based on a sliding income scale. Some hospitals apply other tests, such as residency.

But even if people qualify for assistance, they may not get discounts. That’s because many physicians working at but not for a hospital aren’t bound by its financial assistance policies. Hospitals themselves might limit the types of services eligible for discounted or “charity care,” as it’s sometimes called.

“It’s a hole in the system,” said Caitlin Donovan, a at the , a nonprofit that helps patients with serious illnesses cover their medical bills. Case managers who work with patients report that they’ve seen these problems repeatedly, Donovan said.

In the coming years, more patients will encounter difficulties as demand for financial assistance grows. More than 14 million people are over the next decade, primarily because of changes to the federal Medicaid program and state insurance marketplaces in recently passed championed by the Trump administration. Some of these people will likely qualify for discounted care.

Nonprofit hospitals do not pay taxes on the money they make, but to maintain that tax-exempt status, they are to help patients pay for emergency and other medically necessary care. For-profit hospitals are not required to offer financial assistance to needy patients, but many do.

However, physicians and other providers who work in a hospital as independent contractors rather than as employees are often not subject to a hospital’s financial assistance policy. According to an , a health care think tank, physician services in the emergency, radiology, anesthesia, and pathology specialties are commonly excluded from hospital charity care.

For example, at , a large nonprofit health system serving Connecticut, Massachusetts, and Rhode Island, services performed by physicians, nurse practitioners, and physician assistants employed by HHC, including emergency department physicians at four of its hospitals, are covered by its financial assistance policy. But treatment by emergency physicians at three HHC hospitals is not covered by the financial assistance policy, since they are not employees. Care by doctors working in isn’t covered by the financial assistance policy at any HHC facility.

Hartford HealthCare declined to comment on the record for this article.

Health system researchers have identified another potential barrier to patients’ receiving help from hospital financial assistance policies. require that nonprofit hospitals include emergency and medically necessary care in their charity care policies, but they give hospitals substantial leeway to define what “medically necessary” care means.

Historically, excluded care has been limited to services that insurance doesn’t typically cover, like cosmetic surgery or experimental treatment. But in recent years, hospitals appear to be defining medically necessary care more narrowly, eliminating financial assistance for care that is needed but not urgently required. Care that might fall into this category could be a kidney stone removal, a cancer biopsy, or a cardiac valve replacement, published this year in The New England Journal of Medicine.

Although the study of 209 nonprofit hospitals with more than 200 beds found only isolated examples of hospitals — about 6% of them — that substantially excluded medically necessary care, researchers are concerned that it could be the leading edge of a larger trend, said Mark Hall, a professor of law and public health at Wake Forest University, who co-authored the study.

“There’s not really much in the way of regulatory guidance in what should be in or out” of a financial assistance policy, said , a clinical assistant professor at the University of South Carolina School of Medicine, who has examining hospital financial assistance policies.

The American Hospital Association declined to comment for this article. American Medical Association spokesperson Robert Mills said that the AMA doesn’t have a position on whether all contracted physicians should be required to participate in hospital financial assistance policies.

For-profit hospitals have more latitude to fashion their financial assistance policies as they wish.

At HCA Healthcare, one of the country’s largest for-profit health care systems, with nearly in 20 states and the United Kingdom, discounted or free care is available only for “.”

“Facility charity policies and uninsured discounts are typically specific to emergency services” at HCA Healthcare, said Harlow Sumerford, an HCA Healthcare spokesperson. “Any third-party providers are independent and would have their own financial policies.”

In recent years, medical debt protection laws. A few apply to some doctors and other health care providers who practice at health care facilities and bill patients separately for their care.

Colorado’s is the most expansive. Under its law that took effect in September 2022, covered hospitals have to screen all uninsured people and others who request it for eligibility for Medicaid and other health programs, and provide discounted care to people whose income is up to 250% of the federal poverty level (about ). There are limits on how much qualifying patients can be billed each month and, after three years, their debt is retired.

Under the Colorado law, licensed health care professionals who work at a covered hospital can charge qualified patients no more than the rates set by the state.

“This rule has been a game changer for folks in Colorado,” said Melissa Duncan, consumer assistance program manager at the , which helps patients access health care and cover their bills.

Unfortunately, the law didn’t pass in time to help Cochran-Zipp.

As hospitals grapple with the changes expected under the federal health care legislation passed this summer, discounted care programs may make a tempting target, say some health care financing experts. Facing higher rates of uncompensated care and trouble collecting payments from patients, facilities may reduce the financial assistance that they offer.

Hospitals may say “we are going to do all we can to protect our spending,” said , a professor of accounting and health policy and management at Johns Hopkins University. “In that environment, charity care will be a burden.”

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

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

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

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

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

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

Q: How have the recommendations changed?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Q: What do these changes mean long-term?

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

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

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

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

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