Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.

Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
• ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
• A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes 鈥� though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
• As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Also this week, Rovner interviews 麻豆女优 Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “,” by Anna Clark.

Joanne Kenen: The New Yorker’s “,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “,” by Joedy McCreary.

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by Paul Kane.
• HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
• Politico’s “,” by Alice Miranda Ollstein.
• JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

[Editor’s note:听This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Julie Rovner:听Hello from 麻豆女优 Health News and WAMU听public听radio in Washington, D.C., and welcome to听What the Health?听I’m听Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and听I’m听joined by some of the best and smartest health reporters in Washington.听We’re听taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go.听

Today,听we are joined via video conference by Anna Edney听of听Bloomberg News.听

Anna Edney:听Hi, everyone.听

Rovner:听Alice [Miranda]听Ollstein听of Politico.听

Alice Miranda听Ollstein:听Hello.听

Rovner:听And听Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.听

Joanne Kenen:听Hi, everybody.听

Rovner:听Later in this episode,听we’ll听have my interview with 麻豆女优 Health News’听Elisabeth Rosenthal, who reported and wrote the latest听“Bill of the Month,”听about an ER trip, a scorpion pepper, and a ghost bill. But first,听this week’s news.听Let’s听start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three听years听the Affordable Care Act’s expanded subsidies听鈥斕齮he ones that expired Jan. 1.听听

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.听听

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are听very nearly听鈥斕齣n the words of longtime Congress watcher听听鈥斕齛听[majority]听in name only, which I guess is pronounced听“MINO.”听Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise听fairly routine听labor bill.听Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the听House’s Democrats听to pass听the bill and send听it to the Senate.听But it seems that the bipartisan efforts in the Senate to get a deal are losing steam.听What’s the latest you guys are hearing?听

Ollstein:听Yeah, so it听wasn’t听a good sign when the person who has听sort of come听out as a leader of these bipartisan negotiations,听Ohio Sen.听Bernie听Moreno, at first came out听very strong听and said,听We’re听in the end zone.听We’re听very听close听to a deal.听We’re听going to have听bill听text.听And that was several days ago, and now听they’re听saying that听maybe听they’ll听have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and,听from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before.听There is听not听agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it听should听treat abortion.听

And听so听the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a听nonstarter听for most, if not all, Democrats.听So听I听don’t听know where we听go听from here.听

Rovner:听Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They听seem to听[be]听making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can听come up with听a bill that can get 60 votes in the Senate and a majority in the much more conservative House?听That is a pretty narrow needle to thread.听I听don’t听think abortion is going to be a听huge issue in听Labor,听HHS,听because听that’s听where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the听House听[is]听probably not so excited about putting all of that money back.听I’m听just wondering if there really is a deal to be had, or if听we’re听going to see for the,听you know, however many听year[s]听in a row, another continuing resolution, at least for the Department of Health and Human Services.听

Ollstein:听Well,听you’re听hearing a lot more optimism from lawmakers about the spending bill than you are about a[n]听Obamacare subsidy deal or any of the other things that听they’re听fighting about. And I would say,听on the听spending,听I think the much bigger fights听are going to be outside the health care space. I think听they’re听going to be about immigration, with everything听we’re听seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts.听On health,听yes, I think听you’ve听seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it听impacts听their districts and their voters too. So that makes sense.听

Kenen:听We’ve听also seen the Congress vote for spending that the administration听hasn’t听been spent.听So听Congress has just voted on a series of things about science funding and other听health-related听issues, including global health. But it remains to be seen whether this administration takes appropriations as law or听suggestion.听

Rovner:听So听while the effort to revive the听additional听ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago.听Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital听outpatient payments,听and continued funding for community health centers. Could that finally become law? That thing that they said,听Oh,听we’ll听pass it first thing next year, meaning 2025.听

Edney:听I think听it’s听certainly looking more likely than the subsidies that听we’ve听been talking about. But I do think听we’ve听been here before several times, not just at the end of last year听鈥斕齜ut,听like with these PBM reforms, I feel like they have certainly gotten to a point where听it’s听like,听This听is happening.听It’s听gonna听happen.听And, I mean,听it’s听been years, though, that听we’ve听been talking about pharmacy benefit manager reforms in the space of drug pricing.听So basically, you听know, from听when听[President Donald]听Trump won. And so, you know, I say this with, like, a huge amount of caution:听Maybe.听

Rovner:听Yeah, we will, but听we’ll听believe it when听鈥μ齱e get to the signing ceremony.听

Ollstein:听Exactly.听

Rovner:听Well, back to the Affordable Care Act, for which enrollment in most states听end听today.听We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies.听Sign-ups on the federal marketplace are down about听1.5听million from the end of last year’s enrollment period, and听that’s听before most people听have to听pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans.听I’m听wondering if these early numbers听鈥斕齱hich are听actually stronger听than many predicted, with fewer people听actually dropping听coverage听鈥斕齬eflect people who signed up hoping that Congress might听actually renew听the subsidies this month. Since we kept saying that was听possible.听

Ollstein:听I would bet that most people are not following the听minutiae of听what’s听happening on Capitol Hill and have no听idea听the mess听we’re听in,听and听why,听and听who’s听responsible. I would love to be wrong about that. I would听love for听everyone to be super informed.听Hopefully听they听listen听to this podcast. But you know, I think that a lot of people just听sign up听year after year and听aren’t听sure of听what’s听going on until听they’re听hit with the giant bill.听听

Rovner:听Yeah.听

Ollstein:听One thing I will point out about the emerging numbers is it does show,听at least early indications,听that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans,听that’s really working.听You’re听seeing听enrollment up听in some of those states, and so I wonder if听that’ll听encourage any others to get on board as well.听

Kenen:听But听鈥� I think what Julie said听is听it’s听鈥μ齮he follow-up is less than expected. But for the reasons Julie just听said听is that you haven’t gotten your bill yet.听So听either you听haven’t听been paying attention, or听you’re听an optimist and think听there’ll听be a solution.听So, and听people might even pay their first bill thinking that听there’ll听be a solution next month, or that听we’re听close. I mean, I would think听there’d听be drop-off soon, but there might be a steeper听cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because听they’re听not as bad as some听people听forecast听doesn’t听say that this is going to be a robust coverage year.听

Edney:听And I think,听I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up,听are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out听in other aspects?听I听think听will be听..听of the economy of jobs, like, where does that lead听us? I听think听will be something to watch out for too.听

Rovner:听And by the way, in case you’re wondering why health insurance is so expensive, we got the听, and total health expenditures grew by 7.2% from the previous year to听$5.3 trillion, or 18% of the nation’s GDP听[gross domestic product],听up from 17.7% the year before. Remember, these are the numbers for 2024,听not 2025,听but it makes听it听pretty听hard听for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because听we’re听spending more on health care.听It’s not really that complicated, right?听

Kenen:听This 17%-18% of GDP has been听pretty consistent, which听doesn’t听mean听it’s听good;听it just means听it’s听been around that level for many, many, many years. Despite all the talk about听how it’s听unsustainable,听it’s听been sustained,听with pain, but sustained.听$5.7 trillion,听even if听you’ve听been doing听this听a long time听鈥μ�

Rovner:听It’s听$5.3 trillion.听

Kenen:听$5.3 trillion.听It’s听a mind-boggling听number.听It’s听a lot of dollars!听So the ACA made insurance more听鈥斕齮he out-of-pocket cost of insurance for millions of Americans, 20-ish million听鈥斕齜ut the underlying burden we’ve not solved听the 鈥� to use the word of the moment, the听“affordability”听crisis in health听care is still with us and arguably getting worse. But like, I think听we’re听sort of numb. These numbers are just so insane, and yet you say听it’s听unsustainable, but听鈥μ齀 think it听was听Uwe’s听line, right?听

Rovner:听It was, it was a famous听Uwe听Reinhardt line.听

Kenen:听No,听it’s听sustainable, if听we’re听sustaining it at a high听鈥斕齣n听economically听鈥斕齴any price.听听

Rovner:听Right.听

Kenen:听And, like, the other thing is, like, where is the money?听Right? Everybody in health听care says they听don’t听have any money, so I听can’t听figure out who has the听$5 trillion.听

Rovner:听Yeah, well, it’s not听鈥μ齣t does not seem to be the insurance companies as much as it is,听you know, if you look at these numbers听鈥斕齛nd I’ll post a link to them听鈥斕齳ou know, it’s hospitals and drug companies and doctors and all of those who are part of the health听care industrial complex, as I like to call听it.听

Kenen:听All听of them say they听don’t听have enough.听听

Rovner:听Right.听All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate听health听committee听chairman and ardent anti-abortion听senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about听the reputed dangers of the abortion pill,听mifepristone.听Alice, like me, you watched yesterday’s hearing. What was your takeaway?听

Ollstein:听So, you know, in a sense, this was a show hearing. There听wasn’t听a bill under consideration. They听didn’t听have anyone from the administration to grill. And听so听this is just听sort of your听typical听each side听tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside听鈥斕齮hey’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill.听Their bigger goal is outlawing all abortion,听but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting.听And听so听they’re听frustrated that, you know, both听[Robert听F.]听Kennedy听[Jr.]听and听[Marty]听Makary have promised some sort of review or action on the abortion pill, and they say,听We听want to see it.听Why haven’t you done it yet?听And听so听I think that pressure听is only going to mount, and this hearing was part of that.听

Rovner:听I was fascinated by the Louisiana听attorney听general saying,听basically,听the听quiet part听out loud, which is that听we banned abortion, but because of these abortion pills, abortions are still going up in our state.听That was the first time I听think听I’d听heard an official say that. I mean that,听if you wonder why听they’re听going after the abortion pill,听that’s听why听鈥斕齜ecause they听struck down听Roe听[v. Wade]听and assumed that the number of abortions would go down, and it really has not, has it?听

Ollstein:听That’s听right. And so not only are people increasingly using pills to听terminate听pregnancies, but听they’re听increasingly getting them via telemedicine.听And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal.听You know, a lot of people just really prefer the telemedicine option,听whether because听it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons.听So听the right听鈥斕齳ou know, again, including senators like Cassidy, but also these activist groups听鈥斕齮hey’re听saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And听they’re听pretty open听about saying that.听听

Rovner:听Well, rather听convenient timing from the听, which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single听time, except once, and that once was during the first Trump administration.听Alice,听is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications?听There were,听how many, like 100,听more than 100 peer-reviewed听studies that听basically听show听this,听plus the experience of many millions of women in the United States and around the world.听

Ollstein:听Well, just like听I’m听skeptical that听there’s听any compromise that can be found on the Obamacare subsidies,听there’s听just no compromise here. You know, you have the groups that are making these arguments about the pills’听safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it听can’t听be health care if听it’s听designed to end a life, and that kind of rhetoric. And听so听the focus on the rate of complication听鈥μ齀 mean,听I’m听not saying听they’re听not genuinely concerned. They may be, but, you know, this is one of many tactics听they’re听using to try to curb access to the pills.听So听it’s听just one argument in their arsenal.听It’s听not听their,听like,听primary driving, overriding goal is, is the safety which, like you said, has been well听established听with many, many peer-reviewed studies over the last several years.听

Rovner:听So, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein:听It was one pot of money听they’re听fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last听summer,听those are still in place. And so听that’s听an order of magnitude more than this pot of听Title听X听family planning money that they just got back. So that aside,听I’ve听seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and听it’s听a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a听patient,听you can then听submit听for reimbursement. And听so听if the clinic’s not there,听it’s听not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.听听

Rovner:听Yeah.听The wheels of the courts, as we have seen, have moved very slowly.听

OK,听we’re听going to take a quick break. We will be right back.听

So听while abortion gets most of the headlines,听it’s听not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that听a majority of听justices would strike down the laws,听which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue听in recent weeks.听The House passed a bill in December, sponsored by now former Republican听congresswoman听Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide.听And the Department of Health and Human Services issued proposed regulations just before Christmas that听wouldn’t听go quite that听far, but听would have听roughly the听same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid听funding, and听would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote,听“does not meet professionally recognized standards of health care,”听and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports听team听exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors?听That’s听what this would do.听

Edney:听Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that听we’re听even talking about. And so those who are against it have done an effective job of making that听the issue. And so there听鈥μ齱ho support gender-affirming care, who have听looked into听it, would see that a lot of this is hormone treatment, things like that, to drugs听鈥μ�

Rovner:听Puberty blockers!听

Edney:听鈥μ齮hey’re taking听鈥斕齟xactly听鈥斕齛nd so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think,听too,听talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them.听So听I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like听that that’s kind of winning the day.听

Kenen:听I think,听like,听from the beginning, because, like, five or six years ago was the first time I wrote about this. The听playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now听they’re听talking about it in protecting children’s health. And,听as Anna said,听they’re听using words like mutilation. Puberty blockers are not听mutilation. Puberty听blockers are a medication that delays the onset of puberty, and it is not irreversible.听It’s听like a听brake. You take your foot off the brake,听and puberty starts.听There’s听some controversy about what age and how long, and听there’s听some听possible bone听damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now听鈥斕齧ost of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids,听cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body.听So听you know, I think it’s really important to repeat听鈥μ齮he point that Anna made, you know, 12-year-olds are not getting major surgery.听Very few minors are, and when they are,听it’s听closer听鈥� they听may be under 18,听it’s听rare. But if听you’re听under 18,听you’re听closer to 18,听it’s听later in听teens. And听it’s听not like you walk into an operating room and say, you know,听do this to me.听There’s听years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania,听in particular.听This is something that people听don’t听understand and get听very upset听about, and the inflammatory听language,听it’s听not creating understanding.听

Rovner:听We’ll听see how听this one plays听out. Finally, this week, things at the Department of Health and Human Services听continues听to be chaotic. In the latest round of听“we’re cutting you off because you don’t agree with us,”听the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees听canceling听their funding听immediately.听It’s听not entirely clear how many grants or how much money was involved, but it听appeared to be听something听in the neighborhood of听$2 billion听鈥斕齮hat’s听around a fifth of SAMHSA’s听entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then,听Wednesday night, after a furious backlash from Capitol Hill and听just about every听mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts.听Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?听听

Edney:听That is听a great question. I really听don’t听know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly,听like there was a听miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS.听

Rovner:听I听didn’t听count, but I got dozens of emails yesterday.听听

Edney:听Yeah.听

Rovner:听My entire email box was overflowing with people听basically freaking听out about these cuts听to SAMHSA. Joanne,听you wanted听to say something?听

Kenen:听I think that one of the shifts over听鈥斕齀’m not exactly sure how many years听鈥斕�7,听8,听9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue.听It’s听not that everybody thinks that.听It’s听not that every lawmaker thinks that, but we have really turned this into, we听have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the听“deaths of despair.”听Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is,听you know,听you’ve听had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes听鈥斕齭ome of the听“Opioid听Belts”听are very conservative states,听and Republican governors, you know, really saying we’ve had progress.听Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their听telephones, they听were bombarded.听听

Rovner:听Yeah.听Well, meanwhile, several听hundred听workers have听reportedly been听reinstated at the National Institute of Occupational Safety and Health听鈥斕齮hat’s听a听subagency of CDC听[the Centers for Disease Control and Prevention].听Except that those RIF听[reduction in force]听cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work?听And in news from the National Institutes of Health,听Director Jay Bhattacharya told a podcaster last week that the DEI-related听[diversity, equity, and inclusion]听grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard听Pazdur听said at the J.P.听Morgan听[Healthcare] Conference in San Francisco this week that the听firewall听between the political appointees at the agency and its career听drug reviewers has been,听quote,听“breached.”听How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots?听

Ollstein:听Not to mention听all of听this back and forth and chaos and starting and stopping is costing more,听is costing taxpayers more.听Overall spending is up. After all of the听DOGE听[Department of Government Efficiency]听and听RIFs听and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it听hasn’t听even saved the government any money, either.听

Kenen:听Like, you know, the game we played when we were kids, remember,听“Red听Light-Green听Light,”听you know, you’d听run in one direction, you run back. And if you were听8听years old, it would end with someone crying. And that’s听sort of the听way听we’re听running the government听these听days听[laughs].听The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You听can’t听even keep track. You听don’t听even know what email to use if听you’re听trying to听keep听in听touch听with them听anymore. The churn,听with what logic?听It’s, as Alice said,听just听more expensive, but it’s,听it’s听also just听鈥μ齦ike听you听can’t听get your job done.听Even if you want a smaller government, which many of conservatives and Trump people do,听you still want certain functions fulfilled.听But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring.听I mean, the American public is not against research, and the American public is not against keeping people alive.听You know, the inconsistency is pretty mind-boggling.听

Edney:听Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is听it听kind of seems听like the message as听anybody can do this part, because听it’s听all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different,听like you said, everyone wants research, but I,听Joanne, but I do think they only want certain kinds of research in this case.听So听it’s听been interesting to watch how many leaders in these agencies that are going away and not being replaced.听

Rovner:听And all the institutional memory听that’s听walking out the door. I mean,听more people听鈥斕齛nd to听Alice’s point about how this听hasn’t听saved money听鈥斕齧ore people have taken early retirement than have听been actually, you听know,听RIF’d听or fired or let go. I mean, they’ve just听鈥μ齛 lot of people听have basically, including听a lot of leaders of many of these agencies, said,听We听just听don’t听want to be here under these circumstances.听Bye.听Assuming at some point this government does want to use the Department of Health and Human Services to get things done,听there might not be the personnel around to actually effectuate it.听But we will continue to watch that space.听

OK, that’s this week’s news. Now we will play my听“Bill of the听Month”听interview with Elisabeth Rosenthal, and then we will come back and do our extra credits.听

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at听麻豆女优听Health听News and originator of our听“Bill of the Month”听series, which in its听nearly eight听years has analyzed听nearly $7 million听in dubious, infuriating,听or inflated medical charges. Libby also wrote the latest听“Bill of the听Month,”听which听we’ll听talk about in a minute. Libby, welcome back to the podcast.听

Elisabeth Rosenthal:听Thanks for having me back.听

Rovner:听So听before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated听are you that eight years on,听it’s听as relevant as it was when we began?听

Rosenthal:听We were听worried it听wouldn’t听last a year, and here we are, eight years later, still finding plenty to write about. I mean,听we’ve听had some wins.听I think we听helped contribute to the听No听Surprises听Act being passed.听There are听states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic,听it’s听the same cost. The听country’s听starting to address drug prices.听But,听you know, we听seem to be听the billing听police, and听that’s听not good.听We’ve听gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls,听they’re听like,听Oh, that was a mistake听or听Yeah,听we’re听going to write that off. And听I’m听like,听You’re听not writing that off;听that听shouldn’t听have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system听that听has听left,听as we know, you know, 100 million adult Americans with medical debt.听So听we will keep going until听it’s听solved,听I hope.听

Rovner:听Well, getting on to this month’s patient, he gives new meaning to the phrase听“It must have been something I ate.”听Tell us what it was and how he ended up in the emergency room.听

Rosenthal:听Well, Maxwell听[Kruzic]听loves eating spicy foods, but听he’s听never had a problem with it. And suddenly, one night, he had just听excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right?听So听they were all听like,听ready to go to the operating room. And then the scan came back, and it was like,听whoops,听his appendix is normal. And then,听oh, could he have kidney stones?听And听it’s听like no sign of that either. And finally, he thought, or someone asked,听Well, what did you eat last night?听And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million听[Scoville heat units], which is,听like,听through the roof, and it was a reaction to the chili peppers.听I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff.听

Rovner:听So听in the end, he was听OK.听And the story here isn’t even really about what kind of care he got, or how much it cost.听The $8,000 the hospital charged for his few hours in the ER听doesn’t听seem all that out of line compared to some of the bills听we’ve听seen.听What was most notable in this case was the fact that the bill didn’t actually come until two years later.听How much was he asked to pay two years after the hot pepper incident?听

Rosenthal:听Well, he was asked to pay a little over $2,000,听which was his coinsurance for the emergency room visit. And as he said, you know, $8,000听鈥μ齨ow we go,听well,听that’s听not bad.听I mean, all they did,听actually, was do a couple of scans and give him some IV fluids.听But听in this day and age,听you’re听like, wow, he got away听鈥� you know, from听a听“Bill of a听Month”听perspective, he got away cheap, right?听

Rovner:听But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later?听

Rosenthal:听That’s听the problem,听like,听and Maxwell听鈥斕齢e’s听a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept听thinking,听I must owe something. And he checked and he听checked听and he checked and it kept saying zero. He actually called his听insurer and听to make sure that was right. And they said,听No, no, no,听it’s听right. You owe zero. And then, you know, after like, six months, he thought,听I guess I听owe zero. But then he听didn’t听think about it, and then almost two years later, this bill arrives in the mail, and听he’s听like,听What?!听And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at听“Bill of the听Month,”听and in many cases, it’s legal, because听of听what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like,听Yeah, you know, someone was away on vacation, and someone left their job, and we听couldn’t听鈥μ齳ou know, the hospital听billed them听correctly. And the hospital said,听No, we听didn’t.听And they were just听kind of doing听the usual听back-end negotiations to figure out what a service is worth.听And when they finally agreed two years later听what should be paid,听that’s听when they sent Maxwell the bill. And the problem听is,听whether听it’s听legal really depends on your insurance contracts, and whether they allow this kind of late billing.听I do not know to this day if Maxwell’s did, because as soon as I called the insurer听and听the hospital, they were like,听Never听mind. He听doesn’t听owe听anything. And you know, as he said,听he’s听a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said,听Whoops, I forgot to bill for something, they would be like,听Forget听it!听you听know.听So听I do think this is something that needs to be addressed at a policy level, as we so often discover on听“Bill of the听Month.”听

Rovner:听So听what should you do if you get one of these ghost bills? I should say听I’m听still negotiating bills from a surgery that I had six months ago.听So听I guess I should听count听myself lucky.听

Rosenthal:听Well, I think you should check with your insurer and check with the hospital. I think more听with听your insurer听鈥斕齣f the contract says this is legal to bill.听It’s听unclear听to me,听in this case, whether it was.听The hospital was very much like,听Oh, we made a mistake;听because it took so long,听we听actually听couldn’t听bill Maxwell.听So听I think in his case, it听probably was听in the contract that this was too late to听bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude.听Well,听doesn’t听hurt to try, you know,听maybe听they’ll听pay听it. And people are afraid of bills, right? They听pay听them.听听

Rovner:听I know the feeling.听

Rosenthal:听Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations,听essentially,听on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say,听Well, we won’t pay this.听

Rovner:听And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least听modified听them?听

Rosenthal:听He said he will never eat听scorpion peppers again.听

Rovner:听Libby Rosenthal, thank you so much.听

Rosenthal:听Oh, sure.听Thanks听for having me.听

Rovner:听OK,听we’re听back, and now听it’s听time for our听extra-credit听segment.听That’s听where we each recognize a story we read this听week听we think you should read,听too.听Don’t听worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us off this week?听

Edney:听Sure.听So听my extra credit is from听MedPage听Today:听“.”听I appreciated this article because it answered some questions that I had,听too,听after the sweeping change to the childhood vaccine schedule. There听was听just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will听parents听be confused? Will pediatricians听鈥斕齢ow will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA听Perspectives听that lays out, essentially, to听clinicians, you know, that they should not fear malpractice听..听issues if听they’re听going to talk about the old schedule and not adhere to the newer schedule. And听so听it lays out some of those issues.听And I thought that was really helpful.听

Rovner:听Yeah, this was a big question that I had,听too.听Alice, why don’t you go next?听

Ollstein:听Yeah, so I have a piece from ProPublica.听It’s听called听“.”听So听this is about how听there’s听been this huge push on the right to end public water fluoridation that has succeeded in a听couple听places and could spread more. And the proponents of doing that say that听it’s听fine because there are all these other sources of fluoride. You can get听a treatment听at the听dentist,听you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who听arepushing听for ending fluoridated public drinking water听are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus听all of听the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged听neurological impacts. But it also,听that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what听that’s听going to do to the nation’s teeth?听

Rovner:听Yeah,听it’s听like vaccines. The more you听talk听it听down,听the less people want to do it.听Joanne.听

Kenen:听This is听a piece by听Dhruv Khullar听in听The New Yorker called听“,”听and it was really great, because there’s certain things I think that we who听鈥斕齦ike, I don’t know how all of you watch it听鈥斕齜ut like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED听[emergency department]听have, you know, homelessness problems and can’t afford food and all that. But听Dhruv听talked听about听how it听sort听of brought that home to him, how our social safety net, the holes in it, end up in our听EDs.听And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient听a听day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER听scene.听It’s听just a very thoughtful piece about why we all love that TV show. And听it’s听not just because of听Noah Wyle.听

Rovner:听Although that helps. My extra credit this week is from听The New York Times.听It’s听called听“,” by Maxine听Joselow.听And while it’s not about HHS, it most definitely is about health.听It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost听to听human health when setting clean air rules for ozone and fine particulate matter, quoting the story:听“That would most likely lower costs听for companies while resulting in dirtier air.”听This is just another reminder that the federal government is听charged with ensuring the help of Americans from a broad array of agencies, aside from HHS听鈥斕齩r in this case, not so much.听听

OK, that’s this week’s show.听As always, thanks to our editor, Emmarie听Huetteman,听and our producer-engineer, Francis Ying.听We also had听help听this week from producer Taylor Cook.听A听reminder:听What the听Health?听is now available on WAMU platforms, the NPR app,听and wherever you get your podcasts, as well as, of course, at听kffhealthnews.org.听Also, as always, you can email us your comments or questions.听We’re听at听whatthehealth@kff.org,听or you can find me still on X听, or on Bluesky听.听Where are you folks hanging these days?听Alice.听

Ollstein:听Mostly听on听Bluesky听听and still on听X听.听

Rovner:听Joanne.听

Kenen:听I’m听mostly on听听or on听听.听

Rovner:听Anna.听

Edney:听听or听X听.听

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

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From 麻豆女优 Health News” on , , , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The third time, he sought help from an insurance agent, who got Jones on the phone with the federal healthcare.gov call center to sort things out. During that call, “literally, there was someone opening a new policy without my consent,” Jones said.

Despite new rules that went into effect in mid-2024 aimed at thwarting such unauthorized ACA changes, it’s still happening, said Florida-based agent Jason Fine, who is trying to help Jones and dozens of other clients unravel such switches.

The Government Accountability Office, an independent government watchdog, on Dec. 3 issued a saying that years of similar GAO warnings to federal officials have not produced results needed to better protect against ACA enrollment fraud. Alarms were raised during the Obama and Biden administrations, as well as the first Trump administration.

There were to the Centers for Medicare & Medicaid Services about unauthorized ACA enrollments and plan-switching in 2024, according to the agency, which also administers Obamacare coverage.

“The absolute bottom line is nothing has changed in terms of risk,” Seto J. Bagdoyan, a co-author of the GAO report, said in an interview with 麻豆女优 Health News. Bagdoyan is the director of audit services for the agency’s Forensic Audits and Investigative Service team.

The report landed as Congress in the issue of whether to extend the more generous tax subsidies that have given consumers extra help paying their Obamacare premiums in recent years. Some ACA critics have said .

Citing fraud concerns, included measures in their One Big Beautiful Bill Act that will make it harder to enroll in ACA plans in future years, such as requiring . But lawmakers have not adopted to impose criminal penalties on brokers who knowingly submit false information on ACA enrollments.

“None of the Republicans making political hay out of this report have co-sponsored that legislation or offered any similar measures,” Sen. Ron Wyden (D-Ore.) said in a statement to 麻豆女优 Health News. Wyden is one of the sponsors of the legislation.

The GAO inquiry, during which investigators attempted to submit enrollments using false information, was requested more than a year ago by Republicans from three House committees: Energy and Commerce, Judiciary, and Ways and Means.

The lawmakers asked for findings that could be made public now, even though the final report and any recommendations it will contain won’t be completed until the spring or summer of 2026. the findings was set by House members for Dec. 10.

The report notes that federal officials estimate that $124 billion in tax subsidies were paid in 2024 for nearly 20 million ACA enrollments.

It highlighted some stunning findings. One Social Security number, for instance, was found to have been used for 125 policies in 2023.

However, the number of policies flagged as potentially compromised by rogue sales agents was far smaller than the estimates of some of the program’s biggest critics. The GAO identified about 160,000 cases in 2024, or 1.5% of the ACA applications. Some conservative analysts have broadly estimated that unauthorized enrollments that year numbered in the millions, a finding that has drawn pushback from groups representing , , and

The GAO report does not quantify how much fraud there is, Bagdoyan said: “What it’s focusing on are indicators of potential fraud.”

CMS Anti-Fraud Efforts Fall Short

By October 2024, following consumer complaints, CMS over questions about whether they had been involved with unauthorized enrollment. All were eventually reinstated, CMS told the GAO in May. Also last October, the GAO submitted the first four of its fake applications, seeking coverage for the final months of the year.

A few months earlier, in July 2024, CMS began requiring three-way calls with consumers, the marketplace, and their agents for certain types of changes, such as plan switches. Unauthorized plan-switching nets rogue agents a sales commission, and it can also lead to problems for consumers, such as losing access to their doctors or facing tax bills if they were improperly enrolled with subsidies, as 麻豆女优 Health News reported in 2024.

However, the GAO reported that many agents told them those rules had a lot of loopholes, such as the federal marketplace taking only “limited steps to verify the identity of the consumer on the three-way call,” for instance asking only for publicly available information such as a name and date of birth.

Also, new ACA applicants were exempt from the three-way call rule, which leaves open the possibility of agents saying it’s a new consumer when it isn’t.

“The three-way call is something CMS has promoted,” Bagdoyan said. “It’s better than nothing, but as we point out in the report, it could be easy to overcome by an unscrupulous broker who starts the process from scratch. Or they could impersonate.”

Fine, the agent in Florida, said he alone has filed dozens of complaints with federal and state officials, often showing clients’ records being accessed or changed by multiple agents, sometimes on the same day, even after the CMS rules on plan-switching went into effect.

In one such fraud complaint, Fine listed three marketplace applications tied to one client’s name in which other agents had changed his coverage and included false income information. The client didn’t recall talking with any of those other agents, Fine wrote.

A marketplace representative who was helping Fine restore that client’s coverage told Fine that he often hears agents pretending to be the consumer, sometimes even faking the voice of an opposite-sex person.

Rogue agents can fake it because questions asked by marketplace representatives to verify identity “are from the application: the person’s name, date of birth, and address,” Fine said. “That’s the ID proofing. It’s a joke.”

Asked about the effectiveness of the three-way call rule and about reports of impersonations, CMS spokesperson Catherine Howden said in a statement that “rooting out waste, fraud, and abuse is one of Dr. Oz’s top priorities,” referring to CMS Administrator Mehmet Oz. The agency “takes allegations of fraudulent or abusive conduct seriously and acts swiftly when concerning behaviors are identified or reported,” she added.

Ronnell Nolan, the president and CEO of the insurance broker lobbying group Health Agents for America, said: “Three-way calling is a bust. It needs to go away.”

Instead, she has long called for two-factor authentication, similar to systems used in banking and other industries, to ensure the person making the change is actually the policyholder or their agent.

That hasn’t happened on the federal marketplace, where the problems with unauthorized switching are concentrated.

In the , that run their own ACA marketplaces, such issues are not common. States say that’s because they require more types of authentication 鈥� and they also generally use their own websites for sign-ups.

Bagdoyan said the GAO report did not consider what the states might be doing differently.

“That was beyond our scope,” he said.

Devilish Details

The 26-page document outlines the GAO’s probe, in which investigators filed 20 fake enrollments, some through insurance brokers, spanning 2024 and 2025 coverage. Most were approved, even with counterfeit documents.

One attempted application was dropped by investigators when the broker stopped responding 鈥� the brokers did not know they were part of the investigation 鈥� and another was rejected by the federal marketplace after five months of coverage when required documents were not submitted. But 18 of the plans remain in place and subsidies are being sent to insurers to cover the fake people, according to Bagdoyan.

The investigation also included an analysis of enrollment data from 2023 and 2024 looking for things such as multiple uses of the same Social Security numbers, dead people’s numbers, and cases in which three or more agents submitted enrollment actions for the same person and start date, potentially indicating fraud.

Similar investigations using the filing of fictious enrollments were conducted by the GAO in earlier undercover work , at the start of the ACA.

The new report said that while CMS assessed fraud risks in 2018, it has not updated its assessment since then, even as enrollment in the ACA has grown significantly.

“We have documentary evidence that whatever it is they did, obviously it hasn’t worked,” Bagdoyan said, “because we encountered the same issues as 12 years ago, having to do with identity verification.”

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Open enrollment for health plans under the Affordable Care Act began Nov. 1, yet it remains unclear how much the estimated 24 million Americans who purchase from the ACA marketplaces will be expected to pay in premiums starting in January. Unless Congress acts to extend tax credits added to the program in 2021, most consumers will be expected to contribute much more out-of-pocket; in some cases, double or triple what they are paying in 2025.听

The politics of this year’s ACA fight are also complicated. Democrats are using the only leverage they have 鈥� a government shutdown 鈥� to try to force Republicans to negotiate over the expiring ACA tax credits. Yet many, if not most, of the people who will face much higher premiums in 2026 are from GOP-dominated states such as Texas and Florida, and belong to professions that tend to be more Republican than Democratic, such as farmers and ranchers, or small-business owners.听

In this special episode of “What the Health?” from 麻豆女优 Health News and WAMU, host Julie Rovner talks to Cynthia Cox, a vice president at 麻豆女优 and the director of its Program on the ACA. Cox explains what the nation’s health system looked like before the passage of the health law, how it has contributed to lower health spending and better insurance coverage, and the peculiar politics of the current fight.

Guest

[Editor’s note:听This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Julie Rovner:听Hello from 麻豆女优 Health News and WAMU Public Radio in Washington, D.C.听Welcome to听“What the Health?”听I’m听Julie Rovner, chief Washington correspondent for 麻豆女优 Health News.听

Usually,听I’m听joined by some of the best and smartest health reporters in Washington,听but today we have a special episode.听We’re听taping this week on Monday, Nov.听3,听at 10听a.m.听As always, and especially this week, news happens fast,听and things听might’ve听changed by the time you hear this. So here we go.听

Today,听we’re听going to explore the state of the Affordable Care Act with one of my favorite experts, 麻豆女优’s Cynthia Cox,听who’s听a vice president and director of the program on the ACA. Open enrollment for 2026 health plans began on Saturday, Nov. 1, and there is so much confusion. I thought it would be helpful to see where听we’ve听been and,听possibly,听where听we’re听going.听

Cynthia, thank you so much for joining us.听

Cynthia Cox:听Yeah, thanks for having me, Julie.听

Rovner:听I want to start by reminding everyone how the Affordable Care Act changed the health听care system, what problems the law tried to solve, what听problems were left for another day. I feel like people have either forgotten or never knew what things were like pre-the ACA.听

Cox:听It has been quite听awhile, so听let’s, I guess,听rewind听15 years or so.听

There were a couple of big problems that the ACA was trying to address in the U.S. health care system. One was that there were a lot of people who were uninsured. And that was partly because of cost reasons and partly because of the second big problem that the ACA was trying to solve, which was that people who have听preexisting conditions were often denied access to health insurance.听

And to explain that a bit more,听what that looked like,听was if you had a serious illness like cancer or diabetes or some other illness that might require expensive treatments, and if you had any gap in your coverage听鈥斕齭ay,听you left your job and then needed to find some other health insurance after a period of time听鈥斕齮hen the insurer would often just deny your application and say they wouldn’t insure you. And if you had a less severe condition,听maybe even听something like acne where you needed Accutane treatment or something, then they would still give you insurance,听but they could charge you more. They would charge a surcharge for covering that preexisting condition.听

And then still another issue with preexisting conditions was that insurers听didn’t听have to cover your treatment for a condition,听too. So,听you might get a health insurance coverage for certain treatments but,听say, it might exclude mental health treatment or even pregnancy care or prescription drugs or other things that听didn’t听need to听鈥� There was no听minimum听standard for what needed to be included in these health insurance plans that were sold to individuals.听

Usually, insurance that was sold to larger businesses or that larger companies offered was听pretty comprehensive.听The ACA did make some changes to those plans,听too, like setting out-of-pocket limits and prohibiting lifetime caps. But most of the changes were in what was called the individual market,听where people would buy their own health insurance on their own, usually when they were听between jobs, or between school, or听maybe a听stay-at-home parent, or that sort of thing.听

Rovner:听Or even a self-employed individual,听which听was听鈥μ�

Cox:听Yes. Exactly.听

Rovner:听鈥� growing in the early parts of this century.听

Cox:听Yeah.听

Rovner:听I think people听don’t听remember how much of a wild听West听the individual market really was at that point.听The Congress听had regulated听the employer market in 1996 with HIPAA听[Health Insurance Portability and Accountability Act], which was about a lot more than confidentiality. But听that’s听for another day. But the individual market was so crazy that you could get insurance听鈥斕齣t wasn’t really insurance听鈥斕齩r you could get charged more just for being a woman, right?听

Cox:听Exactly. You could even be charged based on what your job was. People who had risky professions听might’ve听been excluded from health insurance,听too. There were very few rules or standards in this market, it was听鈥μ�

One insurer might have insured you,听and another insurer听wouldn’t听have. And there was no way to really know what was going to be available to you without having to听maybe apply听to multiple companies and go through a lengthy underwriting process,听too.听

Rovner:听How did the ACA change that?听

Cox:听The ACA created a lot of standards, and the way that it did that was to say:听Here are the only ways that you can vary premiums.听Rather than having rules about every single little thing that could have been covered, the ACA was听basically like,听OK, here are the only ways that insurers can change things.听

The only ways that insurers can change premiums are based on how old you are, where you live, and if you smoke cigarettes or used tobacco, and then also,听just how many people are signing up for the coverage. So basically, if your whole family is signing up, then obviously that’s going to be more than if just you听is听signing up.听

And then it听basically prohibits听all those other things,听like you听can’t听rescind coverage based on preexisting conditions or exclude coverage based on preexisting conditions, or听鈥� It听basically is听saying:听If you have a preexisting health condition, that is not a reason for an insurance company to charge you more or deny听you coverage or carve out certain benefits.听So now the health insurance that is sold to individuals听鈥斕齱hich now we’ve started calling听these the听ACA marketplaces or Obamacare markets or that sort of thing听鈥斕齭o that coverage that’s sold there looks a lot more like the coverage that had been available to people with large employer coverage before the ACA.听

Basically, it听was trying to bring the standards for individual insurance coverage up to what already had been the standards for employer coverage. And,听in doing so, it made health insurance more expensive in the individual market because when health insurers听have to听pay out claims for people who are sick, then that brings up their average costs, which they听have to听spread out, meaning higher average premiums that they’re charging.听

Those premiums today are no more expensive than the premiums that employer plans have.听They cover similar benefits. It听costs about听the same, but when you get coverage through work, your work is听paying for听a large part of that premium.听And when you pay your premium,听it’s听usually with some sort of tax benefit,听too.听So听I think a lot of us who have employer coverage just听don’t听realize how expensive employer coverage is. And the ACA听鈥μ�

Rovner:听We also听don’t听realize how much听we’re听getting subsidized by the government because that’s听鈥μ�

Cox:听That,听too. Yes.听

Rovner:听鈥� one of the big fights.听It’s听like:听Why are we giving these people subsidies?听It’s听like:听You’re听getting a subsidy,听too,听if you have employer coverage.听

Cox:听Yeah, exactly.听Yeah,听it’s听a tax benefit.听

And so basically, in the individual market or Obamacare markets, the听premiums听鈥斕齮he raw total gross, whatever word you want to say, how much the insurance company is charging听鈥斕齣s听about the same as in the employer market,听and听it听covers about the same services.听It’s听very听similar听coverage,听and听that’s听why听it’s听expensive. But听that’s听also why there are tax credits that are available to help individuals afford coverage. Because if听you’re听low-income,听there’s听no way听you’re听going to be able to afford full-price health insurance.听

Rovner:听And the tax credits have been a big boon to this market, right? Including听鈥μ�

Cox:听That’s听right.听

Rovner:听鈥� the expanded tax credits from 2021.听

Cox:听Yeah. The ACA included premium tax credits to begin with. But the enhanced tax credits听鈥斕齱hich is what Congress is debating right now听鈥斕齮hose听were passed in 2021,听and those听basically just听boosted the amount of financial听assistance听that people were getting.听

When the ACA was first passed in 2010, there听was a lot of talk about,听well, how do we make health insurance affordable,听but also how do we define what affordable is?听There was not really a standard听against which to say,听OK, this听is what a low-income person can afford to pay. This is what a higher-income person can afford to听pay.听

And听so听there was a table basically in the law that said, at the time, that a low-income person would pay 2% of their income for a premium, and a higher-income person would get no financial help, but a middle-income person would pay 10% or so of their income.听And it turned out that that听definitely helped听people afford coverage.听听

But听a听couple of issues that existed in the early ACA were that those higher-income or even middle-income people were priced out of health insurance if they听didn’t听get a tax credit.听And those were often small-business owners,听or entrepreneurs,听or self-employed people who were a听pretty vocal听group about how they were being harmed by higher premiums and not getting any financial help to听pay for听their costs.听This was a group that got a lot of media attention and was really part of why we were even talking about repealing or replacing the ACA.听It was that group of people who did not get any financial help but had higher premiums that were really, arguably, harmed by the ACA, especially if they had been healthy and had been able to get insurance before the ACA. That was one issue.听

And then the other issue was just that take-up was not as high as what expectations had been, and I think a lot of that was even for听lower-income or people who were getting a tax credit, maybe they just weren’t getting enough financial assistance to make that coverage affordable or attractive.听

Rovner:听And we should talk about the mandate,听because that was the big fight over the ACA听鈥μ齮he idea was听if you were going to let all these sick people into the individual market, we needed to get more healthy people into the individual听market. And听maybe听the听tax credits听wouldn’t听be enough, so听we’re听going to require people to either pay a tax penalty or buy insurance. And that was so controversial that听it got听repealed.听

Cox:听Yeah. The idea here was, well, if听you’re听going to allow people with preexisting health conditions to come in and buy health insurance,听what’s听to stop them from waiting until they get sick to get that coverage? And if they do that, then there was this word that suddenly everyone became a health economist back in 2010 and heard about adverse听selection听or death spirals.听

And听so听the concern was that if you wait until听you’re听sick to get health insurance听鈥斕齣f everyone waits until听they’re听sick to get health insurance and only sicker people are buying health insurance听鈥斕齮hen basically that makes premiums astronomically high. No insurance company is going to want to even听participate听in a market like that because it could lead to听what’s听called a death spiral听鈥斕齧eaning the premiums just get听higher and higher and higher and higher听until no one can afford to听purchase听that coverage.听

And听so听the individual mandate, sorry, was one way in which people were basically compelled to purchase insurance and听not听wait until they听were听sick.听Basically, there听were carrots and sticks in the ACA.听The sticks were the individual mandate听and also听this short open enrollment window.听So听if you听didn’t听sign up during open enrollment and you found out you had some serious illness after open enrollment听ended, you would have to wait until the next open enrollment听to sign听up. And then the carrot was the tax credit,听basically making听coverage affordable.听

So听when the individual mandate penalty was reduced to $0听鈥斕齟ffectively getting rid of the individual mandate听鈥斕齮here was a lot of concern that that was going to lead to a death spiral or adverse听selection听at least. It听didn’t听really play out that way, I think, because what really mattered was the carrots. The open enrollment window is still there as a stick, but听I think people听want health insurance. It just needs to be affordable enough for them to get it. And听so听the tax credits are听really key听there to making the coverage affordable and attractive for someone to buy it even if they are not sick.听

Rovner:听And the enhanced credit just made the carrot that much bigger, right?听

Cox:听Yeah. It听basically supersized听the carrot.听

That’s听when听you see when these enhanced tax credits rolled听out,听people started buying this coverage a lot more.听The markets doubled in size. It went from about听11 million people听signed up to over听24 million people听signed up just within a few years of these enhanced tax credits being available.听

Rovner:听So听there were also some things in the ACA that were supposed to help dampen, if you will, the acceleration of health听care spending. The consensus is those听didn’t听work听quite as听well, but they were there, right?听It’s听not听that听[the]听law just ignored the cost of health听care.听

Cox:听Yeah. The law did not ignore the cost of health听care. But I will say,听I think the primary emphasis听was on making health insurance affordable for individuals rather than making it affordable for our society. There were some measures put in place to slow the growth of health听care.听And actually, another听thing that President听[Donald]听Trump did in his first term was use authority from the ACA to implement price transparency rules for hospitals to try to get at hospital prices. And there were, of course, other efforts,听too,听but I would say nothing that really made听a huge impact听on total health听care spending as a nation.听

We have seen health听care spending has slowed.听It’s听not growing as quickly as it was before the ACA in general.听I听don’t听know if you can attribute all of that to the ACA,听though, but we still are, as a nation, spending about 20% of our GDP听[gross domestic product]听on听health听care. Whereas other countries that are large and wealthy, like the United States, spend closer to 10, 11, 12% of their GDP,听and听that’s听regardless of whether听they’re听a single-payer nation or not. Even countries that have multiple payers will still spend significantly less on health听care than the United States does.听

Rovner:听But the Republican talking point that this is all,听that health听care spending has gotten out of control听because听of the ACA听isn’t听true.听

Cox:听Yeah, no. In fact, I think health听care spending growth has slowed since the ACA.听

When you look at the individual market, which is where so much of the emphasis has been听in听changing how听preexisting听conditions are covered and that sort of thing, yes, premiums are higher today in the individual market than they were in the pre-ACA individual market. But individual market premiums today are really听similar to听employer premiums today, where the ACA,听really,听barely touched those plans.听

I think the issue听is that health insurance is just听really expensive听in this country, and听it’s听really expensive听because we spend a lot on听鈥μ齱e pay听high prices听for doctor’s visits, hospital stays, prescription drugs.听And the ACA did do some things to try to address those underlying reasons why health听care is so expensive in the U.S.,听but it听wasn’t听really the听main focus. I think the听main focus听of the ACA was to subsidize coverage and make it affordable for individuals. But that still means that听it’s听expensive for society.听

Rovner:听So听who are the individuals in the ACA individual听market, if听you will? There’s听鈥斕齱hat? 鈥斕�24 million of them?听

Cox:听Yeah.听There’s听24 million of them,听and about half of them are either small-business employees,听or owners,听or self-employed people, and听that’s听because a lot of us get coverage through work.听

But we work听at bigger companies where that company offers a benefit as part of your total compensation package. You get your salary,听and you also get your health insurance. Smaller companies often do not offer health insurance.听They’re听not required to, especially very tiny companies like mom-and-pop shops or that sort of thing. Also, even people who are not affiliated with a small business are still usually working or in a working household. They might just be working听part-time,听or they might be a stay-at-home parent where their spouse works,听and they just听don’t听get health insurance for themselves.听

And so generally speaking听鈥斕齜ecause you听have to听have an income of at least the poverty level to be getting a subsidy in this market听鈥斕齮hese are working individuals or working families. Also, a lot of farmers and ranchers rely on the ACA marketplace because, again,听that’s听a field where they听don’t听necessarily get health insurance through work. So听that’s听a big part of it.听

The other thing that’s听pretty common听is pre-retirees听or early retirees.听So basically, people听who are听not quite old听enough to be on Medicare听鈥斕齭ince you听have to听be 65 to get on Medicare听鈥斕齳ou see a lot of 64-year-olds buying ACA marketplace coverage.听

Rovner:听I think the thing that confuses most people, at least the most people that I talk to, is that we keep hearing that ACA premiums are going up an average of 17% next year,听or 30%,听or more than 100%. And听all of听those numbers are听actually correct听because听they’re听referring to different things.听So听what’s the difference between premiums the insurers听charge听and the premiums consumers听have to听pay?听

Cox:听Yeah, there are too many percentages out there for a normal person to keep track of, so I will do my best to explain it.听

Basically, there’s听two ways to think about premiums in the individual market.听There’s听how much the insurance company is charging for their premiums.听That’s听the revenue that the insurance company is bringing in. But a lot of that is not听paid听by individuals.听The federal government is paying a large share of that in the form of a tax credit.听

So听then the other way that people think about premiums in this market is how much individuals are paying out of their own pockets for their premiums.听And if听you’re听just a regular person shopping on听,听that’s听what you see as your premium payment is how much you听have to听contribute as an individual.听

The amount that the insurance companies are听charging,听we have a couple of different numbers on that. We have what they requested听to听state听regulators was an 18% increase on average. Four percentage points of that, they were saying, was this extra premium increase that they听weren’t听otherwise going to charge. But they were saying,听we think that when these enhanced tax credits expire, that healthier people are going to drop their coverage, meaning听we’re听going to be left with a sicker group of enrollees, so听we’re听going to have to charge even higher premiums than we otherwise would have.听Either way, even if the enhanced premium tax credits had been extended, insurers in this market still听would’ve听been raising premiums by double digits.听

That’s听the steepest increase that听we’ve听seen in many years in this market. But听we’re听also, I think, looking at double-digit premium increases for employer plans,听too.听It’s听just an expensive year coming up.听That’s听how much听鈥μ�

And then we have newer data that just looks at silver plans. This is super wonky.听But basically, a听certain听plan that听is the benchmark against which subsidies are calculated. The insurers are听actually charging听26% more on average for that plan.听So听I think that these requested rates might’ve understated how much insurers are听actually charging. And听so听these are听really significant听premium increases. But听鈥μ�

Rovner:听I would say听a really important听piece of this is that if the tax credits听weren’t听changing, people听wouldn’t听be paying these increases.听Right?听They would be absorbed听鈥μ�

Cox:听Exactly.听

Rovner:听鈥� by the tax credit.听

Cox:听Yeah. Nine out of 10 people in this market get a tax credit right now.听And if the tax credits were extended, people would pay the same next year that they听do听this year. Their out-of-pocket premium payment would be held听relatively flat. They would not be听paying听these increases that insurance companies are charging.听

Looking into next year, there are people who will lose the tax credit altogether if the enhanced tax credits expire. These are the middle-income, small-business owners who we were talking about before. They will lose听the tax听credit.听So听they will get less financial help or no financial help, and then they will also have to pay this double-digit premium increase that insurers are charging. So听that’s听this double-whammy effect for that group of people.听

But even the people who continue to get a tax credit,听they’ll听just get a smaller tax credit next year.听They’re听still also going to see their premium payments go up, not because of what the insurance company is charging, but听because of听Congress not extending the enhanced premium tax credits. So that means that they听have to听pay a larger share of their income.听So听a low-income person,听instead of paying nothing each month,听will have to start paying听2%听to 4% of their income. A middle-income person,听instead of paying听maybe听6%听to 8% of their income,听might pay听8%听to 10% of their income.听

Again, for most people, this is not a function of what the insurance company is charging. It’s听actually a听function of what Congress sets the law to听be听and how听much of a听tax credit they get.听

Rovner:听If the tax credits do expire, as currently scheduled, is there any way for people to offset that increase, like buying a less generous bronze plan instead of a silver plan? And what would that mean for their out-of-pocket spending on health听care?听It’s听a trade-off, right?听

Cox:听Yeah. Our analysis shows that if people stay in the same plan, they听would听see a premium increase of 114% on average. But for many people,听it could be听an option听to switch to a lower level of coverage. So听maybe instead听of buying a silver plan, they听buy听a bronze plan.听

But the issue there is,听a lot of the people who are buying ACA marketplace coverage right now are so low-income that they’re getting听really generous听financial help for their deductibles,听too.听It’s听not just their premiums. So instead of a silver premium having a deductible of a few thousand dollars for that person, their deductible might be less than a hundred dollars now. And听so听if they were to switch from a silver plan to a bronze plan, they might still be able to keep a听zero premium听payment,听or near-zero premium payment, but their deductible would be $7,000 more than it is today. Either way,听they’re听going to see their costs go up.听It’s听just,听do they see them go up when they go to the doctor,听or have an emergency,听or have a hospitalization,听or听fill听a prescription drug?听Or do they see their monthly costs go up for each month that听they’re听paying their premium?听

If听you’re听young and healthy, it might make sense to take the risk and get the bronze plan. But if听you’re听pretty sure听you’re听going to use some health听care next year, then it makes sense to just pay the higher premium so that you can keep that low deductible.听

Rovner:听Yeah. One of the main Republican talking points is all these people who have insurance but听don’t听file claims every year,听which they say is evidence of widespread fraud. But isn’t it also possible that some of those people听don’t听use their insurance because they听literally听can’t听afford these four-听and five-figure deductibles?听

Cox:听Yeah.听It’s听also听鈥μ齌here’s听a lot of reasons why someone might not use their health insurance. We certainly know whether听you’re听getting your coverage through work or through the ACA marketplaces. If you have a high deductible, then that can be a significant cost barrier. Also,听lower-income people face other non-cost-related access barriers, like getting time听off of听work,听or just the ability to find an appointment.听

But听also听the market has gotten younger. And with enhanced premium tax credits attracting more people to buy coverage, this was part of the whole听idea was听that you get younger, healthier people to sign up for coverage and not wait until听they’re听sick. And so that also can make it look like听there’s听less听utilization听of care. But if听you’re听just young and healthy, then you might not be going to the doctor either way.听

And also听just听鈥μ�

Rovner:听It’s听the opposite of the death spiral, right?听

Cox:听Right. A health spiral is what some people听have called听it.听

But I think听there’s听also just some issues with the data source that was used to do that. I听won’t听go into all those details, but I think听鈥μ齮here’s听something听there. There is fraud.听There’s听no question that there’s fraud in this market. And听it’s听being committed mostly by agents and brokers who are signing people up either without their knowledge, or switching their plan, or switching the name of the broker so they can get the commission. But I think the scale of the fraud has been exaggerated.听

Rovner:听Something else I think has gotten pretty lost in the fight over extending these additional tax credits is that it’s not the only change coming to the Affordable Care Act for 2026.听Republicans听made听some major alterations to the law in their big budget bill that they passed last summer.听Let’s听start with the changes to how much people might have to repay if they estimate their income incorrectly.听What’s听that change?听

Cox:听I think this听is听probably one听of the biggest changes aside from the听expiration听of the enhanced premium tax credit, and it听hasn’t听gotten a lot of attention.听So听I’m听worried that people who are buying their own coverage might not know about this.听

Congress has听basically repealed听any limits on how much you would have to repay when you file your taxes the following year after you enroll in ACA marketplace coverage.听The idea is that when you sign up for ACA coverage, you听have to听project what you think your income will be by the end of the next calendar year.听That can be听really hard听for someone who, say, gets their income from driving Uber or working shifts听at a restaurant,听or so on and so forth.听Or even a听small-business听owner might have听a hard time听projecting exactly how much their income will be next year. And so,听if you guess wrong听鈥斕齣n other words, if you say,听now I think听I’m听going to make $50,000 next year,听but you end up making $60,000 next year听鈥斕齮hen you might have to repay a significant amount of the tax credit.听听

The other听simultaneous thing is that with the enhanced premium tax credits going away next year听鈥斕齣f that actually does come to be听鈥斕齮hen this subsidy cliff will come back, meaning that if you make just a dollar too much,听meaning just over 400% of the poverty level,听then you’ll have to repay the entire tax credit, which could be thousands,听if not tens of thousands,听of dollars. And听so听people who are right around that cutoff will need to be听really careful听about听if听they have control over their income. For some people, it might make sense to make sure that your income is below four times the poverty level. Or you can also adjust your tax credit midyear or decide to wait and get the tax credit at the time you file your taxes instead of getting it up front.听

Rovner:听Yeah,听I think this听is a big deal. And听also听there’s going to be less help available for people to听actually sign听up for coverage, even though there’s all these big changes happening.听

Cox:听Yeah. When the ACA was first passed, there was this idea that it was going听to be听like听going online and booking your own hotel,听or airplane,听or whatever,听and听that’s听just not how it has panned out. Most people need help signing up for health insurance. It听still is听a complicated process. And听so听they turned to agents, brokers, and what are called navigators,听who are nonprofit organizations that have helped听people buy insurance.听But the Trump administration has cut funding for the navigator program听really significantly,听and so听there’s听going to be fewer of those folks to help.听

Also,听I think this听is just听going to be听probably one听of the busiest and most chaotic ACA open enrollment periods听ever,听probably,听and so many听鈥μ�

Rovner:听2013听wasn’t听great but听鈥μ�

Cox:听Yeah. But there听weren’t听so many buying it back then.听

Rovner:听鈥� where the website听didn’t听work.听

Cox:听Yeah,听yeah.听

I remember that well,听but also,听there were not that many people shopping. Now,听there’s听three times as many people shopping for coverage.听

Rovner:听True.听

Cox:听I听don’t听know if there are more agents or brokers than听there听were back then, but I suspect not. But听there’s听just going to be busy people. And听so听if you need to make an appointment with an agent or broker, then go ahead and do that as soon as you can.听

Rovner:听Yeah. This is the trade-off here. On the one hand, people want to wait and see if Congress听maybe comes听to some deal on these expanded subsidies.听On the other hand, it’s going to be听really hard听to sign up at the last minute.听

Cox:听Yeah,听yeah.听So听if it were听me听鈥斕齛nd I obviously would feel more comfortable signing up on my own without the help of someone听鈥斕齜ut I would personally prefer to wait and see what happens.听I wouldn’t wait too long, but I might wait听till听Thanksgiving or early December and wait to听make a decision听about my plan until then.听But you听can’t听advise everyone to do that because if you need an agent or broker to help you,听maybe get听that appointment as soon as you can. But听maybe also听just keep an eye out on things and decide before Dec.听15听if you want to change your plan.听

Rovner:听So听it’s听not just the expanded tax credits. There’s also听[a]听new restriction听on听who’s听eligible. There are a lot of people who are immigrants听鈥斕齱ho were here legally听鈥斕齱ho have been eligible for tax credits who no longer will be, right?听

Cox:听Yeah. There has been a lot of talk about undocumented immigrants getting this coverage.听And just to be clear, the ACA marketplaces are not where undocumented people come to get health insurance. You听can’t听even buy this coverage without a subsidy if听you’re听undocumented.听

Now, there听had听been an exception for DACA听[Deferred Action for Childhood Arrivals]听recipients. That is no longer going to be听an option听for folks. And then also even some folks who are here legally but just have not been in the country for long enough to qualify for Medicaid.听So听you听have to听be in the country for five years before you can qualify for Medicaid. And it had been that if you were, say, here for two听years and still waiting to get Medicaid eligibility, you could get subsidized coverage on the ACA marketplace. And听so听some of those folks will no longer be able to this year,听and then听all of听those folks will no longer be able to in the coming year.听

Rovner:听I know the Trump administration tried to make even more changes in its annual regulation governing the marketplace, although some of those have been blocked by the courts.听What are some of those changes that听aren’t听happening听this听year听but that people may have heard about and that may, depending on what the courts do,听come into play next year?听

Cox:听I think one of the most important ones was this idea that they were going to change how auto re-enrollment works.听So听a lot of people in the ACA marketplaces get a听zero premium听plan. And like all other health听insurances听out there, whether听it’s听your homeowner’s insurance or your car insurance, you just get automatically re-enrolled from one year to the next. And听that’s听true for these ACA marketplaces,听too.听

So听the Trump administration had a rule that said:听Well, if you were going to be auto-re-enrolled into a zero-premium plan, we want to make sure that you still want that plan. Because if听you’re听not paying anything each month, you might be听just getting听automatically re-enrolled without your knowledge.听And听so听the idea was that you would get charged $5 a month until you actively re-enroll. That was one of a few things that was听鈥μ�

There was a stay in听a court听decision听basically saying:听We need to hear more about this before the court听could听make a final decision.听But long story short,听that’s听not going into effect this year. But there will be other changes to auto re-enrollment in the coming years,听basically due to听the summer reconciliation package where auto re-enrollment would effectively end. And so听that’s听an even bigger deal,听but听that’s听not going into effect yet. That will听be in听the coming year.听

Rovner:听Yes.听So听more people will have to听actually go听in and do something with their policy, but there are fewer people to help them. Do I have that right?听

Cox:听That’s听right.听Yeah.听So听there’s听going to be a lot of听activity听this year. This year and in coming years.听Yeah.听

Rovner:听So听what’s听the bottom line here for people who now have Affordable Care Act coverage or who plan or hope to have it for next year?听

Cox:听I think,听first of all, watch this closely and听don’t听make any decision about dropping your coverage or even dropping down to a lower level of coverage until probably early December is probably the right time to really make a final decision on this.听You can still start making听all of听your plans and getting all your paperwork together and听talk听to an agent or听broker, but听just keep watching this until there’s some sort of clear resolution about听what’s听going to happen in Congress.听Because if the enhanced premium tax credits do get extended,听you’re听probably better off听keeping听the same level of coverage that you have now. Or for newer people,听they’re听probably better off in a silver plan than a bronze plan in many cases.听So听you听don’t听want to make a听significant change听to your coverage听just yet听until you know听what’s听going to happen next year.听

But it’s a difficult situation for people to be in. They听have to, at a certain point, just make a judgment call.听And I think that can lead to people听picking听a plan听that’s听not necessarily the best one for听them, or听even going without insurance because they just听don’t听feel like they can afford it anymore.听

Rovner:听This is a conundrum.听It’s听obviously a conundrum for the Democrats because听they’re听keeping the government closed听鈥斕齱hich they normally听don’t听want to do听鈥斕齞emanding that these tax credits be extended. Ironically, a lot of the people who will be helped if the tax credits do get extended are Republicans in Republican states.听They’re听small-business people. There are people in a lot of these very red states where we saw enrollment听skyrocket. Why don’t the Republicans want to do that?听It’s听their voters who would be helped.听

Cox:听Yeah.听That’s听right.听

I think from the Republican perspective, this would be new government spending,听because if Congress does nothing, these enhanced premium tax credits expire.听So听from the Republicans’听perspective, it would cost听$35 billion听a year in new government spending to extend these enhanced premium tax credits.听That’s听a lot of money,听and听that’s听coming at a time when Republicans have already shown willingness earlier in the year to make significant cuts to existing health programs like Medicaid work requirements.听

I think it听is a complicated issue for Republicans and that I think many of them would just rather these enhanced premium tax credits expire. But I think you’re seeing some Republicans, especially in parts of the country where premium increases would be very steep,听or where maybe they’re in a swing district where they’re looking at this and saying,听oh,听actually most听of the growth in the ACA marketplaces has been in听Southern red states.听Most of the people听benefiting听from these enhanced tax credits live in a state that was won by President Trump or in a congressional district that was won by a Republican.听So听it’s听a complicated issue for Republicans.听

Rovner:听Well, we will keep track of听what’s听happening.听Cynthia Cox, thank you so much.听

Cox:听Thank you.听

Rovner:听Thanks听this week to our fill-in editor,听Stephanie Stapleton,听and our fill-in producer-engineer,听Taylor Cook.听A reminder:听“What the Health?”听is now available on听WAMU platforms, the听NPR app, and wherever else听you get your podcasts, as well as,听of course,听at听kffhealthnews.org.听As always, you can email听us听your comments or questions.听We’re听at whatthehealth@kff.org,听or you can find me on X听听or on Bluesky听.听Cynthia, are you hanging on social media these days?听

Cox:听Yes.听@cynthiaccox on both听听and听.听

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

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From 麻豆女优 Health News” on , , , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Open enrollment for 2026 Affordable Care Act insurance plans starts in most states Nov. 1, with no resolution in Congress about whether to continue more generous premium tax credits expanded under President Joe Biden or let them expire at the end of this year. It is unclear whether the backlash from millions of enrollees seeing skyrocketing premiums will move Democrats or Republicans to back away from entrenched positions that are keeping most of the federal government shut down.

Meanwhile, the Trump administration 鈥� having done away earlier this year with a Biden-era regulation that prevented medical debt from being included on consumers’ credit reports 鈥� is now telling states they cannot pass their own laws to bar the practice.

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Paige Winfield Cunningham of The Washington Post, Maya Goldman of Axios, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Tens of millions of Americans are bracing to lose government food aid on Nov. 1, after the Trump administration opted not to continue funding the Supplemental Nutrition Assistance Program during the shutdown. President Donald Trump and senior officials have made no secret of efforts to penalize government programs they see as Democratic priorities, to exert political pressure as the stalemate continues on Capitol Hill.
• People beginning to shop for next year’s plans on the ACA marketplaces are experiencing sticker shock due to the expiration of more generous premium tax credits that were expanded during the covid pandemic. The federal government will also take a particular hit as it covers growing costs for lower-income customers who will continue to receive assistance regardless of a deal in Congress.
• In state news, after killing a Biden-era rule to block medical debt from credit reports, the Trump administration is working to prevent states from passing their own protections. In Florida, doctors who support vaccine efforts are being muffled, and the state’s surgeon general says he did not model the outcomes of ending childhood vaccination mandates before pursuing the policy 鈥� a risky proposition as public health experts caution that recent measles outbreaks are a canary in the coal mine for vaccine-preventable illnesses.
• And in Texas, the state’s attorney general, who is also running for the U.S. Senate as a Republican, is suing the maker of Tylenol, claiming the company tried to dodge liability for the medication’s unproven ties to autism. The lawsuit is the latest problem for Tylenol, with recent allegations undermining confidence in the common painkiller, the only one recommended for pregnant women to reduce potentially dangerous fevers and relieve pain.

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

Julie Rovner: 麻豆女优 Health News’ “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage,” by Bernard J. Wolfson.

Alice Miranda Ollstein: ProPublica’s “,” by Eric Umansky.

Paige Winfield Cunningham: The Washington Post’s “,” by Mark Johnson.

Maya Goldman: 麻豆女优 Health News’ “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown, New England Public Media.

Also mentioned in this week’s podcast:

• The Washington Post’s “,” by Paige Winfield Cunningham
• 麻豆女优 Health News’ “Doctors Muffled as Florida Moves To End Decades of Childhood Vaccination Mandates,” by Arthur Allen.
• CBS News’ “,” by Céline Gounder.

[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.]听

Julie Rovner: Hello, from 麻豆女优 Health News and, starting this week, from WAMU public radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico.听

Alice Miranda Ollstein: Hello.听

Rovner: Maya Goldman of Axios News.听

Maya Goldman: Good to be here.听

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again.听

Winfield Cunningham: Hi, Julie. It’s great to be back.听

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving.听

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either.听

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America.听

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that.听

Rovner: Well, of course, and SNAP isn’t an HHS program.听

Goldman: Exactly. Exactly.听

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find?听

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan 鈥� which, of course, is what, we know 鈥� that’s what the subsidies are pegged to 鈥� is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it.听

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand.听

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to 鈥μ�

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks.听

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain.听

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely 鈥� because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced 鈥� and now they have no cap.听

Rovner: I think 8.5% of their income, actually, under the enhanced premiums.听

Winfield Cunningham: Under the enhanced. OK.听

Rovner: It’s going to go back to 10%.听

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%.听

Rovner: 400%.听

Winfield Cunningham: Right. Yeah. Yeah.听

Rovner: That’s right.听

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it.听

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies.听

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue.听

Winfield Cunningham: This is very true.听

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something.听

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So 鈥μ�

Rovner: Yeah. Although it is 鈥μ�

Goldman: Obviously, that’s a lot of what ifs, but 鈥μ�

Rovner: 鈥� only the death spiral that goes back to prior to covid, which 鈥� it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA.听

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers 鈥� will be subject to the full force of the premium increases because they won’t have any subsidies.听

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.听听

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further 鈥� this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought 鈥� yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget 鈥� states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought?听

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that 鈥� I don’t know what health systems have said about this particular move, to be honest 鈥� but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is.听

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant.听

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC?听

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this.听

Rovner: Yeah. I’ve seen numbers as low as 60,000.听

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels.听

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years.听

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics.听

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades 鈥� focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that.听

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic.听

Ollstein: Exactly.听

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My 麻豆女优 Health News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes?听

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects.听

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head.听

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary.听

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division 鈥� that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo 鈥� to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way 鈥� even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.?听

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data.听

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the 鈥� give credence to this idea that 鈥� I see you nodding, Maya 鈥� that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain.听

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch.听

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So 鈥μ�

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications.听

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do.听

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line.听

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, . Is contraception going to become the next health care service that’s only available in blue states, Alice?听

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services.听

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two.听

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something?听

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate.听

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods?听

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want.听

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but 鈥μ�

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight.听

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week?听

Goldman: Sure. So this story is from 麻豆女优 Health News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked.听

Rovner: Yeah, it is a public health issue, an interesting one. Alice?听

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah.听

Rovner: Yeah. A combination of a lot of different factors in that story.听

Ollstein: Definitely.听

Rovner: Paige?听

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague.听

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my 麻豆女优 Health News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.听听

OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, , or on Bluesky, . Where are you folks hanging these days? Maya?听

Goldman: I am on X as and I’m also on .听

Rovner: Alice?听

Ollstein: on Bluesky and on X.听听

Rovner: Paige?听

Winfield Cunningham: I am still on X.听

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

Credits

Click here to find all our podcasts.

And subscribe to “What the Health? From 麻豆女优 Health News” on , , , , , or wherever you listen to podcasts.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Health care makes some surprising appearances in President Joe Biden’s $2 trillion infrastructure plan, even though more health proposals are expected in a second proposal later this month. The bill that would help rebuild roads, bridges and broadband capabilities also includes $400 billion to help pay for home and community-based care and boost the wages of those who do that very taxing work. An additional $50 billion is earmarked for replacing water service lines that still contain lead, an ongoing health hazard.

Meanwhile, more than half a million people have signed up for health insurance under the new open enrollment for the Affordable Care Act 鈥� and that was before the expanded subsidies passed by Congress in March were incorporated into the federal ACA website, healthcare.gov.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

• When announcing the new ACA marketplace insurance numbers, federal officials said the enrollment opportunity has been particularly popular with Black residents and lower-income customers.
• As part of its effort to spur more enrollment, the administration dramatically increased funding for marketing and outreach, including commercials during the NCAA basketball tournament. The Trump administration had cut advertising by 90%.
• The enrollment bump came even before the new, more generous subsidies were reflected on healthcare.gov, the federal website offering health plans. Biden’s covid relief plan boosted the federal tax credits for people eligible to buy marketplace insurance, especially to middle-income families and those closer to the federal poverty level.
• In describing Biden’s plan to enhance home and community-based health care, administration officials describe it as a jobs measure because it will help raise wages for people doing the work and help others not have to leave their jobs to care for a loved one.
• The need for more help caring for older people has often been overlooked because policymakers do not have an easy way to pay for such programs. But as Americans live longer, officials are grappling with the difficult transition from a health system based on acute disease to one that must handle chronic health issues, too.
• Vaccine credentials are increasingly being required before people can be admitted to public gatherings, but the U.S. does not have a standardized record-keeping system for consumers. When vaccinated, most people get a white card with handwritten details about the date and type of vaccine. Although some health systems and states are keeping records of that, not every facility has an easy way for consumers to get a new record if they lose their card. So, experts are urging them to at least take photos of the card and store that photo electronically.
• The White House has said it is not in favor of setting up a federal vaccine passport system, and the World Health Organization also said it does not want that now. In the U.S., much of the opposition is being raised by conservatives, who object to federal mandates on issues such as health. But the WHO’s concerns stem from fears raised by groups on the left over vaccine distribution: Because so many doses have gone to First World countries, residents of poorer nations would be disadvantaged by a passport system.

Also this week, Rovner interviews 麻豆女优’s Mollyann Brodie, who, in addition to serving as executive vice president and chief operating officer for 麻豆女优, leads the organization’s public opinion and survey research activities. Brodie discusses , which has been tracking Americans’ feelings and behavior regarding the vaccine.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The New Yorker’s “,” by Mallory Pickett

Joanne Kenen: Slate.com’s “” by Elena Debré

Tami Luhby: KHN’s “Despite Covid, Many Wealthy Hospitals Had a Banner Year With Federal Bailout,” by Jordan Rau and Christine Spolar

Sarah Karlin-Smith: Stat’s “,” by Usha Lee McFarling

To hear all our podcasts,听click here.

And subscribe to What the Health? on听,听,听,听, or听.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

When host Dan Weissmann and his wife set out to pick a health insurance plan for next year, they realized that keeping the plan they have means paying $200 a month more. But would a “cheaper” plan cost them more in the long run?听 It depends. And the COVID pandemic makes their choice a lot more complicated.

After trying to puzzle it out, Weissmann debriefs with Karen Pollitz, a health insurance expert at 麻豆女优, who knows about the angst of medical bills from personal experience.

Health insurance can be painful, but the alternative 鈥� not having health insurance 鈥� is so much worse. If you want to go deeper on health insurance, you might want to check out these episodes from the first season of the podcast:

• In “,” we learn: Smart economists have proved it’s actually super hard 鈥� even they aren’t sure they’ll pick correctly.
• In an inspired by KHN reporter Jenny Gold, we learn about insurance companies’ price-gouging. And often we end up paying the price.
• In, Weissmann’s family confronts the big puzzle: Can we even get insurance that’ll work for us?
• In “,” we go on a journey with a kinda-famous “financial therapist” who says she gets rattled when it comes to picking health insurance. And she’s pretty uncomfortable 鈥� morally, personally 鈥� with some of the choices she’s made. (Also, Weissmann’s family makes another cameo.)

And here are some other helpful big-picture takes:

• Listener Anna Jo Beck made a . You can read it online.
• Weissmann borrowed some core insurance-picking advice 鈥� consider what a health plan does for you if you get hit by a bus 鈥� , spelling out how he picked his insurance.

Want to go a lot deeper? Especially if you’re actually looking at buying health insurance, maybe on the Obamacare exchange?

Weissmann found to be super usable this year, way better than the last time he checked.

“I punched in the answers to a few questions, and got to quickly tell it which doctors our family sees (and what meds we take) 鈥� and it provided a clear list that showed which plans cover our docs, how much they would cost us, etc.,” he said.

• Subsidies are available for Affordable Care Act plans. 麻豆女优 has . It’s a slog, but thorough. Print it out, grab a snack and settle in. This bit of research explains that a lot of people qualify for a plan with no premium. (KHN, which co-produces “An Arm and a Leg,” is an editorially independent program of 麻豆女优.)
• 麻豆女优 has a whole database of Hundreds of Q’s and A’s, including 180-plus in Spanish.
• Also great, also very thorough: The Georgetown University Center on Health Insurance Reforms has a whole (It’s actually for “navigators” 鈥� folks who help civilians understand the sign-up process.)

That’s a lot, right? Picking a plan can be overwhelming. But don’t let it get you down.

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

To keep in touch with “An Arm and a Leg,”听. You can also听follow the show on听听and听. And if you’ve got stories to tell about the health care system, the producers .

To hear all Kaiser Health News podcasts,听click here.

And subscribe to “An Arm and a Leg” on听,听,听听or听.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

• Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
• Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
• Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
• Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
• Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
• Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
• Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

“CMS is committed to working with states to provide the flexibility they need to increase choices for their citizens, promote market stability, and more affordable coverage,” a spokesperson for the Centers for Medicare & Medicaid Services, who declined to be identified, wrote in an email to KHN. “We are pleased to see states like Georgia take the lead in health care reform by creating innovative state based solutions.”

Federal officials in recent weeks had requested additional information from Georgia, and Republican Gov. Brian Kemp on Wednesday asked for a delay in the evaluation of a large portion of the proposal.

The state’s plan, which has drawn opposition from ACA supporters, proposes to jettison consumer access to the federal insurance enrollment website 鈥� healthcare.gov 鈥� and instead send people buying individual policies to private companies to choose coverage.

It would also cap how much is spent on premium subsidies, which could mean some consumers would be put on a wait list if they needed financial help to buy a plan. ACA subsidies are not capped in any state now.

The state’s proposal is the boldest yet under new guidelines the Trump administration issued in 2018 and 2019. Those guidelines widen the opportunity for states to try different approaches to expanding coverage and lowering costs for consumers who buy insurance themselves because they don’t get it through their job or a government program.

Georgia officials say the initiative would help drive down insurance costs 鈥� for the state and consumers 鈥� by providing more choices, permitting cheaper plans to be offered and capping financial assistance to consumers.

Last year, 450,000 Georgians enrolled in a health plan through the ACA, 88% of whom received a federal subsidy to help pay their premium.

Nationwide, 11 million people got health insurance through the marketplaces in 2019.

Ryan Loke, who handles special projects for Gov. Kemp, said state officials expected that the federal government would need more details as it reviewed the proposal. Georgia’s request “is a first in the nation approach to reforming the individual marketplace, and given the novelty to the approach 鈥� we expected that supplemental information would be required, and have worked with our federal partners to begin putting together the necessary information for their review.”

But critics in Georgia and two detailed analyses released in late January have slammed the proposal, initially submitted for federal review Dec. 23.

“If CMS were to approve this waiver in its current form, I would expect lawsuits on behalf of Georgia consumers and families,” said Laura Colbert, , a consumer group based in Atlanta that has called the proposal “.” “The proposal would encourage enrollment in substandard plans and likely cause many Georgians to lose coverage. People with preexisting health conditions would be put at risk.”

Such a lawsuit would add to the mountain of litigation surrounding the ACA, including and an appeals court decision in December that threatens the entire law.

A decision favoring Georgia’s proposal would also add to the continuing high-profile political debate over the fate of the ACA.

“This is the first time a state has tried to take advantage of the Trump administration’s new approach to waivers, to implement some of the ideas the administration’s been pushing,” said Justin Giovannelli, a health policy expert at Georgetown University in Washington, D.C. “Other states and a lot of lawyers are watching closely.”

Georgia is making the request for new marketplace rules under a procedure known as a 1332 waiver. Under the law, states using such a waiver must still hew to strict rules set by the ACA.

For example, a state experiment can’t cost the federal government more money (for premium subsidies), raise costs for consumers on average, or result in fewer people gaining coverage than would be the case without the experiment.

Georgia’s proposal is in two parts. The first part seeks to establish a reinsurance program that picks up the tab for the care of high-cost patients using both state and federal funds. That allows insurers to keep costs down so they can offer lower premiums to consumers. The program, if approved, would go into effect in January 2021.

CMS says it will evaluate that part separately, with an eye toward swift evaluation and approval after a 30-day comment period. Final approval would make Georgia the to gain permission to use a reinsurance program.

Kemp has dubbed Georgia’s proposal for more far-reaching changes, starting in January 2022, the “Georgia Access Model.”

Instead of using the federal marketplace, Georgia would require consumers to enroll in coverage directly through insurance companies, brokers or private-sector websites.

At the same time, Georgia proposes to take over the administration of subsidies and cap the amount each year.

Insurers would also be allowed to sell plans that don’t comply with ACA requirements, under Georgia’s request. For example, one proposed type of plan could cover just half of a consumer’s costs for care, as opposed to the 80% to 90% levels of ACA’s silver and gold plans. Such a plan would have lower premiums but sharply higher out-of-pocket costs (such as deductibles and copays) if extensive care was needed.

Insurers and brokers would also be allowed to promote cheaper plans that don’t cover all the benefits required of current ACA plans.

Two studies released late last month concluded that Georgia’s proposal does not meet the guidelines for marketplace experiments set out in the ACA.

“There are very clear errors in Georgia’s proposal,” said Christen Linke Young, co-author of and a fellow at the Brookings Institution in Washington, D.C. “The numbers don’t add up, and the proposal doesn’t meet the standards the ACA established. The plan would harm consumers if approved, and we don’t believe it can or should be approved.”

The , by the left-leaning Center for Budget and Policy Priorities (CBPP), also in Washington, concluded that Georgia’s proposal would “cause thousands of Georgians to lose coverage and 鈥� likely also leave many with less affordable or less comprehensive coverage than they would otherwise have.”

If premiums or enrollment rose by 10%, for example, CBPP calculates that Georgia would have to deny subsidies to between 15,000 and 34,000 people under the proposed cap.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

But Christina Rinehart of Moberly, Mo., who has bought coverage on the federal insurance exchange for several years, won’t be swayed by the new five-star rating system.

That’s because only one insurer sells on the exchange where the 50-year-old former public school kitchen manager lives in central Missouri. Anthem Blue Cross Blue Shield in Missouri was not ranked by the Centers for Medicare & Medicaid Services.

“I’m pleased with the service I get with that and the coverage I have,” she said, noting she focuses on cost and whether her medications and checkups are covered.

Rinehart’s case illustrates one reason why the star ratings are unlikely to play a big role in people’s decision-making for the first year of the national rollout. Nearly a third of health plans on the federal exchanges don’t yet have a quality rating 鈥� including all the plans in Iowa, Kansas and Nebraska. Only one insurer is available in across the U.S. And consumers may not find the information behind the star ratings valuable without additional details, insurance experts say.

Across Missouri, Cigna is the only one of seven insurers to get ratings. The others have not yet been in the marketplace for the three years needed to merit a score.

Missouri is one of eight states that don’t have any health plans that earned at least three stars. The others are Iowa, Kansas, Nebraska, Nevada, New Mexico, West Virginia and Wyoming. States with the most are New York (12), Michigan (10), Pennsylvania (9), Massachusetts (8) and California (7).

The star ratings are largely new to the federal exchanges, which operate in 39 states. About in the federal marketplaces earned three or more stars overall, CMS said. Only 1% earned five stars.

The new federal star ratings are based on three main areas: evaluations of the plans’ administration, such as customer service; clinical measures that include how often the plans provide preventive screenings; and surveys of members’ perception of their plan and its doctors.

Ratings can be viewed at , where consumers review plans’ benefits and prices. Open enrollment runs from Friday through Dec. 15 for the federal exchange states, though enrollment lasts longer in the District of Columbia and most of the 11 states that operate their own marketplaces.

Last year, about 11.4 million people bought coverage on all the exchanges, with more than 80% getting federal subsidies to lower their premiums.

The good news for consumers is premium prices on the federal exchanges are on average for 2020.

And consumers generally will have a wider array of choices as more companies enter the markets. Nationally, the average number of health plan choices per customer has risen from 26 to 38, according to Joshua Peck, co-founder of Get America Covered, a nonprofit that helps people enroll and find coverage. Missouri, for example, will have 28 plans from its seven insurers, he said, up from 14 this past year.

Jodi Ray, who runs Florida’s largest patient navigator program as director of at the University of South Florida, is skeptical consumers will use the new ratings. Instead, she said, they will likely focus first on whether their doctor is on the plan, if their medications are covered, the size of the deductible and the monthly costs.

“The star ratings may fall out the door at that point,” she said.

Many of the states that operate their own exchanges have already offered quality ratings, which were required under the ACA. California’s insurance exchange has been providing quality ratings for several years, though it’s unclear how much weight consumers give them.

“They have a limited effect on consumers but have a significant effect on health plans,” said Peter Lee, executive director of Covered California, the state’s insurance exchange. “It does tip health plans to focus on what they can do to improve care, and I think that is a positive effect.”

Kaiser Permanente (which is not affiliated with Kaiser Health News) is the only insurer in the California exchange to garner the maximum five stars, Lee said. It also has the most enrollment of any plan in the state’s exchange. But, he noted, the plan has a lower share of the enrollment in Southern California partly because its prices are higher compared with rival insurers, indicating low cost may trump high rankings in attracting enrollees.

“It’s good news that nationally the federal marketplace is putting quality data out there for consumers,” Lee said. Still, he added, customers would want to see the specific criteria that matter to them, such as how well plans care for patients with diabetes. Currently, that data is not immediately accessible for consumers at healthcare.gov.

Consumers tend to stick with their insurer even when prices and benefits change, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, the nation’s largest public health philanthropy. “People think changing health insurance plans is a huge pain and they don’t know if things will get better or worse.” But, she added, “people respond to consumer ratings and reviews.”

The federal government already uses star ratings to help consumers choose a Medicare Advantage plan as well as compare hospitals. It began testing the exchange ratings in a handful of states over the past two years.

Heather Korbulic, executive director of the Nevada health exchange, worries the ratings could be steered by a relatively small number of member surveys. “It’s such a narrow sample,” she said, noting one plan’s rating was partly based on just 200 member reviews.

Even though many counties have only one insurer in 2020 鈥� most of them rural areas or clustered in the Southeast 鈥� the number of enrollees with access to just one insurer to 12% next year from 20% now.

In Missouri, that’s the case in more than two-thirds of the counties. Sidney Watson, director of the Center for Health Law Studies at St. Louis University, attributes the lack of choices in Missouri to the failure to expand eligibility for Medicaid. People who earn between 100% and 138% of the poverty line who would be eligible under Medicaid expansion instead are enrolling in marketplace plans, she said. Since they tend to be less healthy, they drive up premiums in the marketplaces.

States that have not expanded Medicaid see premiums that are 7% higher than states that have, according to a .

“If you look at Arkansas, they’ve got nice competition in their marketplace, but they’ve also expanded Medicaid,” Watson said. “We look a lot like Mississippi, which is struggling to get insurance in rural counties.”

That leaves people, like Rinehart, stuck with one insurer.

Rinehart remains loyal to Anthem particularly after it helped her get care and deal with the costs of suffering four heart attacks in 24 hours nearly three years ago. She’s thrilled Anthem’s prices are down slightly for 2020.

“I wasn’t able to afford insurance before [the Affordable Care Act],” she said, “so it was a blessing to have.”

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).