The idea echoes a policy implemented during his first term, when Trump suggested that requiring hospitals to post their charges online could ease one of the most common gripes about the health care system — the lack of upfront prices. To anyone who’s gotten a bill three months after treatment only to find mysterious charges, the idea seemed intuitive.

“You’re able to go online and compare all of the hospitals and the doctors and the prices,” Trump said in 2019 at an event unveiling the price transparency policy.

But amid low compliance and other struggles in implementing the policy since it took effect in 2021, the available price data is sparse and often confusing. And instead of patients shopping for medical services, it’s mostly health systems and insurers using the little data there is, turning it into fodder for negotiations that determine what medical professionals and facilities get paid for what services.

“We use the transparency data,” said Eric Hoag, an executive at Blue Cross Blue Shield of Minnesota, noting that the insurer wants to make sure providers aren’t being paid substantially different rates. It’s “to make sure that we are competitive, or, you know, more than competitive against other health plans.”

Not all hospitals have fallen in line with the price transparency rules, and many were slow to do so. conducted in the policy’s first 10 months found only about a third of facilities had complied with the regulations. The federal Centers for Medicare & Medicaid Services from June 2022 to May 2025 that they would be fined for lack of compliance with the rules.

The struggles to make health care prices available have prompted more federal action since Trump’s first effort. President Joe Biden took his own thwack at the dilemma, by requiring and toughening compliance criteria. And in early 2025, working to fulfill his promises to lower health costs, Trump tried again, signing a new executive order urging his administration to fine hospitals and doctors for failing to post their prices. CMS followed up with a regulation intended to up the fines and increase the level of detail required within the pricing data.

So far, “there’s no evidence that patients use this information,” said Zack Cooper, a health economist at Yale University.

In 2021, Cooper co-authored based on data from a large commercial insurer. The researchers found that, on average, patients who need an MRI pass six lower-priced imaging providers on the way from their homes to an appointment for a scan. That’s because they follow their physician’s advice about where to receive care, the study showed.

Executives and researchers interviewed by Â鶹ŮÓÅ Health News also didn’t think opening the data would change prices in a big way. Research shows that transparency policies can have mixed effects on prices, with of a New York initiative finding a marginal increase in billed charges.

The policy results thus far seem to put a damper on long-held hopes, particularly from the GOP, that providing more price transparency would incentivize patients to find the best deal on their imaging or knee replacements.

These aspirations have been unfulfilled for a few reasons, researchers and industry insiders say. Some patients simply don’t compare services. But unlike with apples — a Honeycrisp and a Red Delicious are easy to line up side by side — medical services are hard to compare.

For one thing, it’s not as simple as one price for one medical stay. Two babies might be delivered by the same obstetrician, for example, but the mothers could be charged very different amounts. One patient might be given medications to speed up contractions; another might not. Or one might need an emergency cesarean section — one of many cases in medicine in which obtaining the service simply isn’t a choice.

And the data often is presented in a way that’s not useful for patients, sometimes buried in spreadsheets and requiring a deep knowledge of billing codes. In computing these costs, hospitals make “detailed assumptions about how to apply complex contracting terms and assess historic data to create a reasonable value for an expected allowed amount,” the American Hospital Association in July 2025 amid efforts to boost transparency.

Costs vary because hospitals’ contracts with insurers vary, said Jamie Cleverley, president of Cleverley and Associates, which works with health care providers to help them understand the financial impacts of changing contract terms. The cost for a patient with one health plan may be very different than the cost for the next patient with another plan.

The fact that hospital prices might be confusing for patients is a consequence of the lack of standardization in contracts and presentation, Cleverley said. “They’re not being nefarious.”

“Until we kind of align as an industry, there’s going to continue to be this variation in terms of how people look at the data and the utility of it,” he said.

Instead of aiding shoppers, the federally mandated data has become the foundation for negotiations — — over the proper level of compensation.

The top use for the pricing data for health care providers and payers, such as insurers, is “to use that in their contract negotiations,” said Marcus Dorstel, an executive at price transparency startup Turquoise Health.

Turquoise Health assembles price data by grouping codes for services together using machine learning, a type of artificial intelligence. It is just one example in a cottage industry of startups offering insights into prices. And, online, the startups’ advertisements hawking their wares often focus on hospitals and their periodic jousts with insurers. Turquoise has payers and providers as clients, Dorstel said.

“I think nine times out of 10 you will hear them say that the price transparency data is a vital piece of the contract negotiation now,” he said.

Of course, prices aren’t the only variable that negotiations hinge on. Hoag said Blue Cross Blue Shield of Minnesota also considers quality of care, rates of unnecessary treatments, and other factors. And sometimes negotiators feel as if they have to keep up with their peers — claiming a need for more revenue to match competitors’ salaries, for example.

Hoag said doctors and other providers often look at the data from comparable health systems and say, “‘I need to be paid more.’”

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A pesar de algunos avances este año, especialmente en estados con mayoría demócrata, los recientes reveses en las legislaturas más conservadoras dejan claro lo difícil que es proteger a los pacientes.

Este año fracasaron proyectos de ley para proteger a los consumidores de deudas médicas en Indiana, Montana, Nevada, Dakota del Sur y Wyoming, debido a la oposición de la industria. Y defensores advierten que los estados deben actuar, ya que se espera que millones de personas pierdan su seguro médico debido a la ley fiscal y de gasto del presidente Donald Trump.

“Este ya era un tema clave incluso antes del cambio de administración en Washington”, dijo Kate Ende, directora de políticas de la organización Consumers for Affordable Health Care, con sede en Maine. “La retirada a nivel federal hizo aún más urgente movilizarse”.

Este año, Maine se unió a una creciente lista de estados que han prohibido que la deuda médica aparezca en los reportes de crédito de sus residentes, una protección que puede facilitar el acceso a una vivienda, un auto o incluso un empleo. La y con apoyo bipartidista.

Se estima que 100 millones de personas en Estados Unidos tienen algún tipo de deuda relacionada con la atención médica.

El gobierno federal estaba a punto de prohibir que la deuda médica apareciera en los reportes de crédito, gracias a una normativa emitida en los últimos días del mandato del ex presidente Joe Biden. Esa medida habría beneficiado a unas 15 millones de personas en todo el país.

Pero la administración Trump no defendió la normativa ante las demandas legales de agencias de cobro y burós de crédito, que argumentaban que la Oficina para la Protección Financiera del Consumidor (CFPB, en inglés) se había excedido en su autoridad.

Un juez federal de Texas, designado por Trump, falló que la normativa debía anularse.

Ahora, solo los pacientes que viven en estados que han aprobado sus propias normas sobre reportes de crédito podrán beneficiarse de esta protección. Más de una docena de estados tienen estas restricciones, entre ellos California, Colorado, Connecticut, Minnesota, Nueva York y Vermont, que al igual que Maine, adoptaron una prohibición este año.

En los últimos años, más estados han aprobado otras protecciones contra la deuda médica, como límites a la tasa de interés que se puede cobrar y restricciones al uso del embargo de salarios o la incautación de bienes para cobrar facturas médicas impagas.

En muchos casos, estas medidas han recibido apoyo bipartidista, lo que refleja la popularidad de las protecciones al consumidor. En Virginia, el gobernador republicano este año que limita el embargo de salarios y establece un tope a los intereses.

Y varios legisladores republicanos en California se unieron a los demócratas para que facilita el acceso a ayuda financiera de los hospitales para quienes enfrentan facturas elevadas.

“Este es el tipo de asunto de sentido común que afecta al bolsillo de las personas y que atrae tanto a republicanos como a demócratas”, señaló Eva Stahl, vicepresidenta de Undue Medical Debt, una organización sin fines de lucro que compra y perdona deudas médicas, y que ha trabajado para que se amplíen protecciones para pacientes.

Pero en varias legislaturas estatales, el impulso por nuevas protecciones se topó con barreras.

Proyectos de ley para prohibir que las deudas médicas aparecieran en los reportes de crédito fracasaron en y , a pesar del apoyo de algunos legisladores republicanos. Y las medidas para limitar los cobros agresivos contra residentes con deuda médica fueron rechazadas en , y .

En algunos estados, las propuestas enfrentaron una fuerte oposición de agencias de cobro, burós de crédito y bancos, que argumentaron ante los legisladores que sin información sobre deudas médicas podrían terminar otorgando a los consumidores préstamos de alto riesgo.

La representante estatal Lana Greenfield (republicana de Dakota del Sur), repitió las objeciones de la industria al pedir a sus colegas que votaran en contra de la prohibición. “Los bancos pequeños de comunidades pequeñas no podrían obtener información sobre una factura médica muy, muy grande. Y entonces, podrían otorgar un préstamo de buena fe a alguien sin saber realmente cuál era su crédito”, dijo Greenfield en el pleno de la Cámara.

Durante el gobierno de Biden, los encontraron que, a diferencia de otros tipos de deuda, la médica no era un buen indicador de la solvencia crediticia.

Pero el representante estatal Brian Mulder (republicano de Dakota del Sur), presidente del comité de salud que redactó la legislación, destacó el poder del sector bancario en el estado, donde regulaciones favorables lo han convertido en un imán para las instituciones financieras.

En Montana, una propuesta para proteger parte de los bienes de los deudores frente al embargo avanzó fácilmente en el comité. Sus defensores esperaban que fuera especialmente útil para pacientes nativos americanos, quienes enfrentan de forma desproporcionada la carga de la deuda médica.

Pero cuando el proyecto de ley llegó al pleno de la Cámara, los opositores “aparecieron en masa” y hablaron personalmente con los legisladores republicanos una hora antes de la votación, contó Ed Stafman, legislador demócrata y autor de la propuesta.

“Juntaron el número de votos suficientes para derrotar el proyecto por poco”, dijo.

Tanto defensores de los pacientes como legisladores que respaldaron estas medidas dijeron que son optimistas respecto a superar la oposición de la industria en el futuro.

Y hay señales de que algunas propuestas para ampliar las protecciones a los pacientes podrían avanzar en otros estados conservadores, como Ohio y Texas.

, una propuesta que obligaría a los hospitales sin fines de lucro a ampliar la ayuda financiera para quienes enfrentan facturas altas ha recibido el respaldo de organizaciones conservadoras influyentes.

“Estas cosas a veces toman tiempo”, dijo Lucy Culp, quien lidera el cabildeo estatal de Blood Cancer United (anteriormente conocida como Leukemia & Lymphoma Society). Esta organización ha impulsado leyes estatales de protección contra la deuda médica en años recientes, incluso en Montana y Dakota del Sur.

Lo más preocupante, dijo Culp, es la ola de pacientes sin seguro que se espera debido a los recortes en la cobertura médica derivados de la nueva ley fiscal aprobada por los republicanos. Esto agravará aún más el problema de la deuda médica en el país.

“Los estados no están preparados para eso”, advirtió Culp.

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Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The with bipartisan support.

An estimated 100 million adults in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under regulations issued in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed other medical debt protections in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in and , despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in , , and .

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are disproportionately burdened by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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

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

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

Abróchate el cinturón.

Comienza aquí

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

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

Un navegador podrá darte más detalles.

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

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

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

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

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

Encuentra tu mercado

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

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

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

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

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

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

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

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

Inscríbete

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

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

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

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

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

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

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

Haz números

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

Debes considerar:

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

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

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

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

Elige con sabiduría

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

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

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

La autorización previa puede ser un proceso largo y complicado.

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

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

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

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

Recurso adicional

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

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

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

Que tengas suerte.

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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.

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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.

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The No Surprises Act, which took effect in 2022, was rightly heralded as a landmark piece of legislation, which “protects people covered under group and individual health plans from receiving surprise medical bills,” according to the . And yet bills that take patients like Chen by surprise just keep coming.

With the help of her software-wise boyfriend, she found the complicated “machine-readable” master price list that hospitals are required to post online and looked up the negotiated rate between Lowell General and her insurer. It was $302.56 — less than she had paid out-of-pocket.

CMS is charged with enforcing the law, so Chen sent a complaint about the surprising bill to the agency. She received a terse email in return: “We have reviewed your complaint and have determined that the rights and protections of the No Surprises Act do not apply.”

When I asked the health system to explain how such a surprising off-estimate bill could be generated, Tufts Medicine spokesperson responded by email: “Healthcare billing is complex and includes various factors and data points, so actual charges for care provided may differ from initial estimates. We understand the frustration these discrepancies can cause.”

Here’s the problem: While the No Surprises Act has been a phenomenal success in taking on some unfair practices in the wild West of medical billing, it was hardly a panacea.

In fact, the measure protected patients primarily from only one particularly egregious type of surprise bill that had become increasingly common before the law’s enactment: When patients unknowingly got out-of-network care at an in-network facility, or when they had no choice but to get out-of-network care in an emergency. In either case, before President Donald Trump signed the law late in his first term, patients could be hit with tens or hundreds of thousands of dollars in out-of-network bills that their insurance wouldn’t pay.

The No Surprises Act also provided some protection from above-estimate bills, but at the moment, the protection is only , so it wouldn’t apply in Chen’s case since she was using health insurance.

But patients who do qualify generally are entitled to an up-front, good-faith estimate for treatment they schedule at least three business days in advance or if they request one. Patients can dispute a bill if it is more than $400 over the estimate. (The No Surprises Act also required what amounted to a good-faith estimate of out-of-pocket costs for patients with insurance, but that provision has not , since, nearly five years later, the government still has not issued rules about exactly what form it should take.)

So, surprising medical bills — bills that the patient could not have anticipated and never consented to — are still stunning countless Americans.

Jessica Robbins, who works in product development in Chicago, was certainly surprised when, out of the blue, she was recently billed $3,300 by Endeavor Health for a breast MRI she had received two years earlier, with prior authorization from her then-insurer, Blue Cross and Blue Shield of Illinois. In trying to resolve the problem, she found herself caught in a Kafkaesque circle involving dozens of calls and emails. The clinic where she had the procedure no longer existed, having been bought by Endeavor. And she no longer had Blue Cross.

“We are actively working with the patient and their insurer to resolve this matter,” Endeavor spokesperson Allie Burke said in an emailed response to my questions.

Mary Ann Bonita of Fresno, California, was starting school this year to become a nursing assistant when, on a Friday, she received a positive skin test for tuberculosis. Her school’s administration said she couldn’t return to class until she had a negative chest X-ray. When her doctor from Kaiser Permanente didn’t answer requests to order the test for several days, Bonita went to an emergency room and paid $595 up front for the X-ray, which showed no TB. So she and her husband were surprised to receive another bill, for $1,039, a month later, “with no explanation of what it was for,” said Joel Pickford, Bonita’s husband.

In the cases above, each patient questioned an expensive, unexpected medical charge that came as a shock — only to find that the No Surprises Act didn’t apply.

“There are many billing problems out there that are surprising but are not technically surprise bills,” Zack Cooper, an associate professor of economics at Yale University, told me. The No Surprises Act fixed a specific kind of charge, he said, “and that’s great. But, of course, we need to address others.”

Cooper’s research has found that before the No Surprises Act was passed, of emergency room visits yielded a surprise out-of-network bill.

CMS’ official No Surprises Help Desk has received tens of thousands of complaints, which it investigates, said Catherine Howden, a CMS spokesperson. “While some billing practices, such as delayed bills, are not currently regulated” by the No Surprises Act, Howden said, complaint trends nonetheless help “inform potential areas for future improvements.” And they are needed.

Michelle Rodio, a teacher in Lakewood, Ohio, had a lingering cough weeks after a bout of pneumonia that required treatment with a course of antibiotics. She went to Cleveland Clinic’s Lakewood Family Health Center for an examination. Her X-ray was fine. As was her nasal swab — except for the stunning $2,700 bill it generated.

“I said, ‘This is a surprise bill!’” Rodio recalled telling the provider’s finance office. The agent said it was not.

“So I said, ‘Next time I’ll be sure to ask the doctor for an estimate when I get a nose swab.’”

“The doctors wouldn’t know that,” the agent replied, as Rodio recalled — and indeed physicians generally have no idea how much the tests they order will cost. And in any case, Rodio was not legally entitled to a binding estimate, since the part of the No Surprises Act that grants patients with insurance that right has not been implemented yet.

So she was stuck with a bill of $471 (the patient responsibility portion of the $2,700 charge) that she couldn’t have consented to (or rejected) in advance. It was surprising — shocking to her, even — but not a “surprise bill,” according to the current law. But shouldn’t it be?

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in making complex decisions about whether to enroll in original Medicare or select among private-sector alternatives, called Medicare Advantage.

filed May 1 by the federal Department of Justice alleges that insurers Aetna, Elevance Health (formerly Anthem), and Humana paid “hundreds of millions of dollars in kickbacks” to large insurance brokerages — eHealth, GoHealth, and SelectQuote. The payments, made from 2016 to at least 2021, were incentives to steer patients into the insurer’s Medicare Advantage plans, the lawsuit alleges, while also discouraging enrollment of potentially more costly disabled beneficiaries.

Policy experts say the lawsuit will add fuel to about whether Medicare enrollees are being encouraged to select the coverage that is best for them — or the one that makes the most money for the broker.

Medicare Advantage plans, which may include , such as vision care or fitness club memberships, already cover more than half of those enrolled in the federal health insurance program for seniors and people with disabilities. The private plans have strong support among Republican lawmakers, but some research shows they per enrollee.

The plans have also drawn attention for requiring patients to , a process that involves gaining approval for higher-cost care, such as elective surgeries, nursing home stays, or chemotherapy, something rarely required in original Medicare. Medicare Advantage plans are under the microscope for aggressive marketing and sales efforts, as outlined from Sen. Ron Wyden (D-Ore.). During the last year of the Biden administration, that reined in some broker payments, although parts of that rule are on hold filed in Texas by regulation opponents.

The May DOJ case filed in the U.S. District Court for the District of Massachusetts alleges insurers labeled payments as “marketing” or “sponsorship” fees to get around rules that set caps on broker commissions. These payments from insurers, according to the lawsuit, added incentives — often more than $200 per enrollee — for brokers to direct Medicare beneficiaries toward their coverage “regardless of the quality or suitability of the insurers’ plans.” The case joins the DOJ in a previously filed whistleblower lawsuit brought by a then-employee of eHealth.

“In order to influence the market, the Defendant Insurers understood that they needed to make greater, illicit payments in addition to the permitted (but capped) commissions,” the lawsuit alleges.

In one example cited, the lawsuit says insurer Anthem paid broker GoHealth “more than $230 million in kickbacks” from 2017 to at least 2021 in exchange for the brokerage to hit specified sales targets in payments often referred to as “marketing development funds.”

Insurers and brokers named in the case pushed back. Aetna, Humana, Elevance, eHealth, and SelectQuote each sent emailed statements to Â鶹ŮÓÅ Health News disputing the allegations and saying they would fight them in court. EHealth spokesperson Will Shanley, for example, wrote that the brokerage “strongly believes the claims are meritless and remains committed to vigorously defending itself.” GoHealth a response denying the allegations.

The DOJ lawsuit is likely to add to the debate over the role of the private sector in Medicare with vivid details often drawn from internal emails among key insurance and brokerage employees. The case alleges that brokers knew that Aetna, for example, saw the payments as a “shortcut” to increase sales, “instead of attracting beneficiaries through policy improvements or other legitimate avenues,” the lawsuit said.

One eHealth executive in a 2021 instant message exchange with a colleague that is cited in the lawsuit allegedly said incentives were needed because the plans themselves fell short: “More money will drive more sales [be]cause your product is dog sh[*]t.”

The DOJ case focuses on large insurance brokerages, which often rely on national marketing efforts to gain customers, rather than mom-and-pop insurance offices.

The filing, which alleges violations under the federal False Claims Act, outlines some of the problems consumers could face because of those payments, including being enrolled or switched into plans without their express permission, and getting coverage that didn’t meet their needs.

A cancer patient, for example, was switched from the original Medicare program into a private-sector managed-care plan by a large brokerage firm, according to the lawsuit, only to get hit with $17,000 in ongoing treatment costs that would have been covered without the change. Another person calling for free advice later discovered she had been enrolled without permission into a plan with a different insurer than she had previously chosen.

Meanwhile, people with disabilities looking to enroll in private-sector Medicare Advantage plans had their calls ignored or rerouted by systems designed to weed out disabled people, especially if they were under age 65, the lawsuit alleges. That’s because the insurers knew that disabled beneficiaries usually cost more to cover than those without medical problems, the case alleges. Medicare plans are not allowed to discriminate against people with disabilities.

Still, private insurers are allowed to offer commissions to brokers — or not.

Congress and regulators, however, concerned about insurers’ potential financial influence over beneficiaries’ choice of plans, set maximum commissions and limited payments for other things, such as administrative costs, to a vaguer standard: their fair market value. (Under the Biden-era rule that’s on hold, administrative fees would have been capped at $100 per enrollment.) On commissions, the national cap in 2021 — the final year cited in the lawsuit — was $539 per enrollment for the initial year, with higher amounts in some states, including California and New Jersey, the lawsuit said.

The allowed commission rates have risen to a in most states this year. Those amounts are higher than what brokers earn if a client enrolls in original Medicare and buys a supplemental drug plan, for which the commission is capped at $109 for the initial year.

Some policy experts say that pay structure alone — aside from any of the allegations in the lawsuit — creates an uneven playing field between the private-sector plans and the original program.

“It’s not my intent to paint all agents and brokers with the same brushstroke, but there are significant financial incentives to steer people toward Medicare Advantage in general,” said , co-director of law and policy at the Center for Medicare Advocacy.

While brokers can be helpful in sorting out complexities, other options are available. Lipschutz suggested that consumers seek information from their federally funded , which can advise beneficiaries about Medicare options, are not affiliated with insurers, and don’t receive commissions.

While encouraged that the Trump administration filed the case under investigations that began under the Biden administration, policy experts say Congress and insurers need to do more.

“What we see in this lawsuit highlights the terrible incentives that desperately need Congress to reform,” said Brian Connell, a vice president at the Leukemia & Lymphoma Society, an advocacy group.

Right now, however, Congress is embroiled in budget battles amid calls by the Trump administration to drastically cut federal spending.

“It doesn’t seem like it’s high in the queue,” said , director of the Center for Health Policy and the Law at Georgetown University’s O’Neill Institute. Some members of Congress may push for more changes to Medicare Advantage, Baron said, “but the real question is whether there will be bipartisan interest.”

The large amounts of money that the lawsuit alleges were involved, though, might add legislative momentum.

“This is money not being spent on care, money not going to providers of health care services,” Lipschutz said. “In my mind, it’s a lot of wasted payment. It’s pretty staggering.”

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The satirical ad pretends to be a news report highlighting a “trend” in which more retail outlets take up “the hospital pricing method”: substituting estimates for actual prices for the cost of meals, merchandise on store shelves, and clothing. The scene ends with a partially deleted expletive from the ice cream-seeking man.

While the use of estimates in retail settings is imaginary and preposterous, the advertisement is part of an ongoing campaign by the advocacy group Patient Rights Advocate, which contends that some hospitals are still falling short of a law that went into effect in 2021 requiring them to publicly post their prices. Even then, said Cynthia Fisher, the group’s founder and chairperson, too many post estimates rather than exact dollar-and-cent figures.

“People need price certainty,” said Fisher. “Estimates are a way of gaming the people who pay for health care.”

Although government data shows that hospitals’ compliance with price transparency rules has improved, updating the requirements of that law is the focus of a , which aims to further standardize the required data, increase its usefulness for consumers, and boost enforcement. Even with all that, however, the goal of exact price tags in every situation is likely to remain elusive.

“We’re closer to that, but we’re not there,” said Gerard Anderson, a professor at the Johns Hopkins Bloomberg School of Public Health, who studies hospital pricing using the data that hospitals have already posted.

The proposed rule is designed to make it easier for consumers to learn in advance exactly what they might owe for nonemergency hospital care — though that was what the original price transparency rules were supposed to do.

Requiring hospitals to post their prices is part of a larger effort to make medical costs less opaque, which could help individual consumers predict their expenses and possibly slow health cost inflation, if it leads employers and insurers to contract with less expensive providers.

But the data files themselves are massive, often hard to find, and complex to decipher.

“Even for us, it’s really hard to use,” said Anderson.

Under current regulations, hospitals must publicly post prices for every service they offer, from drugs to stitches to time a patient spends in an operating room, as well as show all the bundled costs associated with 300 “shoppable” services, which are things people can plan for, such as a hip replacement or having a baby. Several different prices are required, including those they’ve negotiated with insurers and what they charge cash-paying customers.

Similar regulations, but with more prescriptive details and tougher penalties for noncompliance, in 2022, requiring them to post prices not only for hospital care, but also for outpatient centers and physician services.

The new hospital requirements proposed by the Centers for Medicare & Medicaid Services help “catch up to what they did with health plans,” said Hal Andrews, , a market research and analysis company.

“It’s a step down the path to making the data more accessible” to data analysis firms that create online price comparison tools, said Jeff Leibach, a partner at the . “And, ultimately, consumers who want to shop will then find this data more easily.” Many hospitals, insurers, and third-party data firms have made such cost comparison tools available.

Even the new requirements may not resolve the demand that is central to the dystopian ad’s ice cream-seeking man: getting exact prices, in dollars and cents. Such specificity may remain elusive for some consumers, if only because of the nature of medical care.

“Each patient is unique and uses a slightly different bundle of services,” said Anderson of Johns Hopkins. “You might be in the operating room for 30 minutes, or it might be 45. You might need this lab test and not that one.”

The proposed rule would, for one thing, further standardize the data required so that reporting is more comparable between facilities. It also mandates hospitals make their data sets easier to find on their websites, which could help data aggregators and consumers alike, and puts administrators in the hot seat to attest that their hospitals have posted all the required information accurately.

Individual hospitals that fail to post properly would face additional publicity by federal regulators: “Consider it a public naughty list,” said Marcus Dorstel, vice president of operations at data analysis firm Turquoise Health, which provides an online tool consumers can use to check prices across hospitals.

In addition, the proposal adds a data category awkwardly called “consumer-friendly expected allowed charges,” aimed at giving more information tied to the varied ways hospitals set prices. In plainer language, those allowed amounts are what hospitals expect to be reimbursed by insurance companies.

Some experts say that will be helpful.

For example, Dorstel said, currently a service might not be listed as a particular dollar amount, but the hospital will show the price is based on “70% of charges.” 

“Without the expected allowed amount, that doesn’t tell you anything,” Dorstel said.

Still, critics — such as Patient Rights Advocate, the group behind the new ad campaign — say that nodding to such allowed amounts will lead to even more estimates, rather than what they prefer: dollar-and-cent assessments.

“You and I would not buy a blouse at an average estimated amount,” said Fisher.

Health care isn’t like blouses or ice cream, responded executives from the American Hospital Association when asked about the advertisement and Fisher’s concerns about exact, upfront amounts. In many situations, for example, it may be hard to know ahead of time exactly what kind of care a patient will need.

“Very few health services are so straightforward where you can expect no variation in the course of care,” which could then result in a different cost than the original assessment,” said Molly Smith, . “Organizations are doing the best they can to provide the closest estimate. If something changes in the course of your care, that estimate might adjust.”

While hospitals’ compliance with posting price information has improved, it still falls short, said Fisher, whose group said only 36% of 2,000 hospitals it reviewed complied with all aspects of the current law, marking as deficient those that had incomplete data fields or used formulas instead of dollar prices.

But the American Hospital Association says Fisher’s group “, in part because hospitals are allowed to leave spaces blank, if, for example, they don’t have a cash-only price. And formulas are allowed if that is how the prices are set.

The hospital group points instead to a that showed compliance was increasing year over year. It said 70% of hospitals were compliant with the current requirements of the law.

It took some doing to get that far. Since 2021, the federal government has sent more than 900 warning letters to hospitals about their posted data, with most resolving those concerns, according to the proposed rule. Four hospitals have been fined for failing to comply with the transparency law.

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When Brittany Tesso’s then-3-year-old son, Roman, needed an evaluation for speech therapy in 2021, his pediatrician referred him to Children’s Hospital Colorado in Aurora. With in-person visits on hold due to the covid-19 pandemic, the Tessos met with a panel of specialists via video chat.

The specialists, some of whom appeared to be calling from their homes, observed Roman speaking, playing with toys, and eating chicken nuggets. They asked about his diet.

Tesso thought the $676.86 bill she received for the one-hour session was pretty steep. When she got a second bill for $847.35, she assumed it was a mistake. Then she learned the second bill was for the costs of being seen in a hospital — the equipment, the medical records, and the support staff.

“I didn’t come to your facility,” she argued when disputing the charges with a hospital billing representative. “They didn’t use any equipment.”

This is the facility fee, the hospital employee told her, and every patient gets charged this.

“Even for a telehealth consultation?” Tesso laughed in disbelief, which soon turned into anger.

Millions of Americans are similarly blindsided by hospital bills for doctor appointments that didn’t require setting foot inside a hospital. Hospitals argue that facility fees are needed to pay for staff and overhead expenses, particularly when hospitals don’t employ their own physicians. But consumer advocates say there’s no reason hospitals should charge more than independent clinics for the same services.

“If there is no change in patient care, then the fees seem artificial at best,” said , a Johns Hopkins University health economist.

At least eight states agree such charges are questionable. They have implemented limits on facility fees or are moving to clamp down on the charges. Among them are Connecticut, which already , and Colorado, where lawmakers are considering a similar measure. Together, the initiatives could signal a wave of restrictions similar to the movement that to ban surprise bills, which took effect last year.

“Facility fees are simply another way that hospital CEOs are lining their pockets at the expense of patients,” said , the Denver Democrat who sponsored the Colorado bill.

Generally, patients at independent physician clinics receive a single bill that covers the physician’s fee as well as overhead costs. But when the clinic is owned by a hospital, the patient generally receives separate bills for the physician’s fee and the facility fee. In some cases, the hospital sends a single bill covering both fees. Medicare reduces the physician’s payment when a facility fee is charged. But private health plans and hospitals don’t disclose how physician and facility fees are set.

Children’s Hospital Colorado officials declined to comment on the specifics of Tesso’s experience but said that facility fees cover other costs of running the hospital.

“Those payments for outpatient care are how we pay our nurses, our child life specialists, or social workers,” Zach Zaslow, senior director of government affairs for Children’s Hospital said in a February call with reporters. “It’s how we buy and maintain our imaging equipment, our labs, our diagnostic tests, really all of the care that you expect when you come to a hospital for kids.”

Research suggests that when hospitals acquire physician practices and hire those doctors, the physicians’ professional fees go up and, with the addition of facility fees, the total cost of care to the patient increases, as well. Other factors are in play, too. For instance, health plans pay the rates negotiated with the hospital, and hospitals have more market power than independent clinics to demand higher rates.

Those economic forces have driven consolidation, as hospital systems gobble up physician clinics. According to the , 3 in 4 physicians are now employed by hospitals, health systems, or other corporate entities. And less competition usually leads to higher prices.

One that prices for the services provided by physicians increase by an average of 14% after a hospital acquisition. that billing for laboratory tests and imaging, such as MRIs or CT scans, rise sharply after a practice is acquired.

Patients who get their labs drawn in a hospital outpatient department are charged up to three times what they would pay in an office, Sen said. “It’s very hard to argue that the hospital outpatient department is doing that differently with better outcomes,” she said.

Hospital officials say they acquire physician practices to maintain care options for patients. “Many of those physician practices are not viable and they were having trouble making ends meet, which is why they wanted to be bought,” said Julie Lonborg, a senior vice president for the .

Along with Colorado and Connecticut, other states that have implemented or are considering limits on facility fees are , , New Hampshire, Ohio, , and . Those measures include collecting data on what facility fees hospitals charge, prohibiting add-on fees for telehealth, and requiring site-neutral payments for certain Medicaid services. A introduced in 2022 would require off-campus hospital outpatient departments to bill as physician providers, eliminating the possibility of charging facility fees.

Connecticut has gone the furthest, banning facility fees for basic doctor visits off-campus, and for telehealth appointments. But the law’s application still has limitations, and with rising health care costs, the amount of facility fees in Connecticut continues to increase.

“It hasn’t changed much, partly because there’s so much money involved,” said , who heads the state’s Office of the Healthcare Advocate. “They can’t just painlessly take that needle out of their arm. They’re addicted to it.”

The Colorado bill would prohibit facility fees for primary care visits, preventive care services that are exempted from cost sharing, and telehealth appointments. Hospitals would also be required to notify patients if a facility fee would apply. The ban would not apply to rural hospitals. The bill was scaled back from a much broader proposal after criticism from hospitals about its potential consequences.

Rural hospital executives, like , CEO of Lincoln Health, a small community hospital in the eastern Colorado town of Hugo, had been particularly worried about the impact of a fee ban. The state hospital association estimated his hospital would lose as much as $13 million a year if facility fees were banned. The 37-bed hospital’s netted $22 million in patient revenue last year, resulting in a loss. It stays open only through local taxes, Stansbury said.

“This will still harm access to care — and especially essential primary and preventive care that is helping Coloradans stay healthier and out of the hospital,” Lonborg said of the revised approach. “It will also have a detrimental impact on access to specialty care through telehealth, which many Coloradans, especially in rural parts of the state, have come to depend on.”

The Colorado bill presents particular challenges for health systems such as UC Health and Children’s Hospital, which rely on the University of Colorado School of Medicine for staffing. For outpatient appointments, the medical school bills for the doctor’s fee, while the hospital bills a facility fee.

“The professional fee goes solely to the provider, and, very frequently, they’re not employed by us,” said Dan Weaver, vice president of communications for UC Health. “None of that supports the clinic or the staff members.”

Without a facility fee, the hospital would not receive any payment for outpatient services covered by the ban. Weaver said the combination of the clinicians’ and facility fees is often higher than fees charged in independent clinics because hospitals provide extra services that independent physician clinics cannot afford.

“Prohibiting facility fees for primary care services and for telehealth would still cause significant problems for patients throughout our state, forcing some clinics to close, and causing patients to lose access to the care they need,” he said.

Backers of the Colorado bill disagree.

“The data on their costs and their revenue paints a little different picture of their financial health,” said , policy manager for the Colorado Consumer Health Initiative, which backs the bill.

From 2019 through 2022, UC Health had a net income of $2.8 billion, including investment gains and losses.

The Colorado market is dominated by large health systems that can dictate higher rates to health plans. Plans pass on those costs through higher premiums or out-of-pocket costs.

“Unless the employers and patients that are incurring the prices are raising the alarm, there really isn’t a strong incentive for health plans to push against this,” said , a health care economist with the nonprofit think tank Rand Corp.

Consumer complaints helped pave the way for the federal , which protects against unanticipated out-of-network bills. But far more people get hit with facility fees — about half of patients compared with 1 in 4 hospital patients who receive surprise bills, Whaley said.

, a University of Michigan health policy professor, said facility fees are also generally surprises but don’t fall under the definition of the No Surprises Act. And with the rise of high-deductible plans, patients are more likely to have to pay those fees out-of-pocket.

“It falls on the patient,” Fendrick said. “It’s a tax on the sick.”

Tesso held off paying the facility fee for her son’s visit as long as possible. And when her pediatrician again referred them to Children’s Hospital, she called to inquire what the facility fee would be. The hospital quoted a price of $994, on top of the doctor’s fee. She took her son to an independent doctor instead and paid a $50 copay.

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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