His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

But by September he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: The skin lesions disappeared, and the joint pain that kept him up at night dissipated. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen — she estimated $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx — another subsidiary of the same parent company, UnitedHealth Group — showed it did not provide a negotiated discount and covered just $308.34 of the full $5,253.85 charge for a 30-day supply. The charges for the second month depleted the copay card and left Mishra owing the balance.

The Billing Problem: Copay Card ‘Tug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program toward a patient’s deductible.

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug — not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply emptied the card — which he originally expected to last a year — and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, good for $9,450, which again wasn’t sufficient to pay for two months’ supply. He again paid the remaining balance in February from his HSA to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them Ìý²¹²Ô»åÌýÌýthat dissects and explains medical bills.ÌýSince 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?ÌýTell us about it!

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Many young adults are staring down an “insurance cliff” as they turn 26. That’s the age when many can no longer stay on their parents’ health insurance. If they can’t get coverage through their job, they’ll need to start looking for their own. The search can be nerve-racking and confusing. Â鶹ŮÓÅ Health News senior contributing editor Elisabeth Rosenthal appeared on WAMU’s “Health Hub” on Sept. 24 to share some tips for finding the right plan.

Read her full article for more help starting your search.

Already have an Affordable Care Act insurance plan? Check out Â鶹ŮÓÅ’s to find out how much more you may have to pay next year if enhanced tax credits expire.

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

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

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

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

Buckle up.

Start Here

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

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

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

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

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

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

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

Find the Right Marketplace

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

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

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

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

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

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

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

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

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

Sign Up

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

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

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

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

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

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

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

Do the Math

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

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

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

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

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

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

Choose Wisely

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

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

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

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

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

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

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

A Backstop

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

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

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

Good luck.

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

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This story can be republished for free (details).

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

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

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

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

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

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

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

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

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

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

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

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

(Ethan Evans)

(Maxwell Frost)

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

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

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

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

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

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

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

Now 28, he is insured through his federal job.

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

Why 26?

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

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

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

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

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

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

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

(Elizabeth Mathis)

(Kayla Anderson)

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

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

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

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

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

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

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

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

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

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

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

The Affordability Problem

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

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, .

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

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

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

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

(Daisy Creager)

(Madeline Nelkin)

(Valeria Chávez)

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

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

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

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

Over said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Experts agree that the marketplaces need stronger regulation.

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

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

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

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

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

If the subsidies expire, for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

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

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El , aprobado por el Senado el martes 1 de julio, revertiría muchos de los avances en cobertura médica de las administraciones Biden y Obama, cuyas políticas facilitaron el acceso a la atención médica a millones de personas y redujeron la tasa de personas sin seguro en el país a mínimos históricos.

El plan del Senado para recortar drásticamente la financiación de Medicaid y los mercados de ACA podría hacer que unas 12 millones de personas más no tuvieran seguro para 2034, según estima la CBO.

Esto, a su vez, perjudicaría las finanzas de hospitales, residencias de adultos mayores y centros de salud comunitarios —que tendrían que absorber una mayor parte del costo del tratamiento de las personas sin cobertura— y podría obligarlos a reducir servicios y personal, hasta a cerrar instalaciones.

La legislación está en el escritorio de Trump a la espera de su firma, aunque primero el Senado y la Cámara de Representantes deben aprobar la misma versión. La Cámara de Representantes aprobó su propia versión en mayo y se espera que considere la versión del Senado hoy (2 de julio), según Tom Emmer, líder de la mayoría en la Cámara.

A continuación, se presentan cinco maneras en que los planes del Partido Republicano podrían afectar el acceso a la atención médica.

¿Necesita Medicaid? Entonces consigue un trabajo

Los recortes más profundos al gasto en atención médica provienen de la propuesta de un requisito de trabajo para Medicaid, que cortaría la cobertura a millones de afiliados que no cumplen con estos nuevos estándares.

En 40 estados y Washington, D.C., que han ampliado Medicaid bajo ACA, algunos beneficiarios de Medicaid tendrían que presentar regularmente documentación que demuestre que trabajan, hacen voluntariado o asisten a la escuela al menos 80 horas al mes, o que califican para una exención, como por ejemplos el cuidado de un niño pequeño.

El requisito del proyecto de ley no se aplicaría a las personas en los 10 estados, mayoritariamente republicanos, que no han ampliado Medicaid.

Investigadores de salud afirman que la política tendría poco impacto en el empleo. , la mayoría de los beneficiarios de Medicaid en edad laboral que no reciben prestaciones por discapacidad ya trabajan o buscan trabajo, o no pueden hacerlo porque tienen una discapacidad, asisten a la escuela o cuidan a un familiar.

Los experimentos estatales con requisitos de trabajo se han visto plagados de problemas administrativos, como la pérdida de cobertura de los beneficiarios elegibles por problemas con el papeleo, y más gasto.

El requisito de trabajo de Georgia, que se implementó oficialmente en julio de 2023, ha costado más de $90 millones, de los cuales solo 26 millones se han destinado a prestaciones de salud, según el Ìý, una organización de investigación no partidista.

“Los costos ocultos son astronómicos”, afirmó Chima Ndumele, profesor de la Escuela de Salud Pública de Yale.

Menos dinero significa menos atención en las comunidades rurales

Las medidas de ajuste que se aplicarían a los estados podrían traducirse en una disminución de los servicios de salud, profesionales médicos e incluso hospitales, especialmente en las comunidades rurales.

El plan del Partido Republicano reduciría una práctica conocida como impuestos a los proveedores, que casi todos los estados han utilizado durante décadas para aumentar los pagos de Medicaid a hospitales, residencias de adultos mayores y otros proveedores, así como a empresas privadas de atención médica administrada.

Los estados suelen utilizar el dinero federal generado a través de los impuestos para pagar a las instituciones más de lo que Medicaid pagaría de otra manera. (Medicaid generalmente paga las tarifas más bajas por la atención médica, en comparación con Medicare, el programa para personas mayores de 65 años y algunas personas con discapacidad, y los seguros privados).

Los hospitales y residencias de adultos mayores afirman que utilizan estos fondos adicionales de Medicaid para ampliar o añadir nuevos servicios y mejorar la atención para todos los pacientes.

Los hospitales rurales suelen operar con márgenes de ganancia reducidos y dependen de los pagos de impuestos de Medicaid para sostenerlos. Investigadores del que examinaron el proyecto de ley de la Cámara concluyeron que este obligaría a más de 300 hospitales rurales, muchos de ellos en Kentucky, Louisiana, California y Oklahoma, a reducir sus servicios o cerrar.

Los senadores republicanos agregaron un fondo de $50 mil millones a su versión del proyecto de ley para amortiguar el impacto en los hospitales rurales.

Más dificultad para obtener, y mantener, la cobertura de ACA

Para quienes tienen cobertura del mercado de seguros de salud de ACA, el plan republicano dificultaría la inscripción y el conservar los planes.

Los asegurados del mercado de seguros estarían obligados a actualizar sus ingresos, estatus migratorio y otra información cada año, en lugar de reinscribirse automáticamente, algo que más de 10 millones de personas hicieron este año.

También tendrían menos tiempo para inscribirse; el proyecto de ley acorta el período anual de inscripción abierta en aproximadamente un mes.

Las personas que soliciten cobertura fuera de ese período —por ejemplo, porque pierden su trabajo u otro seguro, o necesitan agregar a un recién nacido o cónyuge a una póliza existente— tendrían que esperar a que se procesen todos sus documentos antes de recibir subsidios del gobierno para ayudar a pagar sus primas mensuales. Actualmente, reciben hasta 90 días de ayuda con las primas durante el proceso de solicitud, que puede tardar semanas.

Los legisladores republicanos y algunos centros de estudios de políticas conservadoras, incluido el , afirman que los cambios son necesarios para reducir las inscripciones fraudulentas, mientras que los opositores afirman que son el último intento de desmantelar el Obamacare.

La legislación tampoco contempla una extensión de los subsidios mejorados implementados durante la pandemia de covid-19. Si el Congreso no actúa, estos subsidios expirarán a finales de año, lo que resultará en en las primas el próximo año, según Â鶹ŮÓÅ.

¿Tienes Medicaid? Se pagará más por las consultas médicas

Muchos beneficiarios de Medicaid podrían tener que pagar más de su bolsillo por las citas.

El proyecto de ley exigiría a los estados que han ampliado Medicaid cobrar a los beneficiarios hasta $35 por algunos servicios si sus ingresos se encuentran entre el nivel federal de pobreza (este año, $15.650 por persona) y el 138% de esa cantidad ($21.597).

Los beneficiarios de Medicaid generalmente no pagan nada cuando buscan servicios médicos, ya que estudios han demostrado que cobrar incluso copagos pequeños lleva a las personas de bajos ingresos a renunciar a atención necesaria. En los últimos años, algunos estados han agregado cargos inferiores a $10 por algunos servicios.

Esta política no se aplicaría a las personas que buscan atención primaria, atención de salud mental o tratamiento de adicciones.

Recortes para inmigrantes con residencia legal

El plan republicano podría provocar que al menos cientos de miles de inmigrantes con residencia legal —incluyendo solicitantes de asilo, víctimas de tráfico humano y refugiados— pierdan su cobertura del mercado de seguros al eliminar los subsidios que hacen que las primas sean asequibles. La restricción no se aplicaría a los titulares de tarjetas de residencia permanente (Green Card o tarjeta verde).

Dado que los inmigrantes que perderían subsidios bajo este plan tienden a ser más jóvenes que la población general, su salida dejaría una población de afiliados de mayor edad, con mayor riesgo de enfermedad y costos más elevados, lo que incrementaría aún más las primas del mercado, según directores de los mercados de seguros de salud en California, Maryland y Massachusetts, y analistas de salud.

Quitar el acceso a la atención médica a los inmigrantes que viven legalmente en el país “causará un daño irreparable a las personas que hemos prometido proteger e impondrá costos innecesarios a los sistemas locales que ya están sobrecargados”, declaró John Slocum, director ejecutivo del Refugee Council USA, un grupo de defensa, en un comunicado.

Tanto la versión de la Cámara de Representantes como la del Senado del proyecto de ley reflejan el enfoque restrictivo de la administración Trump hacia la inmigración.

Sin embargo, debido a que contravenía las normas del Senado, la legislación no incluirá una propuesta que habría reducido los pagos federales de Medicaid a estados como California, que utilizan sus propios fondos para cubrir a inmigrantes sin papeles.

La corresponsal principal de Â鶹ŮÓÅ Health News en Washington, Julie Rovner, contribuyó con este artículo.

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

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This story can be republished for free (details).

, passed in both the House and the Senate without a single Democratic vote, is expected to reverse many of the health coverage gains of the Biden and Obama administrations. Their policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows, though Republicans say the trade-off was far higher costs borne by taxpayers and increased fraud.

Under the legislation Trump’s expected to sign on Friday, Independence Day, reductions in federal support for Medicaid and Affordable Care Act marketplaces will cause nearly 12 million more people to be without insurance by 2034, the Congressional Budget Office estimates. That in turn is expected to undermine the finances of hospitals, nursing homes, and community health centers — which will have to absorb more of the cost of treating uninsured people. Some may reduce services and employees or close altogether.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.

The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.

Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, , a health information nonprofit that includes Â鶹ŮÓÅ Health News.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with of that spent on health benefits, according to the , a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that targets states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan curtails a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. Medicaid generally pays lower fees for care than Medicare, the program for people over 65 and some with disabilities, and private insurance. But thanks to provider taxes, some hospitals are paid more under Medicaid than Medicare, , a health research nonprofit.

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on payments from Medicaid taxes to sustain them. Researchers from the who examined the original House version of the bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republicans in the Senate tacked a $50 billion fund onto the legislation to cushion the blow to rural hospitals. The money will be distributed starting in 2027 and continue for five years.

Harder To Get, and Keep, ACA Coverage

For those with Obamacare plans, the new legislation will make it harder to enroll and to retain their coverage.

ACA marketplace policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including , say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.

The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by next year, according to Â鶹ŮÓÅ.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

Trump’s legislation requires states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for certain services.

The policy won’t apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction won’t apply to green-card holders.

Because the immigrants who will lose subsidies under the legislation tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said .

The bill reflects the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation doesn’t include a proposal that would have reduced federal Medicaid payments to states such as California that use their own money to cover immigrants without legal status.

Â鶹ŮÓÅ Health News chief Washington correspondent Julie Rovner contributed reporting.

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

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After all-night markups, two key House committees approved GOP budget legislation that would cut hundreds of billions of dollars from federal health programs over the next decade, mostly from the Medicaid program for people with low incomes or disabilities. The legislation is far from a done deal, though, with at least one Republican senator voicing opposition to Medicaid cuts.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. testified before Congress for the first time since taking office. In sometimes surprisingly combative exchanges with lawmakers in the House and Senate, Kennedy denied cutting programs despite evidence to the contrary and said at one point that he doesn’t think Americans “should be taking medical advice from me.”

This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Julie Appleby of Â鶹ŮÓÅ Health News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• House Republicans this week released — then quickly ushered through committee — major legislation that would make deep cuts to federal spending while funding President Donald Trump’s domestic priorities, including renewing tax cuts and boosting border security. A preliminary estimate by the Congressional Budget Office found the bill would cut at least $715 billion from federal health spending over 10 years — with most of that money coming from the Medicaid program.
• Overall, the House GOP’s proposal would make it harder to enroll, and stay enrolled, in Medicaid and Affordable Care Act coverage. Among other changes, the bill would impose a requirement that nondisabled adults (with some exceptions) work, volunteer, or study at least 80 hours per month to be eligible for coverage. But Democrats and patient advocates point to evidence that, rather than encouraging employment, such a mandate results in more people losing or dropping coverage under burdensome paperwork requirements.
• Republicans also declined to extend the enhanced tax credits introduced during the covid-19 pandemic that help many people afford ACA marketplace coverage. Those tax credits expire at the end of the year, and premiums are expected to balloon, which could prompt many people not to renew their coverage.
• And Kennedy’s appearances on Capitol Hill this week provided Congress the first opportunity to question the health secretary since he assumed his post. He was grilled by Democrats about vaccines, congressionally appropriated funds, agency firings, and much more.

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

Julie Rovner: The New York Times’ “,” by Rob Copeland.ÌýÌý

Alice Miranda Ollstein: ProPublica’s “” by Margaret Coker, The Current.

Julie Appleby: Scientific American’s “,” by Andrea Thompson.ÌýÌý

Joanne Kenen: The Atlantic’s “,” by Nicholas Florko.

Also mentioned in this week’s podcast:

• Politico’s “,” by Alice Miranda Ollstein.
• The New York Times’ “,” by Sen. Josh Hawley (R-Mo.).
• NPR’s “,” by Pien Huang.

[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.]Ìý

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for Â鶹ŮÓÅ Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 15, at 9:30 a.m. As always, and particularly this week, news happens fast and things might have changed by the time you hear this. So, here we go.Ìý

Today we are joined via videoconference by Alice Miranda Ollstein of Politico.Ìý

Alice Miranda Ollstein: Hello.Ìý

Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.Ìý

Joanne Kenen: Hi, everybody.Ìý

Rovner: And my Â鶹ŮÓÅ Health News colleague Julie Appleby.Ìý

Julie Appleby: Hi.Ìý

Rovner: No interview this week because so much news, so we will get straight to it. So, quiet week, huh? Just kidding. The House Ways and Means and Energy and Commerce committees completed all-nighter markups on their portions of President [Donald] Trump’s “one big, beautiful” reconciliation bill. And in fact, Ways and Means is officially calling it the “One, Big, Beautiful Bill” in its summary of the measure.Ìý

We will start with Energy and Commerce, which after a 26-hour marathon, one hour short of the record it set in 2017, voted out its part of the bill Wednesday afternoon, including an estimated $715 billion in reductions to health programs, mostly Medicaid, over the next 10 years. Now, the final committee bill does not include the threatened cuts to the 90% match for the Affordable Care Act expansion population, nor does it include the per capita cap for that population.Ìý

Nonetheless, it would represent the biggest cut to Medicaid in the program’s 60-year history. Guys, tell us some of the things that it would do instead to get to that $715 billion amount.Ìý

Kenen: The 715 includes some ACA cuts as well. It’s not 100% Medicaid, but it’s largely Medicaid. The biggest one is the one that we knew was almost inevitable given the current Congress, which is work requirements. It is something the Republicans have wanted a long time. In the prior administration, a few states did pass them. Arkansas got going with them. The courts stopped it.Ìý

The Medicaid statute is pretty clear that it’s about health, not about health for working people. The courts today are different. If I had to guess, I would guess there will be a legal battle and that the courts are likely to uphold work requirements.Ìý

Rovner: We’ll talk more about work requirements in a minute. But what else is in the bill?Ìý

Kenen: There’s lots of extra layers of verification. Supposedly, it’s about fraud. We can get to the Kennedy testimony later, but there were some assertions that did not add up for me. The biggest thing is work requirements, and there’s other things that will make it harder to maintain coverage, that it’s not that tou’re getting kicked off, per se. And there are also some copays. There are some copays for the upper rank. There’s been a lot of information this week. And if I get any details wrong, because we’ve all had to absorb a lot in 48 hours, someone correct me. But my recollection was a $35 copay for certain treatments for the people who are on the higher end of the income.Ìý

Rovner: Right, meaning over 100% of poverty—Ìý

Kenen: Right.Ìý

Rovner: —but still under the level required to qualify for Medicaid.Ìý

Appleby: Right. It would require states actually to impose these cost sharings of up to $35 per service. Although they’re excluding some things like primary care, emergency stuff, that kind of thing, for people in that 100% of poverty to 138% of poverty, and there’s also an upper limit of 5% of the family’s income. But that’s a lot for people in that category.Ìý

Rovner: And we know, there is an enormous body of research that says when you put copays on services, people get fewer of them. And it’s not like people who are just scraping by have a lot of extra money to spend. So we know that one of the ways that they’ll save money is that people won’t get services, presumably needed services.Ìý

Kenen: Although the primary care exemption is important, because primary care, which also usually includes pediatricians, are considered primary care, can deal with a lot of diseases that you don’t always need to see a specialist. I’m not saying it’s a good idea. I’m just saying in terms of an incentive to get basic care, keeping primary care free is an important distinction.Ìý

Rovner: Well, I do want to talk a little bit about that work requirement, which Massachusetts Democratic Rep. Jake Auchincloss called not a work requirement but a paperwork requirement. Once more, for those who haven’t heard us explain this 100 times, it’s not just people who don’t work who lose coverage because of this. I see you nodding, Alice. Please explain this again.Ìý

Ollstein: Yes. So Democrats really hammered over the course of this 26-hour hearing that the only states that have made a foray in this direction so far, Arkansas and Georgia, have seen that these work requirements do not boost employment. They kick people off who should have been eligible because they can’t navigate, like you said, the paperwork. And so it was really striking, over this hearing, where — I watched from 8 a.m. Wednesday to 2 p.m. Wednesday — and during that whole time, every single amendment vote was party-line. Nobody crossed in either direction. So this was really a political exercise in Democrats because they were not able to convince Republicans to change or soften the bill at all. They really focused on branding it, branding it as punishing the poor and threatening their health care.Ìý

And so they were pointing to what happened in Arkansas, what happened in Georgia, where the work requirements really were successful in only that they cut people from the rolls and saved the states money, not successful in helping people find work or helping people get coverage. They also made an effort to brand the copays issue. I heard Democrats calling it a “sick tax.” We’ll see if that phrase sticks around throughout this process.Ìý

Rovner: So kind of in an interesting twist, the work requirements in the bill don’t become mandatory until the year 2029. That suggests to me that those who voted for this don’t really want it to take effect, but they do want to be able to count the savings to pay for other things in the bill. And then, cherry on top of the sundae, if Democrats want to repeal the work requirements later, they would have to find a way to pay for them, because the savings would get built into the budget baseline. Or is that just me being cynical because I’ve only had like five hours of sleep this week?Ìý

Kenen: Well, there are two important dates between now and 2029. One is the 2026 off-year elections, the House elections and some Senate, and then 2028 is the presidential. So there’s several things that have changed politically about Medicaid in recent years, which we can talk to and which I’ve written about quite extensively. One of them is that a lot of people who are Trump’s base are now on Medicaid and particularly that expansion population, and nobody likes having their health care taken away from them, particularly if it’s free or very, very heavily subsidized in the lower ranks of the exchanges.Ìý

So if you’re going to kick your own voters off of their health care, you’re probably more likely to want to do it after they voted for you again. It is not uniquely cynical. We have seen both parties do similar things over the years, either for budgetary game-playing or for political things. It’s quite notable that this goes into effect in 2029.Ìý

Ollstein: It’s just interesting that this is getting criticized from both sides. So Democrats are upset that Republicans want to reap the nominal savings but not have to look like the bad guy. And conservative Republicans are upset that this doesn’t kick in sooner, because they want stricter work requirements even sooner to cut the program even more. So it’s pleasing few.Ìý

Rovner: Well, as Joanne alluded to, it’s not just Medicaid. This bill is also a bit of a stealth assault on the Affordable Care Act, too. Right, Julie? We haven’t talked about it a lot, but this administration seems to be working very hard to make the ACA a lot less effective. And the combination of reductions in Medicaid and changes to the ACA will mean lots more people will be uninsured if this bill becomes law in its current form. Yes?Ìý

Appleby: There are a lot of moving parts to this. So yeah, let’s back up just briefly and look at March, when the Trump administration did propose their first major rule affecting the Affordable Care Act, and it’s called the Patient Protection and Affordable Care Act; Marketplace Integrity … it’s a long-name rule. Anyway, it does a bunch of things. For one, it shortens the open enrollment period by about a month. So open enrollment would end on Dec. 15. And notably, this would apply to all states that run their own state-based marketplaces, as well as the federal marketplace. So there’s 16 plus D.C. that do that. So they would all also be tied to this. So that’s one of the things that the rule would do if it’s finalized in its form.Ìý

It would also end a special enrollment period that allows low-income people to essentially enroll anytime during the year. And people who are automatically reenrolled in a zero-premium plan would instead be charged a $5 premium for reenrollment in that same plan until they confirm their eligibility. Now, the Trump administration says that a lot of these rules are in part to try to combat what they say is fraud and waste, and they point to situations where people are being enrolled without their permission or switched to different plans, generally these zero-premium plans, by unscrupulous brokers who are trying to get commissions.Ìý

We’ve written a lot about that over the past year. So they’re saying that, Oh, we need to do this so that people know they’ve been enrolled. The special enrollment period for low-income people they thought was part of that. That’s disputed by a number of places. And some of the states have pushed back on this, too, and said, Hey, we don’t have this problem with fraud, so why would this now apply to us? Why would the special enrollment period, the shortened enrollment period, etc., etc.?Ìý

So those are things in the proposed rule. And the proposed rule acknowledges that it would reduce enrollment by about up to 2 million people in 2026, with coverage losses concentrated in a bunch of states like Alabama, Florida, Georgia, etc. So that’s the proposed rule. And then if you look at the House bill, like, for example, Energy and Commerce, these would codify some of those proposals from that ACA rule. So it would make it harder for a future president to change the rule and that kind of thing.Ìý

So those things that are codified would be — there’d be more hoops to jump through to verify income, for one thing. That special enrollment period based on income would be barred, and the shorter enrollment period would be in it. And if this goes through, these changes are set to go into effect next year. So a lot of insurers and states would have to scramble to try to get this put in place by then. So that’s just a short thing about what some of the ACA effects would be.Ìý

Rovner: So, it feels like there’s kind of a theme here that’s going to make it harder for people to get on and stay on both the ACA and Medicaid. Is that sort of a fair way to describe this?Ìý

Appleby: Yeah, that’s fair. In the House bills, there are also a lot of things that would bar automatic reenrollment, which a lot of people rely on. People just don’t go back in and sign up for their coverage. They’re automatically reenrolled. The bills differ a little bit. The harshest one would require everybody to sort of verify their income before they can reenroll. There would be a lot more of that. So it would essentially bar reenrollment. And we haven’t even talked about the enhanced tax credits, because that’s also sort of fitting here.Ìý

Rovner: Which was my, yes, my next question. So there’s been a lot of fighting this week about how many people would lose coverage as a result of this bill, and a lot of it is sort of philosophical fighting. We don’t have final CBO [Congressional Budget Office] numbers yet. We may not have them for another week, I am told. But what we do know is one of the things this bill could do but doesn’t do is re-up those additional subsidies that were installed during the Biden administration, during covid, that basically effectively doubled the number of people who enrolled under the marketplaces, right?Ìý

Appleby: It certainly added a lot. Most people who get a subsidy are benefiting from the enhanced subsidies. And remember, these sort of expanded at the lower end and it cut off that cliff at 400% of the poverty level that used to exist where you wouldn’t get a subsidy if you made more than that. So it smoothed all that out. So a lot of people are getting these extra subsidies.Ìý

And a lot of the data I’ve seen have said — I’m looking at an Oliver Wyman report earlier — something like, if these enhanced subsidies are allowed to expire at the end of this year, which they’re poised to do unless Congress acts, that, on average, premiums would go up by about 90%. That will be enough to cause a lot of people not to reenroll. So that’s where we’ve seen some of these estimates of I think it’s around 5 million people may not reenroll as a result of that over time.Ìý

That’s a pretty big number. But like you said, there’s a lot of numbers in the mix, but the enhanced premium subsidies do cost taxpayers. It’s not inexpensive. So if they’re looking for savings, which they are, Congress may decide not to extend them. But at the same time, many people and in a lot of states that are dominated by the GOP and others, people are getting these subsidies, and it would suddenly be a huge hit to many people to have a 90% increase in their premiums, for example.Ìý

Rovner: Yeah, as Joanne said. Which you’re about to say again, right? These are Republican voters now, right?Ìý

Kenen: I think that’s more mixed, the upper income within the ACA. We’ve expected that to go away, because there’s a difference between Congress having to yank something away versus something in the law that expires and they have to proactively renew it. We have always anticipated that enhanced subsidies would decline this year. But I just sort of want to point out, during the first Trump administration, without all this coverage, the uninsurance rate rose in the country.Ìý

And that even before ’29, there are all sorts of things, with shortened enrollment periods, how much outreach they do, there’s lots of things even before 2029 that we can expect a fairly significant erosion of health coverage. Not to what it was in pre-ACA levels — it’s not going to be that extreme, and not all the benefits that those of us with employer-sponsored insurance also get, some things through the ACA.Ìý

So this is not repeal — it’s damage. And it’s more damage than they did in the first Trump administration. All of us would be extremely surprised if there was not a significant drop in the number of insured Americans one, two years from now.Ìý

Rovner: One of the ways conservatives hope to secure the votes for this bill in the House is a provision that would bar Planned Parenthood from the Medicaid program. This would certainly be popular in the House. But when it was in the Affordable Care Act repeal bill in 2017, the Senate parliamentarian ruled that it couldn’t be included in budget reconciliation, because it is not primarily budgetary. Alice, are House leaders just hoping no one will remember that?Ìý

Ollstein: If at first you don’t succeed, try, try again. Yes, I think so. And especially because we just got a new CBO estimate of what the budgetary impact of cutting these funds would be. And it’s, like they have found before, it does not save money. It actually costs the government money because people lose access to contraception and don’t have other sources that they can afford to obtain contraception. And it’s a lot more expensive to have a baby on Medicaid than to access contraception. So I think that also contributes to the parliamentarian problem.Ìý

Rovner: Yes. You can put stuff in reconciliation that costs money, but that was sort of not the intent here. Joanne, you wanted to say something.Ìý

Kenen: And we should point out that this is still at the committee level, right? Is it going to get through the House in this exact form? We can’t be sure yet. Is something going to get through the House at the end of the day? Yes. Yes. But is all of this going to get in? Is this the final draft? Probably not. You have moderates who are still, don’t like some of the things in here, and you have conservatives who think it doesn’t go far enough.Ìý

As we said at the beginning, as far as it does go, it does not go anywhere near as far as the initial, of some of the things that were being discussed, which really would have ended Medicaid as an entitlement. These are big changes. They’re not existential in the same way that a per capita cap or a block grant or blowing up the ACA expansion by changing the rates. There are things they could have done that were far more radical that they don’t have the votes for. And—Ìý

Rovner: But they still can only lose, what, three or four votes and get something through the House.Ìý

Kenen: Right. Right. Because Medicaid is actually quite popular, and people in both parties are covered by it. We still don’t know the pathway, what gets through the House at the end of the day. Something does, right? We all think that they will, somehow or other. Not necessarily by Memorial Day, right? But something at some point will get through the House, and we don’t know exactly what it looks like.Ìý

Rovner: For the record, I’m still shrugging. I think something gets—Ìý

Kenen: And it is a bigger question mark, you know?Ìý

Rovner: Which is my next question. What are the prospects for this bill in the Senate? Do we really believe that the very conservative Missouri Republican Josh Hawley would vote against this? He had a piece in The New York Times this week saying, “.”Ìý

Kenen: He’s been really consistent. Have we seen politicians do huge flip-flops in our years of covering Congress and politics? Yes. He’s really out there on this. It’s sort of hard to see how he just says, Whoops, I didn’t really mean it. But right now in terms of who’s out there in public, we don’t have a critical mass of people who’ve said they can’t vote for this. But we do know there are provisions in this very extensive bill that some people don’t like. It will go through changes in the Senate.Ìý

I don’t have a grasp and I don’t think any of us have a grasp on exactly what’s going to change. I think work requirements, depending on what bells and whistles are attached, could get through the Senate. There might be changes like making it a state option or redefining certain things with it. I think there probably are 51 votes for a work requirement of some type in the Senate.Ìý

That doesn’t mean the way this has been written survives. And there’s just — these are big cuts. And there’s also, remember, we’re only talking about the health stuff. There’s a lot. There’s energy. There’s all sorts of — this is a big bill. This is a big, historic bill. There’s lots and lots of hurdles. We all remember that the ACA repeal, it took several tries. It was really harder than expected. It finally got through the House, and it did die in the Senate. So this is not the last word. We don’t have to shut the podcast.Ìý

Rovner: Yes, long way to go. All right, moving on. Health and Human Services Secretary Robert F. Kennedy Jr. testified before not one but two committees on Wednesday: the House labor, HHS Appropriations subcommittee in the morning and the Senate Health, Education, Labor, and Pensions Committee in the afternoon. And shall we say it didn’t all go swimmingly. Right off the bat, this was the greeting he got from House Appropriations Committee ranking member Rosa DeLauro of Connecticut. DeLauro basically saying, Everything you’re doing is illegal.Ìý

Rep. Rosa DeLauro: Mr. Secretary, this administration is recklessly and unlawfully freezing and stealing congressionally appropriated funds from a wide swath of agencies, programs, and services across the government that serve the American people. And recall that this is a violation of the Constitution.Ìý

The power of the purse resides with the Congress. It’s Article 1, Section 9, Clause 7. Yourself and President Trump and Elon Musk are attacking health programs to pay for tax cuts for billionaires. And by promoting quackery, we are endangering the health of the American people with pseudoscience, fearmongering, and misinformation.Ìý

Rovner: If you want to hear more, we did a live recap of the hearings yesterday afternoon. You can find that on . But I want to know what you all took away from the hearings. Joanne, you watched most of them, right?Ìý

Kenen: I watched a lot of it. I did not watch every minute of both hearings, but I watched enough. And I thought that very first exchange with DeLauro was really striking because she kept saying, over and over and over again she kept saying: Congress appropriated this money. You don’t have the right to not spend it. And he kept saying, If you appropriate the money, I will spend it. And she said, We have appropriated the money, and you’re not spending it. And he said, If you appropriate the money …Ìý

And she explained. What a continuing wrestle. It was like this endless — well, it wasn’t endless, but it was repeated when she kept saying, We appropriated it, and he kept saying, Huh? And she actually said the first time sort of under her breath, but the mic picked it up, and then she said it again. She said, “Unbelievable.” She’s not known for understatement, but she said, “Unbelievable.” And then she said it again. “Unbelievable.” So that was sort of — the rest of the day was sort of there.Ìý

Rovner: Yeah. I personally found it refreshing that someone finally called out HHS, saying: You know, there was an appropriations bill that got signed by the president, and you are withholding this money. And this is our province. We get to decide how the money is spent. You don’t get to decide how the money is spent. The other big headline that came out of this hearing was when Kennedy said that, after being raked over the coals again about his vaccine comments, he said, Well, you shouldn’t be taking medical advice from me. And I’m like, isn’t that the job of the HHS secretary?Ìý

Ollstein: It was very clear that, like in the markups of the bill, Democrats, unless Republicans are willing to cross the aisle and join them, are just left sort of railing against what’s happening and not really having any power to impact it. We did see some Republicans expressing some concern about the cuts that have happened. But unless that turns into real oversight action, real legislative action, I just imagine we’re set up for this to happen again where Congress appropriates and the cuts happen anyway.Ìý

Rovner: I was surprised at how much Sen. Cassidy, Sen. Bill Cassidy, the chairman of the HELP Committee, didn’t say. He basically said when he voted for Kennedy’s nomination that he was torn. He believes in vaccines. He’s a practicing doctor. He, Cassidy. And he made Kennedy promise that he wasn’t going to change any of these vaccine rules, which he’s already done. And he’s installed anti-vax people at many levels of HHS. And yet Cassidy was incredibly conciliatory in his opening statement.Ìý

And it was left to Chris Murphy of all people, the firebrand Democrat from Connecticut, to basically be Cassidy’s anger manager. And sort of, he said, “If I were the chairman … my head would be exploding,” which I believe is a line that I’ve been saying for the last several months. What’s happening with Cassidy? Do we know? He can’t be happy with what’s happening here.Ìý

Ollstein: This was well previewed by everything Cassidy has sort of put out publicly since the confirmation hearing. If you track his press releases, they’ve been sort of selectively praising HHS for doing certain things and being silent on the things that we imagine he might not like on the vaccine front. And so that dynamic carried forward right into this hearing, which was the first opportunity for Congress to really grill Kennedy since he’s taken office.Ìý

And so many people have pointed out that Cassidy is up for reelection. He is facing a primary challenge from the right. He wants to align himself with the Trump administration and with the sort of “MAGA [Make America great Again]” movement. And he has pushed back on accusations that his treatment of Kennedy is influenced by that, but people can draw their own conclusions.Ìý

Kenen: I also wanted to point out that Kennedy insisted that he hadn’t fired any scientists, and he made that assertion a few times, which I think the Democrats, their jaws collectively dropped in unison. The cuts to NIH [the National Institutes of Health] have been extreme, in the billions. And in addition to the NIH scientists, there are also the ripple effect of training the next generation of scientists, because of the cuts to universities.Ìý

And also Kennedy, I sort of noticed at one point he was saying something about some universities don’t need this money, but then he mentioned specifically but Maine, where Susan Collins is the chair of the Appropriations Committee of the Senate, and Alabama, where Katie Britt has been, Sen. Katie Britt, has been sort of vocal about this, which is also, people don’t think of or may not realize that University of Alabama is a huge scientific center.Ìý

It is a powerhouse, but it is a state-funded university without such a big environment. Kennedy said: You know what? We’re going to make these cuts. But maybe not Maine and Alabama. It was like — talk about politics. But I think that they were really floored when he said over and over again that no scientists have been let go.Ìý

Rovner: You were right. There was also a lot of sort of ad hoc, If you have a particular problem, why don’t you—Ìý

Kenen: Call my office.Ìý

Rovner: —call my office. Yeah. And we can take care of it. Which seemed just sort of mind-blowing to me. It’s like, this is how we’re making policy now. And somebody, I meant to go back and look at who, somebody in the morning at the House hearing, one of the Democrats, said, Is there a special phone number for Democrats to call your office to see if we can get some of these cuts restored? That literally seems to be how HHS is being run right now.Ìý

Ollstein: And I think it’s reflected across the government. When Elon Musk was more involved directly with the DOGE [Department of Government Efficiency] stuff, he was reportedly telling Republican senators the same. Oh, if you have an issue, you know, just text me, just call me. And folks who study government pointed out that this smacks of the kind of personalism that has defined some authoritarian governments in the past where things happen more through favors than through normal government processes that are more transparent.Ìý

Kenen: And a phone call from your senator is not how you should be able to get back into a clinical trial. There was also a lot of exchanges about what’s happening to clinical trials and harm to patients, which he was — there was some gaps there. And you’re watching him saying, Oh yeah, I can get her in. Just, you call me tomorrow. Call my office, to Sen. [Patty] Murray. And the state of him asserting that not much has changed and anything we got wrong we’ll fix versus the fact that huge numbers of things have changed that have affected both patients and future patients.Ìý

One of the Democrats said: What’s wrong with researching cancer and Alzheimer’s, particularly if you’re trying to deal with chronic diseases? These are chronic conditions, and we’re gutting research into them. So there was a lot of disconnects. There was some, also—Ìý

Rovner: It’s not just cuts. They are pushing the “Make America Healthy Again” agenda. Just this week the FDA [Food and Drug Administration] is for kids. These are generally drops, tablets, and lozenges prescribed to kids who live in places that don’t have fluoridated water.Ìý

This move contradicts recommendations from both the CDC [Centers for Disease Control and Prevention] and the U.S. Preventive Health Services Task Force. And RFK was taken to task at the House hearing by Congressman Mike Simpson of Idaho, who’s one of a handful of dentists in the chamber. I have to say I didn’t have eliminating fluoride on my 2025 public health bingo card.Ìý

Ollstein: Yes. And I think that this is raising concerns for a few reasons. One, the public health impact. This goes against decades of research and evidence and the medical community’s consensus. But this also is moving sort of beyond the personal-choice, medical freedom kind of framing that has been used to argue about fluoridating public water. This is taking away a parent’s choice, potentially. If they want these supplements for their kids, they’re not going to be available any longer. And this is exactly what people fear could extend into the vaccine space. It’s not just that it’s going to not have mandates for schools or rules around that, that it won’t even be an option for the people who want it.Ìý

Rovner: All right, well, moving on to abortion, the one piece of potential news out of the Kennedy hearings came in response to a question from the aforementioned Sen. Josh Hawley from Missouri about a new study claiming that the abortion pill mifepristone has way more complications than numerous studies over the past 40 years it’s been in use have found. Alice, tell us about this particular study, which RFK Jr. suggested might prompt the FDA to change the status of the abortion pill.Ìý

Ollstein: So, one, it’s not a study. Even its supporters admit in private that it’s not a study. that a lot of these groups pushing this held recently to talk about how they hoped to use this information to influence government policy. And they noted that because this is something that a conservative think tank just put out themselves, they did not submit it to a medical journal. It did not go through peer review.Ìý

So they said directly that it is not a study in the traditional sense. Still, you have senators and now the secretary of health and human services referring to it as a study and calling for policy changes based on it. So I want people to keep that in mind as this is discussed going forward. These drugs have been available for 25 years now. There have been lots of more rigorous, peer-reviewed studies that have found them to be overwhelmingly safe and effective.Ìý

Some of this new data actually aligns with some of the findings from those previous, more rigorous studies, but their own unique definitions of certain things, calling some things adverse events when the FDA does not consider that to be so, and so medical experts told me, including some from Â鶹ŮÓÅ, that this has so many red flags that they think it could never have been published in a credible medical journal.Ìý

Rovner: And just to clarify, while we’re talking about different time periods: It’s been available in the U.S. for 25 years.Ìý

Ollstein: Yes.Ìý

Rovner: It’s been available internationally since the 1980s.Ìý

Ollstein: Right. Right.Ìý

Rovner: So, it has been well studied for quite a long time. Well, in other abortion news this week, the Texas Legislature is moving forward with a new piece of anti-abortion legislation that can’t be challenged in court, this one aimed at the abortion pill. Alice, this is like Chapter 2 in Texas trying to figure out how they can ban abortion-related things without anybody challenging the law, right?Ìý

Ollstein: There’s a lot of different moving parts right now. There’s that. There’s the new case that’s also pending in Texas, brought by three GOP states seeking to impose national restrictions on abortion pills. There’s this new review that the FDA is allegedly going to undertake around dispensing rules. And so this has been an overwhelming focus of the anti-abortion movement since even before Dobbs, but especially now.Ìý

They know that the ability of people to get these pills prescribed online, sent by mail, is the primary way that people are getting around state bans, other than travel, which is not always possible for folks. And so there are just efforts going on in state legislatures, in Congress, in the FDA, in state courts and federal courts, all to impose restrictions.Ìý

And so it’s a very throw-spaghetti-at-the-wall-and-see-what-sticks approach. But that has proven very effective for them over the decades. Arguably that’s how we got to where we are now, where abortion is banned in much of the country. So it’s something to take seriously and watch carefully.Ìý

Rovner: And this is Texas trying again with this. Individuals can sue other individuals who they think have used the abortion pill. It does not require the involvement of the state to prosecute, which has not, I don’t think, spread beyond Texas at this point, but it would be Texas’ second bite at this apple.Ìý

Kenen: But the proposed language in that bill is extraordinary. We at the state legislature of Texas is passing a bill and no court has the right to review whether it is constitutional, etc. It seems pretty extreme, right?Ìý

Rovner: Well, this was how Texas did their first ban.Ìý

Kenen: Right.Ìý

Rovner: Remember that the Supreme Court allowed it to stand because they weren’t quite sure what to do with it.Ìý

Kenen: But that was also because they did unique legal things in terms of, they sort of created a legal structure. This, the language is in the bill — and no court can double-check us.Ìý

Rovner: Yeah.Ìý

Kenen: So, and then what else can they use that for, right? And apparently there are even some Republicans who are a little concerned about that language. And I’m not up on the exact makeup of constitutional views of the entire Texas Legislature.Ìý

Rovner: Yes. We should point out, it hasn’t passed the full legislature yet.Ìý

Kenen: No. It’s proposed.Ìý

Rovner: Just the Texas Senate. It’s passed the Senate. We’re awaiting to see if it will pass the Texas House. All right, well, finally in this incredibly newsy week, just before he left for his overseas trip, President Trump unveiled what he touted as an enormous announcement that turned out to be an executive order basically wishing down drug prices by tying them to other countries’ price-controlled prices. Except this isn’t really going to happen anytime soon. Right, Julie?Ìý

Appleby: Well, it is interesting. It’s this “most favored nations” idea that we would tie drug prices in the United States to what’s paid by other countries where they have much stronger drug negotiation issues. And it’s not clear how it works. So yeah, it’s not clear what the path forward is with that.Ìý

Ollstein: The problem with saying drug prices are coming down is if they do not come down, people might be mad at you for saying they’re coming down.Ìý

Rovner: I would say he did wish down the price of eggs. He said that egg prices were coming down when they weren’t, except now they are, because he had nothing to do with them going up or coming down. It had to do with the bird flu. And so now he can say, See, I got egg prices down.Ìý

Kenen: But they’re still higher than they were when he—Ìý

Rovner: They are still higher than they were.Ìý

Kenen: But they have come down.Ìý

Rovner: But I will say, I was going to say, this is super-clever marketing. This is the one thing that President Trump is really, really good at. He hyped this announcement ahead of time. He actually got headlines insisting that this will really do something. I have had people tell me that they’ve had sort of their grown kids and stuff saying: Oh look, drug prices. He’s going to reduce drug prices. When in fact this is one of those executive orders that just doesn’t really do anything.Ìý

Kenen: We don’t know what’s going to happen to drug prices over the next four years. There’s a law on the books from the Biden administration. In his first administration, I think it might’ve even been a day or two before inauguration, he went on a tear against the drug companies. Remember, he called them killers or something like that. And he also came up with a list of something like 40-odd steps that he could take. And I think half of them had a question mark after them. So he’s been mad at drug prices for a while now. He did not achieve that in the first administration. That’s bipartisan. There’s no Americans who want to pay higher prices for drugs, unless maybe they work for a drug company. People want more—Ìý

Rovner: Right. It’s an 80/20 issue — 80% of people want drug prices down.Ìý

Kenen: Right.Ìý

Rovner: That’s probably more than an 80/20 issue.Ìý

Kenen: There could be some room for bipartisanship on drugs. There’s not a lot of room for bipartisanship, but that’s particularly if he’s not trying to repeal what [President Joe] Biden did, if that stays or gets built on. We don’t know what’s going to happen. But no, you can’t just sign an executive order. It’s not a magic wand.Ìý

Rovner: And I don’t think we’re going to be importing other countries’ price controls anytime soon. I’m going to go on a limb on that one. All right, that is this week’s news. Now it is time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Alice, I want you to go first this week because you have a story that’s directly relevant to something that we talked about in the Medicaid discussion.Ìý

Ollstein: Yeah. So I have this great story from ProPublica [“”] about Medicaid work requirements and about how the small-business owner that Georgia decided to make the face of its program, and they filmed a video of him praising it, even he multiple times lost his coverage, even though he tried to do everything right. He logged his work hours. He signed up for alerts. And just because of bureaucratic things and falling through the cracks, two times he lost his coverage and he had to plead for someone to intervene to get him his benefits back. And he has really soured on all of this, even though he was the face of selling it that the governor used. So I think this is a great example of what could happen as this is debated as a national policy.Ìý

Rovner: And I will say, I learned about this ProPublica story from the markup, where a number of members brought it up. He’s now the poster child for what happens when you have work requirements, even if people are working. Joanne.Ìý

Kenen: There’s a great piece in The Atlantic by Nick Florko called “.” And although it is not in the headline, it’s particularly romaine, which has periodically been in the news as being a source of harmful bacteria. And if you think you can just buy bagged lettuce and wash it yourself and it’ll be safe — no, that doesn’t work, either.Ìý

Basically it goes through like the equivalent of a salad woodchopper and there are all this different lettuce. All this lettuce goes through it. And once one blade gets contaminated, it all gets contaminated. So also, if you are a part of a marriage or one of you likes romaine and the other one would rather have red leaf, this is pretty good ammunition, right? But we should be going back to buying heads of lettuce, washing them yourself.Ìý

And they’re not as safe and sanitary as it sounds, particularly as some issues are going on right now. And of course, we have less public notification and less monitoring and there’s less, less, less of food safety kinds of things coming down the pike at FDA. So it’s even more timely.Ìý

Rovner: It’s a pretty vivid story. Julie.Ìý

Appleby: Thanks. Mine is also, the story I’ve picked is also along the same lines of cuts and what the perhaps unintended consequences were, but the consequences nonetheless. And it’s from the Scientific American. It’s by Andrea Thompson. The headline is “.”Ìý

And it just talks about the National Weather Service with a lot of interesting facts that I didn’t know for sure, that how the improvements have been made in forecasting, why this is important, and how it’s understaffed, and how these cuts are going to just make things worse. And it talks about it costs the average American, it says, about $4 a year for the National Weather Service. “It’s a cup of coffee,” said one person that’s being quoted.Ìý

And it said the National Weather Service provides an overall benefit of $100 billion to the economy. Aside from the fact that you might want a tornado warning ahead of time, that kind of thing, this is also just really important to quantify the overall value at a time when we are seeing a lot of hurricanes and tornadoes and other climate issues going on. So that would be my pick.Ìý

Kenen: But the Sharpie can just make it move.Ìý

Rovner: Yeah, that’s true. All right, my extra credit this week is what Joanne has dubbed “Theranos for Pets,” though the actual headline in The New York Times is “.” And it’s kind of a scary history-repeats-itself story. Even as Elizabeth Holmes herself remains in jail, having been convicted of fraud over her novel blood-testing company that was really cool but also didn’t work, her partner and the father of her two children, Billy Evans, is raising money for a new blood-testing company.Ìý

He’s called it Haemanthus — I hope I’ve said that right — which is a flower also called the blood lily. And unlike his incarcerated partner, Evans plans to start out by testing the blood of pets, then move to humans. As they say, what could possibly go wrong?Ìý

All right, that is this week’s show. 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. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Yang. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, , or on Bluesky, . Where are you guys hanging these days? Julie Appleby.Ìý

Appleby: I’m still on X, .Ìý

Rovner: Joanne.Ìý

Kenen: I’m only a little . I’m more on and , @joannekenen.Ìý

Rovner: Alice.Ìý

Ollstein: Mostly on Bluesky, , and still on X, .Ìý

Rovner: We will be back in your feed next week. Until then, be healthy.Ìý

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Greenseid’s daughter has Type 1 diabetes, which means she requires daily injections of manufactured insulin to stay alive. The price of a single vial of insulin between 1996 and 2018, and the gold vial was a reminder, Greenseid said, that this lifesaving pharmaceutical shouldn’t be as expensive as precious metal.

“What I heard is that that gold vial remained on his desk at the governor’s office, and he brought it up throughout that summer and fall when he was trying to talk to legislators to get them moving,” Greenseid said.

Ten months later, in April 2020, Walz signed the . The law was named after the 26-year-old Minnesotan whose from rationing insulin for the patient the high cost of insulin in the U.S. into a national political priority.

Now it’s an issue in the presidential campaign. Both former President Donald Trump and Vice President Kamala Harris and her running mate, Walz, have sought to appeal to the nation’s 8.4 million insulin users and their families by touting policies that make insulin cheaper for some patients.

But advocates for diabetes patients fret that neither presidential candidate would go as far as Walz’s Minnesota law, which helps patients even if they are uninsured, despite the law being under legal attack by the drug industry.

The landscape on insulin pricing has already changed significantly in the past five years. One month after Walz signed the Minnesota law, the Trump administration announced a voluntary program for Medicare prescription drug plans to cap copayments for some insulin products at $35. Two years later, President Joe Biden signed a law to cap copayments for insulin at $35 a month.

Now, amid the current presidential campaign, Harris has proposed extending that $35 cap on insulin copayments to Americans with commercial health insurance.

The Trump campaign’s national press secretary, Karoline Leavitt, touted his efforts on prescription drug prices when he was in the White House, including approval of a pathway for prescription drugs to be imported from Canada as well as the voluntary $35 insulin Medicare copayment cap. But she did not offer new insulin-specific initiatives for his possible second stint as president.

“President Trump will finish what he started in his first term,” Leavitt wrote in a statement.

Copayment caps, which , are popular policies because they provide an immediate financial benefit that many patients see at the pharmacy, according to University of Southern California economist . They’re also relatively easy to implement.

But copayment caps don’t address the high list price of insulin itself, so uninsured patients don’t benefit from such rules. About 1 in 12 Americans lacked health insurance last year.

That’s what makes Minnesota’s insulin safety net different. The system has two parts: an that allows individuals to get a one-time, 30-day supply of insulin for $35, and a that provides insulin to eligible patients for a year at no more than $50 for a 90-day supply.

By contrast, list prices for a 30-day supply of insulin can easily top $215, depending on the insulin.

The bill that created Minnesota’s program was bipartisan out of necessity. Republicans controlled the state Senate at the time, while the Minnesota Democratic-Farmer-Labor Party held the House and governor’s office.

Nicole Smith-Holt, whose son the bill was named after, as it finally passed the state legislature in 2020.

“I was happy. I was relieved,” Smith-Holt said. “I was sad that it took Alec dying to get to the point where people could walk into the pharmacy and pick up their prescription for an affordable price.”

But because Minnesota’s program requires insulin manufacturers to provide the insulin, it has prompted a backlash from manufacturers. Pharmaceutical industry lobbying group PhRMA filed a , arguing it violates the “” of the U.S. Constitution, which says private property can’t be taken for public use “without just compensation.”

That suit is ongoing, yet the state program is up and running and by the end of 2023 it had been .

PhRMA spokesperson Reid Porter said his group is committed to helping patients afford medicines. Insulin makers voluntarily dropped list prices last year and now offer patient assistance programs for affording the drugs. And the the voluntary Medicare copay cap Trump announced in 2020.

Porter said insulin costs have been driven up by insurance companies and pharmacy benefit managers, also — the middlemen between insurance plans or employers and drug manufacturers — when they pocket the discounts from the list price of drugs that they negotiate with manufacturers.

“Minnesota’s insulin program does not solve this problem and is unconstitutional,” Porter said. “This is not how the system should work, and why it’s critical that policymakers should prioritize reforming the PBM system, a solution that puts patient health over politics.”

In 2021, Sood that found that, despite insulin list prices rising between 2014 and 2018, income received by drugmakers decreased while increasing for intermediaries like PBMs and pharmacies.

In September, the Federal Trade Commission against the nation’s three biggest PBMs, alleging they created a system that inflated insulin prices. The .

, a physician at the University of Pittsburgh, said that regardless of who wins in November he doesn’t expect existing insulin policies like Medicare’s to be rolled back, due in part to the advocacy of people like Smith-Holt and Greenseid.

“They’ve been really effective at tying high insulin prices with really bad, morally repugnant outcomes,” Luo said.

The key in Minnesota was including real stories, Greenseid said.

“We had enough real people who reached out and had conversations and helped to show politicians the extent of the problem,” Greenseid said, “and they listened.”

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That must be a mistake, she told the pharmacy. But it wasn’t. It turned out that the health insurance plan through her husband’s job had a new program in which it stopped applying any financial assistance they received from drugmakers to the family’s annual deductible.

Insurers or employers can tap into funds provided to patients by drugmakers through copay assistance programs, which were designed by the companies to help patients afford increasingly expensive medications. But, because those payments are no longer counted toward the deductible, patients must pay an amount out-of-pocket, too, often for the same drugs. Those deductibles or other out-of-pocket costs can easily run into thousands of dollars.

Here’s what that meant for Hepworth, who lives in Utah. Before the change, the drugmaker’s copay assistance would almost immediately meet her family’s deductible for the year, because both Hepworth and her daughter need expensive medications. As a result, the family was responsible for copays of only 20% of their medical costs instead of the 100% required by their plan until they met their deductible. By the middle of the year, the family would have reached the plan’s out-of-pocket maximum of nearly $10,000 and would no longer owe any copays.

Hepworth ended up paying the $3,500 to the pharmacy, equivalent to the family’s annual deductible, because she didn’t want to stop giving her daughter a treatment that could extend her life. “We were struggling and everything went on credit cards.”

Why did the insurer do this?

Employers or the health insurance plans they hire are saving 10% to 15% of the cost of prescription plan claims by using these copay accumulator programs, said Edward Kaplan, a , a benefits consulting firm. Even so, Kaplan doesn’t recommend that his clients, who include public and private employers, take advantage of the program because of the increasing pushback from lawmakers and advocacy groups. However, are in plans governed by these types of programs, according to Avalere, a consulting firm.

now limit copay accumulator programs for some insurance plans. And patient advocacy groups against the programs. States’ limits on the practice, however, do not apply to larger, self-insured job-based plans, through which many Americans have coverage.

Bipartisan legislation has been introduced in both chambers of Congress that would require financial assistance to count toward deductibles and other out-of-pocket costs. Called the , it would govern plans that are exempt from state rules.

Change is unlikely to come soon.

Insurers and employers have long complained that copay assistance programs are mainly a marketing ploy by the drug industry that encourages patients to stay on costly drugs when lower-cost alternatives might be available. Insurers say capturing more of that money themselves can help slow the rising price of premiums.

In a , the Blue Cross Blue Shield Association called the practice “a vital tool in keeping health insurance affordable.”

Patient advocacy groups, including the and two diabetes groups, disagreed and took a case against copay accumulator programs to U.S. District Court last fall.

And “we won,” said Carl Schmid, executive director of the institute. The groups argued the practice can cause some patients to skip their medications because of the unexpected costs they must now shoulder.

Some critics say it’s a form of double dipping because even though the patient hasn’t personally paid out-of-pocket, “that payment was made, and it was made on your behalf. I think that should get counted,” said Rachel Klein, deputy executive director with the , an advocacy group.

, Schmid said, essentially overturns a 2021 provision in Centers for Medicare & Medicaid Services rules that allowed insurers to expand the practice to cover almost any drug. Previous rules from 2020 would now be in effect, said Schmid, and those rules say copay assistance should count toward the deductible for all drugs for which there is no medically appropriate generic alternative available.

Even so, billing changes for many insured patients may take a while.

While the Biden administration of the court decision, it has filed motions noting “it does not intend to take any enforcement action against issuers or plans” until regulators draw up new rules, said Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS, in a written statement to Â鶹ŮÓÅ Health News.

A version of these programs being used by insurers, sometimes called a “maximizer,” works a bit differently.

Under a maximizer program, insurers partner with outside firms such as and . The programs declare certain drugs or classes of drugs “nonessential,” thus allowing them to circumvent some Affordable Care Act rules that limit patient cost sharing. That lets the insurer collect the maximum amount from a drugmaker’s assistance program, even if that is more than the patient would owe through deductibles or out-of-pocket maximums had the drugs remained essential benefits. These partner companies also work with large pharmacy benefit managers that oversee prescription services for employers.

Those maximizer payments do not count toward a patient’s deductible. Many insurers don’t charge patients an additional copay for the drugs deemed nonessential as a way of enticing them to sign up for the programs. If patients choose not to enroll, they could face a copayment far higher than usual because of the “nonessential” designation.

“This is a loophole in the ACA that they are exploiting,” said Schmid of the HIV+Hepatitis Policy Institute, referring to the Affordable Care Act. Johnson & Johnson filed a lawsuit in federal court in New Jersey in 2022 against such a maximizer program, saying it coerced patients into participating because if they didn’t they faced higher copays. The drugmaker warned it might reduce the amount of overall assistance available to patients because of the increasingly common practice.

Now, though, a provision in the governing health insurers says plans must consider any covered drug an “essential benefit.” If finalized, the provision would hamper insurers’ ability to collect the maximum amount of drugmaker assistance.

Employers are watching for the outcome of the lawsuit and the proposed federal rules and don’t yet have clarity on how rulings or regulations will affect their programs, said James Gelfand, president and chief executive of the ERISA Industry Committee, which advocates for large, self-insured employers.

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La inscripción abierta comienza el 1 de noviembre para el mercado federal, , y los mercados estatales. Los consumidores pueden ir en línea, llamar o buscar ayuda de un corredor, o un navegador, para conocer sus opciones de cobertura para 2024, calcular sus posibles subsidios o cambiar de plan.

En la mayoría de los estados, la inscripción abierta dura , aunque algunos tienen períodos diferentes. El de California, por ejemplo, es más largo, , pero el de va desde el 15 de octubre hasta el 15 de diciembre.

En general, la inscripción debe realizarse antes del 15 de diciembre para obtener cobertura que comience el 1 de enero. Si el plan se adquiere en enero, entrará en vigencia el 1 de febrero.

Expertos en política de salud y corredores recomiendan que todos los titulares de pólizas de ACA al menos revisen las opciones del próximo año, porque los precios, y los médicos y hospitales en las redes de los planes, pueden haber cambiado.

Podría ser otro año récord. Ahora estos planes están bien establecidos: se estima que más de 16.3 millones de personas se inscribieron el año pasado. Y este año podrían ser aún más. Se mejoró la ayuda disponible, cambios que se aprobaron en el apogeo de la pandemia de COVID-19 que siguen vigentes, y algunos estados han aumentado la ayuda financiera de otras maneras.

Además, millones de personas en todo el país están perdiendo la cobertura de Medicaid a medida que los estados reevalúan la elegibilidad de los afiliados por primera vez desde el inicio de la pandemia.

Muchas de las personas excluidas podrían ser elegibles para un plan de ACA. Pueden inscribirse tan pronto como sepan que están perdiendo la cobertura de Medicaid, incluso fuera de la temporada de inscripción abierta.

Una advertencia importante: no esperes hasta el último minuto, especialmente si estás buscando ayuda de un corredor. Este año, se les pedirá a los consumidores que que acordaron voluntariamente la ayuda de los corredores y que la información sobre sus ingresos y otros datos proporcionada por los corredores es precisa.

“Es una buena protección para ambas partes”, dijo el corredor , fundador de PA Health Advocates en Pennsylvania. Pero los corredores están preocupados de que este requisito pueda causar demoras, especialmente si los clientes esperan hasta último momento para buscar un plan médico.

Las primas están cambiando. Mientras que algunos planes de salud están reduciendo las primas (el pago mensual por la cobertura) para el próximo año, muchos las están aumentando, generalmente entre , según una revisión inicial de las solicitudes de tarifas de Peterson-Â鶹ŮÓÅ Health System Tracker. El aumento medio es del 6%.

Las primas, ya sea que suban o bajen, varían ampliamente por región y por aseguradora.

Expertos dicen que esa es una gran razón para iniciar una sesión en el sitio web federal, , en los 32 estados que lo utilizan, o en el mercado de seguros para uno de los que administran sus propias plataformas. Cambiar de aseguradora podría significar una prima más baja.

“Todo es muy localizado”, dijo , profesora de investigación y co-directora del en la Universidad de Georgetown. “La gente debería comprar para maximizar su subsidio, aunque eso podría requerir no solo cambiar a un nuevo plan, sino también a una nueva red de proveedores”.

La mayoría de las personas que compran su propia cobertura califican para créditos fiscales, que es un subsidio para compensar parte o incluso la totalidad de la prima mensual.

Los subsidios se basan en parte en la prima del segundo plan de nivel de Plata de precio más bajo en una región. Cuando estas primas suben o bajan, posiblemente porque una nueva aseguradora entra en el mercado con tarifas iniciales bajas, afecta la cantidad del subsidio.

Los ingresos del hogar también son un factor. Los subsidios se calculan en una escala móvil basada en los ingresos.

Los subsidios aumentaron durante la pandemia, para que más inscriptos pudieran recibirlos y para permitir que más familias calificaran. Esas mejoras se extendieron hasta 2025 por la Ley de Reducción de la Inflación del presidente Joe Biden, aprobada el año pasado.

Las calculadoras en línea, incluida una en , pueden proporcionar estimaciones de subsidios.

Es posible que califiques para deducibles y copagos más bajos. Además de los subsidios para las primas, la en estos planes califican para deducibles reducidos, copagos y otros tipos de costos compartidos si sus ingresos no superan 2.5 veces el nivel federal de pobreza, o para una familia de cuatro personas.

Los planes de ACA se agrupan en niveles de colores: Bronce, Plata, Oro y Platino, en gran parte según cuánto requieran de costos compartidos. Los planes de Bronce ofrecen las primas más bajas, pero generalmente los copagos y deducibles más altos. Los planes de Platino tienen las primas más altas, pero gastos de bolsillo más bajos para la atención médica

Las reducciones en los costos compartidos solo están disponibles en planes de nivel de Plata y son más generosas para aquellos en el extremo inferior de la escala de ingresos. Una novedad de este año: para ayudar a más personas a calificar, el mercado federal a las personas elegibles a un plan de Plata para el próximo año si actualmente están inscritas en un plan de Bronce, siempre y cuando el inscrito no haya hecho un ajuste en la cobertura por sí mismo.

Hay salvaguardias incorporadas, dijo , experta en seguros y corredora, para que las personas sean inscritas automáticamente en un plan con la misma red de proveedores médicos y una prima similar o más baja. Además, nueve de los estados que administran sus propios mercados, California, Colorado, Connecticut, Maryland, Massachusetts, Nueva Jersey, Nuevo México, Vermont y Washington, han mejorado sus programas de al extender la elegibilidad o aumentar los beneficios.

Algunos jóvenes de 26 años podrán permanecer en los planes de sus padres por más tiempo. Algunos que tienen cobertura a través de sus padres podrán permanecer en ella hasta el final del año calendario en el que cumplen 26 años, en lugar de perder la cobertura el mismo día de su cumpleaños 26. Esto se ha convertido .

Los estados que administran sus propios mercados pueden establecer reglas similares, y algunos ya permiten en el plan de los padres.

Las redes pueden seguir siendo pequeñas. A menudo, los planes de salud intentan reducir las primas asociándose con un conjunto limitado de médicos, hospitales y otros proveedores. Esos pueden cambiar de un año a otro, por lo que expertos en seguros como Norris dicen que los inscritos siempre deben verificar sus planes durante la inscripción abierta para asegurarse de que sus médicos y hospitales preferidos estén incluidos en la red. También es una buena idea observar detenidamente los cambios en la cobertura de medicamentos recetados o en los copagos, agregó.

“El mensaje general es no asumir nada y asegurarse de verificar quién está en la red”, enfatizó Norris.

El año pasado, la administración Biden estableció reglas que requerían que los planes de salud tuvieran suficientes proveedores en la red para cumplir con estándares específicos de tiempo de viaje y distancia. Una propuesta para limitar cuánto tiempo esperan los pacientes para una cita de rutina se ha retrasado hasta 2025.

Lo que todavía no sabemos. Hay algunas cosas inciertas a medida que se acerca el final del año. Por ejemplo, la administración Biden propuso este verano revertir una regla de la era Trump que permitía la venta de planes de corto plazo para períodos de cobertura de hasta un año.

Los planes de corto plazo no cumplen con los requisitos de ACA, y muchos tienen menos beneficios y pueden establecer restricciones en la cobertura, incluido no permitir que los adquieran personas con afecciones preexistentes como diabetes o colesterol alto. Como resultado, son mucho menos costosos que los planes del mercado. La propuesta de Biden los limitaría a períodos de cobertura de cuatro meses, pero la regla aún no es definitiva.

También está pendiente una regla final que permitiría a las personas inscribirse en la cobertura de ACA si fueron traídas a Estados Unidos por sus padres cuando eran pequeños, sin estatus legal permanente, el grupo conocido como “Dreamers”.

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