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

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

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

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

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

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

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

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

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

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

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

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

Sowing Choices

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

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

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

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

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

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

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

Staying Rooted in Coverage

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

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

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

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

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

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

Meanwhile, policy experts share Howard’s concerns.

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

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

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

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

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact �鶹Ů�� Health News and share your story.

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�鶹Ů�� Health News Southern correspondent Sam Whitehead discussed high Affordable Care Act premiums on WUGA’s The Georgia Health Report on March 27.

• Read Renuka Rayasam’s “When Health Insurance Costs More Than the Mortgage.”

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

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More changes lie ahead that make it important for those getting subsidies in 2026 to track their income and take steps to protect against that kind of financial hit.

First, the basics of how the subsidies work.

Enrollees pay a percentage of their household income toward their health insurance premiums based on a sliding scale, ranging in 2025 from nothing for very low-income people to 8.5% at higher income levels. Subsidies, usually paid directly to insurers, cover the rest.

The income calculation done during open enrollment is an estimate of what a household thinks it will earn in the coming year. At tax time, ACA enrollees must reconcile what they received in subsidies with what they actually earned. If their income rose, they might owe some of the subsidies back.

But don’t skip filing! People who get ACA subsidies must file tax returns no matter their income, and that is becoming even more important: The Trump administration people from subsidy eligibility if they have gone two consecutive years without filing, and it is proposing lowering that to one year.

Beware Surprise Tax Bills

All enrollees who received subsidies for ACA coverage in 2025 — — need to include a special form, the , with their tax filings. That form is used to reconcile a person’s actual income with the amount of subsidies they received, information the IRS mails them on a separate, . Subsidy amounts are based in part on the income projections they made when they enrolled in their ACA plans.

And that can lead to surprises. Some may find they get money back if their income was less than they estimated. But, if their income went above their initial or updated estimates, they probably qualify for less in assistance and will have to pay money back.

Groups that help people file their taxes say it’s not always easy for people to accurately estimate their income for the year ahead, especially those who run their own businesses, work multiple jobs, or have work that comes with varying hours.

Clients will say, “I can make anywhere between $20,000 and $45,000 next year. I just don’t know,” said Katie Alexander, director of training and volunteers for the health and economic opportunity program at Pisgah Legal Services, a western North Carolina nonprofit that provides free tax and health insurance help to people with low incomes.

Still, for taxes being filed now for the 2025 tax year, on what many people must repay.

That cap is $375 for a single individual who earned less than $31,300 in 2025, or . The maximum owed under that sliding scale for people whose income is on the higher end of the range is $1,625 for an individual and $3,250 for a family.

There is no repayment cap for people earning more than four times the federal poverty level — totaling $62,600 in 2025 for an individual or $106,600 for a family of three — so they could owe back all amounts that exceeded their eligibility.

“The amount is just so staggering for folks,” Alexander said.

One woman whom Pisgah staff helped with pulling together her taxes for 2025 made just above $50,000, which was more than she initially estimated. Her repayment was capped at $1,625, Alexander said. Without that cap, she would have owed $4,000, a substantial chunk of her annual income.

Plan Ahead: The Rules Will Be Tougher Next Tax Season

Congressional Republicans’ One Big Beautiful Bill Act, signed into law by President Donald Trump last summer, . That means come next year’s tax season, there will be no sliding-scale limit to how much people could owe back in subsidies for 2026 if their income exceeds their projections.

“That’s just going to be absolutely devastating,” Alexander said.

There are at least two other things to keep in mind, both stemming from covid-era enhanced tax credits, which expired at the end of last year because Congress did not extend them. One is that the amount of household income people must pay toward their premiums this year before subsidies kick in has risen to just over 2% on the low end of the income scale and up to nearly 10% for higher-income earners.

The second is that households earning over four times the federal poverty level no longer qualify for ACA subsidies.

The biggest financial hit could be felt by enrollees whose income rises enough during the year to exceed four times the poverty level. In that case, they would owe back all the subsidies they receive in 2026.

And that could be a lot.

In 2025, for example, the average monthly premium for ACA coverage was $619, but the average enrollee received subsidies worth enough to offset all but $74 of that, according to the .

There’s another twist for some. Because the enhanced credits were not extended, people are paying, on average, double the amount toward their premiums this year, so they may be looking to add to their incomes to cover the cost. A found that 43% of people who remained enrolled in coverage this year are planning to work more hours or get additional work to cover those costs.

“That makes sense, but it can also present a risk of being eligible for less subsidy money than they thought, or even mean they would have to repay the entire tax credit,” said Cynthia Cox, senior vice president and director of the Program on the ACA at �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News.

People can update their projected income at the marketplace website as it changes during the year.

Pisgah staff are calling people they’ve worked with and saying, “Please, please, please, if your income changes, call us so we can adjust your income through the marketplace,” Alexander said.

As much as possible, keep track of income during the year. This isn’t easy, especially for workers who don’t have a job with regular paychecks.

“If you’re meeting with a CPA to talk about taxes, have a conversation to make sure you’re making enough money to afford your costs, but not too much to lose eligibility for a subsidy,” Cox said. “Contributing toward a retirement plan or a health savings account can lower part of your income that counts toward subsidy eligibility.”

Others might choose to dial back their work hours or forgo a new client contract.

“If taking that extra shift means putting you over the line of 400% of the federal poverty level and that’s going to cost you $10,000 in repayments, maybe don’t take that shift,” said Jason Levitis, a senior fellow at the Urban Institute who follows ACA and tax policy issues.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact �鶹Ů�� Health News and share your story.

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

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Recent polling finds that health costs are a top worry for much of the American public, while Republicans in Congress are considering still more cuts to federal health spending on programs such as Medicaid and the Affordable Care Act.

Meanwhile, the Supreme Court ruled that Colorado cannot ban mental health professionals from using “conversion therapy” to treat LGBTQ+ minors, a decision that’s likely to affect other states with similar laws.

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Jessie Hellmann of CQ Roll Call, Alice Miranda Ollstein of Politico, and Sandhya Raman of Bloomberg Law.

Panelists

Among the takeaways from this week’s episode:

• Republicans reportedly are weighing still more cuts to federal health spending. With the war in Iran draining military coffers, GOP leaders in Congress are eying a drop in health funding — a decision that could exacerbate problems following the passage of legislation expected to lead to major reductions in Medicaid spending, as well as the expiration of enhanced ACA premium subsidies that were not renewed by lawmakers last year. And President Donald Trump’s budget could include another sizable reduction in funding to the National Institutes of Health.
• The Supreme Court this week struck down a Colorado law prohibiting licensed professionals from practicing a form of therapy that tries to change the sexual orientation or gender identity of LGBTQ+ minors. States have long had the power to regulate medical care, with the goal of restricting treatments that can be harmful. Also, the Idaho Legislature passed a bill requiring teachers and doctors to out transgender minors to their parents.
• Meanwhile, the Department of Health and Human Services is studying whether to make private Medicare Advantage plans the default option for seniors enrolling in Medicare, a change that would seem to conflict with the Trump administration’s scrutiny of overpayments to the private insurance plans. And a tech nonprofit’s lawsuit seeks to reveal more about the administration’s pilot program testing the use of artificial intelligence in prior authorization in Medicare.

Also this week, Rovner interviews �鶹Ů�� Health News’ Elisabeth Rosenthal, who wrote the last two �鶹Ů�� Health News “Bill of the Month” stories. If you have a medical bill that’s outrageous, infuriating, or just inscrutable, you can submit it to us here.

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

Julie Rovner: New York Magazine’s “,” by Helaine Olen.����

Jessie Hellmann: The Texas Tribune’s “,” by Colleen DeGuzman, Stephen Simpson, Terri Langford, and Dan Keemahill.��

Sandhya Raman: Science’s “,” by Jocelyn Kaiser.����

Alice Miranda Ollstein: The New York Times’ “,” by Ed Augustin and Jack Nicas.����

Also mentioned in this week’s podcast:

• �鶹Ů�� Health News’ “States Pay Deloitte, Others Millions To Comply With Trump Law To Cut Medicaid Rolls,” by Samantha Liss and Rachana Pradhan.
• �鶹Ů�� Health News’ “Trump’s Hunt for Undocumented Medicaid Enrollees Yields Few Violators,” by Phil Galewitz.
• The Colorado Sun’s “,” by John Ingold.
• Politico’s “,” by Alice Miranda Ollstein, Erin Doherty, Marcia Brown, and Carmen Paun.
• The New York Times Magazine’s “,” by Coralie Kraft.
• NOTUS’ “,” by Margaret Manto.
• The Dallas Morning News’ “,” by Emily Brindley.

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

Julie Rovner:��Hello, from �鶹Ů�� Health News and WAMU Public Radio in Washington, D.C. Welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �鶹Ů�� Health News, and��I’m��joined by some of the best and smartest��health��reporters covering Washington.��We’re��taping this week on Thursday,��April 2, at 10��a.m.��As always, news happens fast, and things might have changed by the time you hear this. So here we go.��

Today, we are joined��via��video conference by Alice Miranda��Ollstein��of Politico.��

Alice Miranda��Ollstein:��Hello.��

Rovner:��Jessie Hellmann��of CQ��Roll Call.��

Jessie Hellmann:��Thanks for having me.��

Rovner:��And Sandhya��Raman,��now at Bloomberg Law.��

Sandhya Raman:��Hello, everyone.��

Rovner:��Later in this episode,��we’ll��have my interview with���鶹Ů�� Health News’��Elisabeth Rosenthal, who reported and wrote the last��two���鶹Ů�� Health News��“Bills of the��Month.”��One is about a patient who got caught in the crossfire over prices between insurers and drug companies. The other is about a woman who, and this is not an April Fools’��joke, got her insurance canceled for��failing to pay��a bill for��1��cent. But first,��this week’s news.��

So��Congress is on spring break, but when they come back,��health��policy will be waiting. A new Gallup poll out this week found 61% of those surveyed said they worry about the availability and affordability of health care, quote,��“a great deal.”��That was 10 percentage points more than the economy,��inflation,��and the federal budget deficit, and it topped a list of 15 domestic concerns. And while we are still waiting for final enrollment numbers for Affordable Care Act plans, we do know that the share of people paying more than $500 a month for their coverage doubled from last year to 2026.��Yet Axios this week is reporting that Republicans are considering still more cuts to the Affordable Care Act to potentially pay for a��$200 billion��war supplemental. What exactly are they thinking? And��it’s��looking more like Republicans are going to try for another budget reconciliation bill this spring. Isn’t that, right,��Jessie?��

Hellmann:��House��Budget��chair Jodey Arrington has kind of been pushing this idea��really hard��of going after what he says is fraud��in��mandatory programs like Medicare and Medicaid.��He’s��also talked about funding��cost-sharing��reductions, which is an idea that slipped out of the last reconciliation bill, and��it’s��a wonky kind of idea��…��

Rovner:��But��I think the best way to explain��it��is that it will raise premiums for many people.��That’s��how��I’ve��just been doing it.����

Hellmann:��Yeah, exactly.��

Rovner:��Let’s��not get into the details.��

Hellmann:��It would��reduce spending for the federal government but��wouldn’t��really help people who buy insurance��on��the marketplace. He��hasn’t��been��very specific.��He’s��also talked about,��like,��site-neutral��policies��in��Medicare, but��it’s��hard to see how all of this could make a serious��dent in��a��$200 billion��Iran supplemental.��There’s��also a new development.��I think President��[Donald]��Trump threw a wrench in things yesterday when he said he wanted the reconciliation bill to focus on border spending and immigration spending to cover a three-year period, and now Senate Majority Leader John Thune is saying that there’s probably not room for much else in the bill. So,��unclear what the path forward is for all of that.��

Rovner:��Yeah, and of course, that was part of the deal to free up the Department of Homeland Security’s budget in the appropriation.��It’s��all one sort of big, tied-up mess at this point.��Alice, I see��you’re��nodding.��

Ollstein:��Yeah.��I mean, what often happens with these reconciliation bills is it starts out with a tight focus and everyone’s unified, and then, because it can often be the only legislative train leaving the station,��everybody gets desperate to get their pet issue on board, and then the more and more things get piled onto it, then they start losing votes, and people start disagreeing more. And��so��I think even though this is still in the ideas phase,��you’re��already seeing some signs of that happening. And when it comes to health care, it can be particularly fraught. And of course, you have lawmakers, especially in the��House, with wildly��different needs. Some of them need to fend off a primary from the right, and so they want to be as conservative as possible. Some are fighting to hang on in swing districts, and so they want to be more moderate. And these things are in conflict. And��so��these proposals to cut health spending, even more than the massive amount that was cut last year,��are already, you know, raising some red flags among some moderate Republican members.��And��it’s��very possible the whole thing falls apart.��

Rovner:��Well, along those lines,��we’re��supposed to get the��president’s budget on Friday, which is only two months late. It was due in February.��And while I��haven’t��seen much on it, Jessie, your colleagues at��Roll��Call��are reporting that the budget will seek a 20% cut to the National Institutes of Health.��That’s��only half the cut that the administration proposed last year. But given that Congress actually boosted the��agency’s��budget slightly this year, that feels kind of unlikely.��

Hellmann:��Yeah, I��don’t��think that the appropriators are likely to��go along with this.��They have really strong advocates, and Sen.��Susan Collins, who’s chair of the Senate Appropriations Committee.��And,��like��you��said, they rejected cuts last year.��Kind of surprised.��Twenty percent��is not as deep as the Trump administration went last year.��I was actually kind of surprised it wasn’t��a��bigger proposed cut.��But either way, I��don’t��think Congress is going to go along with that.����

Rovner:��Meanwhile, I saw��a late headline that FDA is looking to hire back people after��DOGE [Department of Government Efficiency]��cut��thousands��of people last year. Sandhya,��HHS��[Department of Health and Human Services]��is just in this sort of personnel churn at this point, isn’t it?��

Raman:��Yeah, I think that HHS is kind of getting��bit��in the foot from, you know, we’ve had so many of these layoffs, and we’ve also had a lot of people just flee the various agencies over the past year because of some of this instability and all of these changes. And as��we’re��getting��closer and closer��to, you know, deadlines of things that they need to get done,��they’re��realizing that they do need more personnel to get some of those things done,��as��we’ve��been passing deadlines.��So��I��don’t��think��it’s��something��that’s��unique to just FDA.��But I think the way to solve this��—��it’s��not an overnight thing for the federal government to staff up.��It’s��a longer process, but��it’s��really showing in a lot of areas right now.��

Rovner:��Yeah, I would say this is not like TSA��[Transportation Security��Administration], where you can, you know, hire new��people��and train them up in a couple of months. These are��…��many of them scientists��who’ve��got years and years of training and experience at doing some of these jobs that,��you know,��the federal government is ordered to do by legislation.��

Raman:��Yeah, those��statutes are things that,��you know, if they��don’t��meet those��deadlines,��those��are things that are��going to be challenged, and just further tie things up in litigation.��And we already see so many of those right now that are making things more complicated.����

Rovner:��Well, in news that is not from Congress or the administration, the Supreme Court this week said Colorado could not ban licensed mental health professionals from using so-called��conversion therapy aimed at LGBTQ individuals, at least not on minors.��What’s��the practical impact here? It goes well beyond Colorado,��I��would think.��

Ollstein:��Interesting,��because a lot of people think of this as regulating health care, restricting providers from providing health care that is not helpful and��maybe actively��harmful to the health of the patients.��

Rovner:��And that’s��…��I would say��that’s��been a state��…��

Ollstein:��Power.��

Rovner:��… power.��For generations.����

Ollstein:��Absolutely.��Right,��I mean, you don’t want people selling sketchy snake oil pills on the street, etc. So many people view this as akin to that.��But it has morphed in the hands of conservative courts into a free speech issue, and that, you know, these laws are restricting the speech of mental health workers who are against people transitioning. And so, yes, it��definitely has��national implications. And of course, we are in a national wave right now of both state and federal entities, you know, moving in the direction of rolling back trans rights in the health care space and beyond.��

Rovner:��Yeah. In related news,��regarding��Colorado and minors and gender,����that Children’s Hospital Colorado has not yet resumed providing gender-affirming care for transgender youth.��That’s��despite a federal judge in Oregon having struck down an HHS declaration that would have punished hospitals for providing such services.��Apparently, the��hospital in Colorado is concerned that the��judge’s��ruling��doesn’t��provide it with enough legal cover for them to resume that care.��I’m��wondering, is this the administration’s strategy here to get organizations to do what they want, even if they might lack the legal authority to do it?��Just by making them worry that they might come after them?��

Raman:��I think the chilling effect is definitely a big part of this broader issue.��I mean, we’ve seen it in other issues in the past, but just that if there is this worry that it’s a)��going to stop on the provider side, new folks taking part in providing care, and also just it’s going to make patients, even if there are opportunities,��even less likely to want to go because of the fears there. I mean, it goes broader than that.��We’ve��had FTC��[Federal Trade Commission]��complaints,��where they have gone and investigated��different places��that provide gender-affirming care or endorse it.��So��I think��it’s��broader than this, and really part of that chilling effect.����

Rovner:��And Alice, as you were saying, I mean, the subject of transgender rights, or lack thereof,��remains��a political hot topic. The Idaho��Legislature this week passed a bill that now goes to the governor that would require teachers and doctors to out transgender minors to their parents. Parents could sue teachers, doctors,��and��child care��providers who, quote,��“facilitate the social transformation of the minor student.”��That includes using pronouns or titles that��don’t��align with their sex at birth.��I don’t know about teachers, but that definitely seems to violate patient privacy when it comes to��doctors, right?��

Ollstein:��There’s definitely patient privacy issues there. I also think, you know,��it’s��interesting that��this kind of nonmedical��transitioning��is now coming under attack. Because, you know, you would think that there would be some support for letting a kid, you know, go by a different name for a few weeks, test it out, see how it feels.��Maybe it’s a phase, then they discover that they don’t want to actually pursue taking medications and going through a medical transition.��But this is sort of shutting down that avenue as well.��You��can’t��even change your appearance, change how you present in the world, at a time when kids are really trying to figure out who they are.��So��I think the broad acceptance of hostility to medical transitioning for youth is now spilling over into this kind of social transitioning, and I wonder if��we’re��going to see more of that in the future.��

Rovner:��Yeah, I feel like we started with��minors��shouldn’t��have surgery.��They��shouldn’t��do anything��that’s��not easily reversible.��And now��we’ve��gotten down to,��in��the Idaho��law,��there’s��actually mention��of nicknames. You��can’t��… a��kid��can’t��change his or her nickname. It feels like we’ve��sort of��reduced��this way, way, way down.��

Ollstein:��And I think��we’ve��seen these��laws,��laws related to bathrooms.��We’ve��seen these have negative impacts on people who are not trans at all, people who just are a tomboy or not looking like people’s stereotypes of what different genders may look like. And��so��there’s��a lot of policing of people who are not trans in any way. You know, there’s media reports of people being confronted by law enforcement for going into a bathroom that does align with their biological sex. And��so��it’s��important to keep in mind that these laws have an effect��that’s��much broader than just the��very small��percentage of people who do consider themselves trans.��

Rovner:��Yeah,��it’s��kind of the��opposite of not being��woke. All��right,��we’re��going to take a quick break. We will be right back.����

So��while��we’ve��had lots of news out of the Department of Health and Human Services the past few weeks,��it’s��been mostly public��health-related.��But��there’s��a lot going on in the Medicare and Medicaid programs too. Item��A:��Stat News��is reporting��that HHS is studying whether to make the private Medicare Advantage program the default for seniors when they qualify for Medicare. Right now, you get the traditional fee-for-service plan that allows you to go to any doctor or hospital that accepts Medicare, which is most of them.��You have to affirmatively opt into Medicare Advantage, which often provides extra benefits but also much narrower networks.��What would it mean to make Medicare Advantage the default,��that people would go into private plans instead of the��government��plan, unless they affirmatively opted for the traditional fee-for-service?��

Hellmann:��Someone’s experience with��…��can vary��greatly between��being on traditional Medicare and Medicare Advantage. If��you’re��in Medicare Advantage, you could be exposed to narrow networks. You can only see certain doctors that are covered by your plan. You can be exposed to higher cost sharing. A lot of people are��kind of fine��with their plans until they have a medical issue and need to go to the hospital or they need skilled nursing care.��So��making this the default could definitely be a challenge for some people, especially people that have complex health needs. Some people on the early side of their Medicare eligibility are fine with Medicare Advantage, and then they get��older��and��they’re��not fine with it anymore.��So��it’s��interesting that the administration would��kind of float��this��idea��because��they’ve��been critical��of Medicare Advantage.��

Rovner:��Thank you.��That’s��exactly what I was thinking.��

Hellmann:��Yeah,��they’ve��talked about the federal government��pays��these plans too much, and��it’s��not for better quality in a lot of cases, and��they’ve��talked about reforms in that area.��So��I was a little��surprised to see that.��

Rovner:��Yeah, Republicans have been super ambivalent. I mean, Medicare Advantage was their creation. They overpaid them at the beginning when they, you know,��sort of redid��the program in 2003.��And they purposely overpaid them to get people into Medicare Advantage. And then the Democrats pointed out that this is wasting money because��we’re��overpaying them. And now the Republicans seem to have joined a lot of their��—��at least some Republicans��—��seem to have joined a lot of the Democrats in saying,��Yes,��we’re��overpaying them.��We’re��paying��them too much. And you know, they talk about the big, powerful insurance companies, and yet��they’re��now��floating��this idea to make Medicare Advantage the default.��So��pick a side, guys.��

All right, well, in other Medicare news, the Electronic Frontier Foundation is suing Medicare officials to learn more about the pilot program��that’s��using artificial intelligence to oversee prior authorization requests in the traditional Medicare��fee-for-service��program.��The idea here is to cut down on,��quote,��“low-value services,”��things that doctors might be prescribing that aren’t either particularly necessary or shown to actually work.��But the fear, of course, is that needed care for patients will be delayed or denied, which is what��we’ve��seen with prior authorization in Medicare Advantage. This is the perennial push-pull of our health care system, right? If you do everything that doctors say,��it’s��going to be too expensive, and if you second-guess them,��it’s��going to be,��you know, it��might turn out to be too constraining.��

Hellmann:��Well, I was just going to say��this��is another issue that was��kind of a��little surprising to me, because��there’s��been so much criticism of the use of prior authorization and Medicare Advantage. And CMS��[Centers for Medicare & Medicaid Services]��looked at that and said,��Oh, what if we did it in traditional Medicare?��Like it was never going to go over well politically,��and��I think there��are even some Republican members of Congress who are not in support of this, but they��haven’t��really made a huge stink about it.��Yeah, this��wasn’t��something I really expected��to see.��

Rovner:��Yeah,��we’ll��see how��this one plays��out too.��Well, meanwhile,��regarding��Medicaid, two��really good��stories this week from my���鶹Ů�� Health News colleagues Phil��Galewitz, Rachana Pradhan,��and Samantha Liss.��Phil’s story��found that efforts in multiple states to find enrollees who were not eligible for the program due to their immigration status turned up very few violators. While��Samantha and��Rachana��detailed��the hundreds of millions of dollars states and the federal government are spending to set up computer programs to track��Medicaid’s new work requirement, despite the fact that we already know that most people on Medicaid either already work or they are exempt from the requirements under the new law. Is it just me, or are we spending lots of time and effort on��both of these��policies that are going to��have not��a very big��return?����

Ollstein:��Well,��that’s��what��we’ve��seen in the few states that have gone ahead and��attempted��this before,��that it costs a lot, and you insure fewer people. And��that’s��not because those people got great jobs with great health��care. You insure fewer people, and the level of employment does not meaningfully change.��

Rovner:��I would��say you insure fewer people who may well still be eligible. They just get caught in the bureaucratic red tape of all��of this.��

Ollstein:��Exactly.��These tech systems that are being set up are challenging to navigate, if people even have a means to do it, if they even have a smartphone or a computer or access to Wi-Fi.��There are not that many physical offices they can��go��to��to��work it out if they need to. And some of those are��very far��from where they live. And��so��you see some of these tech vendors,��you know, are set to make off very well out of this system, and people who need the care not so much. And then, of course, you know,��it’s��not just the patients who will feel the impact. You have these hospitals around the country that are on the brink of closure. And if they have people who used to be insured��—��they used to be able to bill and get reimbursed for their services, suddenly they’re uninsured��—��and they’re coming in for emergency care that they can’t pay for, that the hospital has to throw out-of-pocket for, that puts the strain that some of these facilities can barely cope with.��And��so��you’re��seeing a lot of state hospital associations��sounding��the alarm as well.��

Raman:��I would also say the timing is interesting. You know, we spent so much time and energy last year going through the reconciliation process to tighten these areas, to get in the work requirements, to reduce immigrant eligibility for Medicaid. And then, you know, as they’re gearing up to possibly do this again, to defer their crackdown on health care as part of that, instead of it saving money��—��that it’s not having as much of an effect and costing so much, in the case of the work requirements, where we’re not expected to see the return of it.��

Rovner:��Yeah, that may be, although��I guess the return��is that people will not have insurance anymore, and so the federal government,��the states,��won’t��be spending money��for��their medical care.��They’ll��be spending money on other things. All right, of course,��there’s��more news from HHS than just Medicare and Medicaid��this week.��We also have a lot of news about the Make America��Healthy��Again movement, which is a sentence��that 2023��me��would��definitely not��recognize.����about a new poll that finds the MAHA vote��isn’t��necessarily locked in with Republicans. Tell us about it.��

Ollstein:��Yeah,��that’s��right.��So��Politico did our own polling on this, because we��hadn’t��really seen good data out there on who identifies as MAHA��and what do they even believe about the different parties and about different issues. And��so��we found that,��OK, yes, most people associate MAHA��with the Republican Party��—��most, but not all. But a lot of voters who identify as MAHA, and a lot of voters who voted for Trump in 2024��don’t��think that the Trump administration has done��a good job��making America healthy again.��And they rank the Democratic Party above the Republican Party on a lot of their top priority issues, like standing up to influence from the food industry and the pharmaceutical industry. They rank Democrats as caring more about health. So, you know, we found this very fascinating, and it supports what we’ve been hearing anecdotally, where Democratic candidates, a handful of them, and��Democratic electoral groups, are really seeing a lot of opportunity to go after MAHA��voters and win them over for this November. And you know, we should remember that even if you��don’t��see��a big swing of people��voting for Democrats, even if MAHA��voters are disillusioned and stay home, that alone could decide races. You know, midterms are decided by very narrow margins.��

Rovner:��Well, two other really interesting MAHA��takes this week.��.��It’s��about the tension in and among medical groups, about how to deal with HHS Secretary��[Robert��F.]��Kennedy��[Jr.]��and the MAHA movement. The American Medical Association seems to be trying to play nice, at least on things it agrees with the��secretary about, lest it risk things like its giant contract to supply the CPT billing codes to Medicare. On the other hand, the American Academy of Pediatrics and the American College of Physicians have been more confrontational to the point of going to court.��The other story,��from����pushing MAHA.��One thing I noticed is that��all of��the teens in the story seem to suffer from physical problems that are not well understood by the mainstream medical community, and so they turned online to seek advice instead, which is understandable in each individual case. But then they turn around and try to influence others. And you can see how easily misinformation can spread. It makes me not so much wonder��—��it makes me see how, oh, this is how this stuff sort of gets out there, because you see so much��… and Alice, this��goes back to what you were saying about MAHA��is not a movement that’s allied with one particular political party.��It’s��more of sort��of a mindset that��doesn’t��trust��expertise.��

Ollstein:��I think it��spans people who identify as Democrats, identify as Republicans. And, you know,��we’re��not really interested in politics until the rise of Robert F Kennedy Jr., and so I think it does show a lot of malleability. And there is a fight for this, for this cohort right now, on the airwaves, on the internet, etc.����

Rovner:��And,��as��The New York Times pointed out, you know,��we’ve��thought of this as being��sort of a��young men cohort.��It’s��now also a young woman cohort,��too.��So��there’s��lots of people out there to��go and get,��for these people who are pursuing votes.����

Well, turning to reproductive health, we have a couple of follow-ups to things we covered earlier. The big one is��Title��X, the federal family planning program, whose grants were set to end as of April 1. Sandhya, it looks like the federal government is going to fund the program after all?��

Raman:��Yeah, the family planning grantees in this space have been on edge for so long, you know, waiting to see would they finally just issue the grant applications.��And then it was such a short timeline for them to get them done. And then everyone that I talked to in the��lead-up��was expecting some sort of delay, just because it was such a short��timeframe��before they were set to run out of money. And��so��I think that they��were all pleasantly surprised that HHS was able to turn things around when they confirmed that the money��is��going to go out the day before the deadline. It does take a couple��of��days to go through the process and get that done. But I think the new worry now is also that in the statements that the White House and HHS have made is just that they are still at work on getting��Title��X��rulemaking out so that a lot of these groups would be ineligible if they also��provide��abortions.��Or we also��don’t��know what will be in the rule��—��if it will be broader than what was under the last��Trump administration, if it encompasses other restrictions.��So��a little bit of both there.����

Rovner:��Yeah. And I also was��gonna��say, I mean, we know that anti-abortion groups are unhappy with the administration, so this would be one place where they could��presumably throw��them a bone, yes?��

Ollstein:��So��people on both sides have been a little mystified why we��haven’t��seen a new��Title��X��rule yet.��They were expecting that near the beginning of last year, especially if the administration was just planning to reimpose his 2019 version, that would be pretty straightforward and simple.��And yet, here we are, more than a year into the administration, and we��haven’t��really seen this yet. The administration did confirm to me��—��we put this in our newsletter��—��that a new rule is coming.��And they said it will��align with pro-life values. And the White House’s comments to some conservative media outlets were very explicit that this will be the last time Planned Parenthood can get funding. Now I wonder if that statement will come back to bite them in court, because the rule previously was��very careful��not to name Planned Parenthood or name any specific organization. It just imposed criteria that applied to a lot of Planned Parenthood facilities, and��in order to��make them ineligible for��Title��X��funding. And��so��I wonder if that will help Planned Parenthood��sue��later on.��But��we’ll��put a pin in that and come back to it.��But we have confirmed that some sort of new rule is coming, but we don’t know when, and we don’t know what it would entail.��There’s��a lot of speculation that this could go way beyond an attempt to kick Planned Parenthood out. There’s speculation it could involve restrictions on��particular forms��of birth control. There’s speculation that it could entail restrictions on gender-affirming care. There’s speculation that it could involve rules around parental consent, stricter parental consent requirements, which are currently something that’s not part of��Title��X. And��so��we just��don’t��know, you know,��in order to��mollify the anti-abortion groups that are upset, they are saying,��Don’t��worry, new rule is coming.��But again, we don’t know when, and we don’t know what’s going to be in it.��

Rovner:��Well,��we’ll��be here when it happens. Another topic��we’ve��talked about at some length is crisis pregnancy centers, which are anti-abortion organizations that sometimes offer some medical services.����who was told after an ultrasound at a crisis pregnancy center that she had a normal pregnancy, and three days later, ended up in emergency surgery because the pregnancy was not normal, but rather ectopic��—��in other words, implanted in her fallopian tube rather than her uterus, which could have been fatal if not caught. This is not the first such case, but it again raises this question of whether these centers should be treated as medical facilities, which��we’ve��talked about many states��do.����

Raman:��And I think a lot of the rationale that people have for trying to do some of these��mandatory ultrasounds, you know, encouraging people to go to this is because the talking point is that��you don’t know if you have an ectopic pregnancy, you don’t have another complication, so you should go here to instead of just taking a medication abortion. So��…��we’re��coming full circle here, where this is also not helping the��case, if��you’re��not finding the full information there.��So��I think that��was an interesting point to me��…����

Rovner:��Yeah,��it’s��going on both��sides��basically.��It is fraught, and we will continue to cover it.��

All right, that is this week’s news. Now��we’ll��play my interview with Elisabeth Rosenthal at���鶹Ů�� Health News, and then we will come back and do��our��extra credits.��

I am pleased to welcome back to the podcast���鶹Ů�� Health News’��Elisabeth Rosenthal, who reported and wrote the last��two��“Bills of the��Month.”��Libby, thanks for coming back.��

Elisabeth Rosenthal:��Thanks for having me.����

Rovner:��So��let’s��start with our drug copay card patient.��Before we get into the particulars,��what’s��a��drug copay card?��

Rosenthal:��Well, copay cards, or��copayment programs, are things that the drug companies give patients. You know,��when it says you could pay as little as $0,��where they��pay��your copayment, which is usually��pretty big��—��when you see a copay card, it means��the��price is big, and��they’ll��bill your insurance for the rest.��So��for patients, it sounds like a good deal, and it is a good deal when they work.��

Rovner:��So��tell us about this patient, and what drug did he need that cost so much that he��required��a copay card?��

Rosenthal:��Well, the funny thing is��—��his name is Jayant Mishra, and he has��a psoriatic��arthritis. And the doctor told him, you know,��there’s��this drug called Otezla that would really help you.��And he was, he was a little cautious, because he knew it could be expensive, so he did wait a few months, and his symptoms, his joint pain, in particular, got worse.��He was like,��OK,��I’ll��start it.��So��he started it the first month, and it worked��really well.����

Rovner:��“It”��the drug, or��“it”��the copay card, or both?��

Rosenthal:��Both seemed to work very well.��So��the copay card covered his copay of over $5,000 and he was like,��Oh, this is great. And then what happened was, the next month, he tried to fill��it,��and it was like,��Wait, the copay card��didn’t��work!��And really what happens is copay��cards,��they are often limited in time and in the amount of money that’s on them.��So��depending on how much the copay is,��they can run out,��basically expire. You used all the money, and you have a drug that��you’ve��used that is working��really well��for you, and then suddenly��you’re��hit with a big bill.��So��they��kind of get��people addicted to drugs,��which they then��can’t��afford.����

Rovner:��And what happened��in this case was the insurance company charged more than expected, right?��

Rosenthal:��Well, Otezla, you know,��there’s��so many things about this, and many��“Bill of the��Month”��stories that,��you know,��are eye-rollers. Otezla��—��there are biosimilars that were approved by the FDA in��…��2021?��…��which��everyone’s��talking about, faster approval of biosimilars. Well, this was approved, but the drugmaker filed multiple suits and patent infringement, and so in the U.S., it��won’t��be on the market, the��biosimilar,��until 2028,��so��that’s��a problem too.��

Rovner:��So��if you want this drug,��it’s��going to be expensive.��

Rosenthal:��It’s��going to be expensive. And the other problem is copay cards. Insurers used to say,��OK, that will count towards your deductible, right?��So��you��didn’t��really feel it,��right?��Because you got a $5,000 copay card,��and you had a $5,000 deductible if you had a high-deductible plan.��And everything was good. Now, insurers��kind of said,��Whoa,��we’re��not sure we like these things.��So��yeah, you can use them, but it��won’t��count towards your deductibles.��So��they’re��not��nearly as��useful as they might have been in the past. But patients are really stuck, because these are��really expensive��drugs that most people��couldn’t��afford without copay cards.��

Rovner:��So��what eventually happened to this patient, and how can other people avoid falling into the copay card trap?��

Rosenthal:��So basically, because he had used up the amount on the copay card, which was��$9,400 for the year,��by the second month, he tried for the third month to kind of ration his drugs to take half as much, and his symptoms came back. And then the lucky thing for him was then it was January,��right,��copay cards��are usually done for the year.��So��he got a new copay card for another $9,400 and he was good for January, and he paid with his health savings account for the first month’s��copay,��with the copay card the second month, with the copay card and his health savings account. And when this went to press, he��wasn’t��sure how he was going to pay for the rest of the year. And for him,��it’s��not a huge problem, because he has a very��well-funded��health savings account, which few of us do, but he was��really up��in the air for the rest of the year when we wrote about this.��

Rovner:��So��sort of moral of this story, be careful if you want to take an expensive drug, and the theory that when the drugmaker promises,��Oh, you can have this for as little as��$0��copay.��

Rosenthal:��Well, I��think it’s��you have to understand what a particular card does.��You have to understand what’s the limit on how much is on the copay card.��You have to understand how many months it’s good for.��You��have to��understand, from your insurer’s point of view,��if��that will count as your deductible or not. And then, man, you know,��you’re��kind of on��your own,��right?��Sometimes your copay card will work great for you, and at other times it will work for a shorter amount of time. And you��got��to figure out what to do. I think the third,��bigger lesson is getting biosimilars, which are these��very expensive��drugs approved,��is not really the big problem in our country. The problem is the patent thickets that surround so many of these drugs that prevent them from getting to the patients who need them.����

Rovner:��In other words,��you can make a copy of this drug, but you might not be able to get it onto the market.����

Rosenthal:��Right.��You can make a��copy��this drug��—��it��[a generic]��was approved in 2021��—��but that won’t help patients until 2028,��which is really terrible. You know,��it’s��available in other countries, but not here.��

Rovner:��So��moving��on,��our March patient had insurance through the Affordable Care Act exchange and was��benefiting��from one of those zero-premium plans until she got caught in a��literally Kafkaesque��mess over a��1-cent bill that turned into a��5-cent bill. Who is she and what happened here?��

Rosenthal:��Yeah, her name in this wonderful, terrible story is��Lorena Alvarado Hill. And what happened here is she was on one of these $0 insurance plans through the Obamacare exchanges with that great subsidy, the Biden-era subsidy, and she and her mother were on the same plan, and her mother went on to Medicare,��turned 65.��So��Lorena��didn’t��need��the family��coverage and told the insurer that. And the insurance, of course, automatically recalculates your subsidy, and her premium went from being zero to��1��cent. Now,��no human would make that, you know, would say,��Oh, that makes sense. And to Lorena, it��didn’t��really make sense either. She was like,��I’m��not sure how to pay��1��cent, like, will it work on my credit card? And some of the bills said, you��know,��you understand that this could��impact��the continuation of your insurance, but, you know, she was like,��1��cent,��I��don’t��think so. And then she kept going to doctors, and the insurance still worked, and then at some point, four months later, she��got��a letter in November saying,��Oh, your insurance was canceled in July, and you owe money for all these bills.��

Rovner:��And what happened with this case?��

Rosenthal:��Well, you know, like many of our��“Bill of the��Month”��patients, I celebrate them for being real fighters, because her bill, since her premium was��1��cent a month, went from��1��cent to��2��cents to��3��cents to��4��cents to��5��cents,��when they sent her the note saying your insurance has been canceled for the last four months.��And what turns out, which is really interesting,��is this is a known glitch in the way the subsidies were calculated, were administered.��There’s��a recalculation of subsidies every time��there’s��a life event, a kid goes off the plan, you change jobs, get married, you��get divorced.��So��the recalculation��happens automatically.��And the Biden administration, understanding that this glitch could exist, they gave the insurers the��option��not to cancel insurance if the amount owed was less than $10.��And there were��apparently 180,000��people caught in this situation where their insurance could have been canceled for under $10��of a��recalculated premium. The Trump administration revoked that rule because their feeling was, you owe something, you pay something.��So��it’s��part of their��“stamp out fraud and abuse,”��and this was, in their view, abuse of a system when people��didn’t��pay what they owed.����

Rovner:��One cent.��

Rosenthal:��One cent,��right.��So��what happened��with��her is, you know,��a��good bill-paying��citizen sending her daughter to college with loans. She wrote her insurers, she wrote to the state, she wrote to everyone. And as a last resort, of course, someone said,��Well,��there’s��this thing called��Bill of the��Month you could write to.��So��when we��looked into��this,��at first��HealthFirst, which was her insurer in Florida, said,��Oh,��she’s��not insured through us.��And I was like,��Yeah, because you canceled her insurance. And then I gave them her insurance number, and they said,��Well, yes, according to law, we did the right thing.��She��didn’t��pay,��so it was canceled. Somehow, through all of this,��word got back to the hospital and the insurer,��and they worked together, and her bills were suddenly zero on her portal. So��that’s��the good news for Lorena Alvarado��Hill. It��doesn’t��really help all those other people whose insurance may have been canceled for premiums that were under $10.��

Rovner:��So,��basically, if you get a bill for��5��cents, you should pay it.��

Rosenthal:��Yeah, you know, it was funny when this story went up, many��people were sympathetic, but other commenters said,��Well, she should have just paid $1 because you can pay that.��And��maybe there��was a way to pay��1��cent. And��I’m��kind of with��her, like, if I got a bill for��1��cent, life is busy. This is a woman who is a teacher’s aide and works on weekends at a store to help pay for her daughter’s college. Life is busy. You just��can’t��sweat over��1-cent bills and spend a lot of time figuring out how to pay them. And��I guess the lesson��is,��what’s��the worst that can happen in a very dysfunctional system where so much is automated��now?��The��worst��that can happen is always really bad. Your insurance could be canceled.��

Rovner:��So basically, stay��on top of it, I guess,��is the message for��both of these��stories this month. Elisabeth Rosenthal, thank you so much.��

Rosenthal:��Thanks,��Julie,��for having me.��

Rovner:��OK, we��are back.��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 will post the links in our show notes on your phone or other mobile device. Jessie, why don’t you go��first this week?��

Hellmann:��My story is from��The Texas Tribune, from a group of reporters who I��can’t��name individually.��There’s��too many of them. But it is����in Texas after the governor issued an executive order a few years ago requiring that hospitals check patients’��citizenship.��So��the story found that hospital visits by undocumented people dropped by about a third, and the story also got into how this is bleeding into other types of health care at other facilities, free vaccine clinics are not being attended as widely anymore. People��aren’t��attending their preventive care appointments,��like cancer screenings or prenatal care checkups. Some of these other health facilities��are required to��check citizenship status, but��it’s��definitely a��chilling effect over the broader health��care landscape in Texas.��

Rovner:��Yeah. There have been a lot of good stories about that. Sandhya.��

Raman:��My extra credit is from��Science, and��it’s��by Jocelyn Kaiser, and the story is��“.”��In her story, she talks about how last year, you know, the administration cut a lot of staff at the Agency for Healthcare Research and Quality. They’ve canceled all of the open grants, but Congress still appropriated $345 million for the agency this year, and so supporters kind of want to revive what should be going on��at��the agency, which hasn’t been issuing any of the grants since the start of the fiscal year, and just kind of make progress on some of the things that this agency does do, like running the U.S.��Preventive Services Task Force, which has been, you know, something that has been talked about this year. So thought it was an interesting piece.����

Rovner:��Yeah,��I’m��old enough to remember when��AHRQ��was bipartisan. Alice.��

Ollstein:��So��a��very harrowing story in The New York Times titled��“.”��And I will say, since this piece ran, we have seen that an oil shipment from Russia is going through to the island, but I don’t think that will be sufficient to completely wipe away all of the upsetting conditions that this piece really gets into,��what is happening as a result of the ramped-up U.S.��embargo and blockade of the island. People��can’t��get food, they��can’t��get medicine, they��can’t��get electricity, and that is having a devastating effect on health��care. The Cuban health��care system has been��really miraculous��over the years, just the pride of the government.��It has meant,��prior to this blockade,��that their life expectancy was better than ours, and a lot of their outcomes were better. And��so��this has been really devastating. There’s, you know, harrowing scenes of people on ventilators having to be hand-pumped when the electricity cuts out,��babies��in��incubators, you know, losing power.��You know, people��having��to skip medications, etc. And��so��this is really shining a light on a foreign policy situation that this administration��is behind.��

Rovner:��Yeah,��that’s��really been an under-covered story, too,��I think, you know, right off our shores.��My extra credit this week is one I simply could not resist.��It’s��from New York Magazine, and��it’s��called��“,”��by��Helaine Olen. And as the headline��rather vividly��points out, we are��witnessing��the rise of pet medical tourism, along with human medical tourism, which has been a thing for a couple of decades��now.��It seems that veterinary medicine��is getting��nearly as��expensive as human medicine, and that one way to find cheaper care is to cross the border, which is obviously easier if you live near the border.��I’m��not sure how much cheaper veterinary care is in Canada, but as the owner of two corgis, I may have to do some investigating of my own.����

OK, that is this week’s show.��As always, thanks 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 you get your podcasts��—��as well as, of course,��kffhealthnews.org.��Also,��as always, you can email��us��your comments or questions.��We’re��at whatthehealth@kff.org.��Or you can find me still on X��, or on Bluesky��.��Where are you folks hanging these days?��Sandhya.��

Raman:��On����and on����.��

Rovner:��Alice.��

Ollstein:��On Bluesky����and on X��.��

Rovner:��Jessie.��

Hellmann:��I’m��on LinkedIn under Jessie Hellmann��and on X��.��

Rovner:��We’ll��be back in your feed next week. Until then, be healthy.��

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A teacher’s aide in Melbourne, Florida, Hill is a single mom who works shifts at J.Crew on the weekends to send her daughter to college. Hill and her mother, who lives with her, had been enrolled in an insurance plan through HealthFirst.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

Hill was on the hook for a $2,966.93 MRI, as well as more than half a dozen doctor visits costing about $200 or $300 each. Without that kind of money on hand, Hill said, she put a few of the bills on payment plans and tried to figure out what had gone wrong.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Premium subsidies for ACA plans are automatically recalculated every time coverage is changed because of a life event, such as marriage, a change of job, or a child turning 26. In June, Hill removed her mother from the family’s group plan because she turned 65 and became eligible for Medicare and Medicaid.

The change triggered a recalculation of Hill’s monthly premium contribution, increasing it from $0 to 1 cent. She said she thought the amount was so small that she couldn’t pay it with her credit card.

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

But she said that her doctors collected the usual copayments during subsequent visits and that her insurance broker told her not to worry, reassuring her that the plan was “active.” Hill figured the 1-cent monthly premium was probably a rounding error that couldn’t result in termination, she said.

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

She made an appointment the next day with her broker, who called HealthFirst for clarification. The news was even worse: Not only had her insurance been canceled, but the 5-cent bill could be sent to a collection agency.

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

Others have lost their coverage over owing small amounts, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “This woman’s situation is not so unusual with the enhanced subsidies,” she said.

The American Rescue Plan, passed in 2021, increased the amount of government assistance available to ACA plan holders. Those enhanced subsidies, which Congress let expire at the end of last year, meant enrollees with lower incomes had to pay little or nothing toward their premiums.

The Biden administration found that, in 2023, about 81,000 subsidized ACA insurance policies were terminated because the enrollee owed $5 or less. Nearly 103,000 more were canceled for owing less than $10.

To prevent that kind of coverage loss, most likely hitting people with little income, Biden administration health officials to allow ACA enrollees to retain coverage if they owed less than $10, or less than 95% of premium costs.

Insurers were required to keep insurance active for a 90-day “grace period” to give enrollees time to respond. That’s why Hill’s doctors initially took her copayments and sent no bill, as if nothing had changed.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She filed a complaint in December with HealthFirst and the Florida Department of Financial Services asking for a write-off of her 5-cent balance and retroactive restoration of her policy, citing state and federal laws that seemed to apply to her situation.

In particular, she wrote, “creditors are not required to collect, and consumers are not required to pay, credit-card balances of $1.00 or less,” adding that “all major insurers and payment processors in Florida follow a 1-cent write-off policy.”

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

Weeks after a reporter’s query to the insurer, Hill said she looked at her billing statements for all the medical services she received in 2025 and was pleasantly surprised that the balances owed had been adjusted to $0.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

And while insurance policies have grace periods allowing coverage to remain in place if you miss a payment, some are not very long. For subsidized ACA marketplace plans, the period is 90 days, but others last just 30 or 45.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

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

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

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Now, the Trump administration in reducing the problem while simultaneously saying more controls are needed.

It has proposed a for next year, including stepped-up requirements for some applicants to prove eligibility for subsidies or enrollment and new scrutiny of sales agents and marketing practices.

While there is a general acknowledgment that there is fraud in the ACA marketplace, some health policy analysts say these new requirements miss that mark and instead will make it harder for people who are eligible to enroll.

“There is a trade-off, particularly with the provisions focused on consumers, that maybe it will prevent some fraudulent enrollment, but also potentially a large number of valid applicants,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at the Brookings Institution.

In its proposal, though, the administration expresses optimism that efforts already in place will continue to pay off, despite the fact that the number of complaints about unauthorized enrollment or switching rose to 341,906 in 2025, compared with 229,734 the year before Donald Trump took office. Still, according to the rule, “program integrity measures implemented during the past year,” along with the expiration of enhanced tax credits, “are likely to lead to a decrease” in complaints in 2026.

The end of those tax credits also means the amount people pay toward their coverage has increased. Data released Jan. 28 by federal officials showed a year-over-year����enrollments across the federal healthcare.gov marketplace and those run by states. And from �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News, found that of those who remained covered this year, 80% said their premiums or other costs are higher than they were last year, with 51% saying they are “a lot higher.”

Katie Keith, a director at Georgetown University’s O’Neill Institute for National and Global Health Law, said the administration was sending mixed messages, on one hand “talking about its fraud-fighting efforts” being successful, but releasing a proposed rule “that says we have to have all these restrictions on consumers because of fraud.”

Closing Consumer Windows

Last year, the Trump administration reversed some of the Biden administration’s ACA efforts, including eliminating a special enrollment period for low-income people that let them sign up year-round.

This year’s rule includes proposed changes aimed at preventing people from fudging their incomes — higher or lower — to qualify for subsidies.

For instance, applicants whose federal data shows they were previously below the poverty level — and thus not eligible for subsidies — would have to submit additional income verification to show they expect to earn above the poverty level in the coming year.

Another part of the proposed rule would require the federal marketplace, used by 30 states, to step up verification efforts for people who want to sign up outside of the ACA’s annual open enrollment period, for reasons including getting married, adopting a baby, or losing other coverage. Currently, the marketplaces conduct such reviews only when people say they qualify because they lost other insurance, according to an .

The income verification requirements “will be burdensome,” she said.

Some ACA applicants, especially those running small businesses or working several part-time jobs, find it more difficult to estimate or document their anticipated income and might find they’re prevented from getting subsidies, Keith and other analysts said.

These proposals are among policies reprised from last year’s ACA rule and initially intended to take effect in 2026. But several cities filed a lawsuit to challenge those regulations. The judge overseeing the case pending its outcome.

In his order issuing a temporary stay, questioned whether the government adequately responded to questions about the accuracy of data it used in citing widespread fraud.

Additionally, many of the provisions purportedly targeting fraud are “unsupported by data showing that if enacted, they will, in fact, reduce any such fraud,” the judge wrote.

The proposal for 2027 has “new supporting information since the original policies were established” that includes clarifying what documentation is needed for some of the verification processes, Centers for Medicare & Medicaid Services spokesperson Catherine Howden said in an email. In addition, she said that CMS is now reviewing public comments that have been submitted before finalizing the provisions.

Targeting Fraud by Agents, Marketers

Critics of the ACA argue that more-generous subsidies put in place as a response to the covid pandemic, in addition to other changes during the Biden administration, led rogue brokers to enroll or switch people without their consent, seeking to collect commissions. That could be done easily, critics say, because with many plans, subsidies covered the entire premium. The lack of a monthly bill made it easier to sign people up without their knowledge — a long-running problem that ramped up in 2024. When that happens it can leave people unable to access their coverage or with tax bills they did not expect.

Those expanded subsidies have now expired, but the administration’s proposed rule would still add requirements for agents. For example, they would be barred from providing cash or most other freebies as incentives to enroll, have to use a standard consent form that must be signed by the consumer, and be held responsible if they hired a marketing firm that used questionable advertising to lure customers. That includes touting nonexistent gift cards or making websites look like official government ACA portals. Such websites would have to be removed.

“This would help ensure no additional consumers would see the advertisement and be misled,” the proposal says.

Insurance agents told �鶹Ů�� Health News that some of the proposals, such as delineating what counts as a misleading marketing effort, are good first steps but might not fully address concerns about unauthorized enrollment.

It doesn’t “address all the system vulnerabilities,” said Jason Fine, who runs a brokerage in Florida. He said he has filed more than 100 reports about unauthorized rivals accessing his clients’ coverage over the past two years but has yet to see any of those agents removed from the federal marketplace.

More than 850 agents had their certification suspended with little notice in late 2024 under the Biden administration, which said it was looking into complaints about them. The Trump administration told the Government Accountability Office in May that it had reinstated all or most of those agents to fulfill its “statutory and regulatory” responsibilities, according from the independent oversight group. The report, which outlined long-running fraud problems in the ACA, noted that CMS would continue to monitor those agents and could take “further enforcement action” against them.

Another Biden rule, this one aimed at combating unauthorized sign-ups, remains in place and requires agents to have three-way calls with the client and a federal marketplace call center representative for some enrollments or plan changes.

But Fine and other agents said bad actors are finding ways around that requirement, including by faking that they are the customer during the calls. That contention is backed up in the administration’s new proposal, which notes that federal regulators have received reports that some brokers “may be using artificial intelligence to impersonate consumers and falsely attest to household income.”

Still, the proposal does not include some of the measures agents say would improve the situation.

Fine, for example, said the federal marketplace should more proactively flag unusual activity on consumer accounts, such as multiple agent changes or switches to new insurers within a short period of time, or changes made in the dead of night.

“Overnight is when a lot of this fraud occurs,” Fine said. “No one is changing their insurance at 4 a.m., and that should trigger an automatic fraud alert.” He also wants to see a proposal to rein in overseas call centers that contact U.S. residents — often repeatedly, sometimes making claims about free gift cards or other nonexistent perks — then send their information to agents looking to enroll them or switch their ACA plans.

Others, including Ronnell Nolan, president of Health Agents for America, have also long called for two-factor authentication, similar to what banks require, to confirm that enrollments or switches are approved by the consumer. The 20 states, plus the District of Columbia, that run their own marketplaces incorporate additional measures, including two-factor authentication, few of the types of problems that the federal market has seen, Nolan said. The administration’s proposed rule does not call for this protection.

A conservative think tank, the , estimates there are several million fraudulent enrollments, but other groups — including the GAO, using a different methodology — have put the estimate far lower.

Based on its preliminary analysis, the GAO estimated there were “at least 160,000 applications in plan year 2024 that had likely unauthorized changes,” representing about 1.5% of all applications.

Meanwhile, Brookings’ Fiedler said the debate around the proposal highlights an ongoing question — not just how much fraud exists or what to do about it, but “how much government should help people get covered at all.”

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

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The Trump administration this week missed a deadline to nominate a new director for the Centers for Disease Control and Prevention. Without a nominee, current acting Director Jay Bhattacharya — who is also the director of the National Institutes of Health — has to give up that title, leaving no one at the helm of the nation’s primary public health agency.��

Meanwhile, a week after one federal judge blocked changes to the childhood vaccine schedule made by the Department of Health and Human Services, another blocked a proposed ban on gender-affirming care for minors.��

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Rachel Cohrs Zhang of Bloomberg News, Lizzy Lawrence of Stat, and Shefali Luthra of The 19th.

Panelists

Among the takeaways from this week’s episode:

• A federal judge ruled against the Trump administration’s declaration intended to limit trans care for minors, though the ruling’s practical effects will depend on whether hospitals resume such care. And a key member of the remade federal vaccine advisory panel resigned as the panel’s activities — and even membership — remain in legal limbo.
• Two senior administration health posts remain unfilled, after President Donald Trump missed a deadline to fill the top job at the Centers for Disease Control and Prevention — and the Senate made little progress on confirming his nominee for surgeon general.
• The percentage of international graduates from foreign medical schools who match into U.S. residency positions has dropped to a five-year low. That’s notable given immigrants represent a quarter of physicians, many of them in critical but lower-paid specialties such as primary care — particularly in rural areas. Meanwhile, new surveys show that more than a quarter of labs funded by the National Institutes of Health have laid off workers and that federal research funding cuts have had a disproportionate effect on women and early-career scientists.
• And new data shows the number of abortions in the United States stayed relatively stable last year, for the second straight year — largely due to telehealth access to abortion care. And a vocal opponent of abortion in the Senate, with his eyes on a presidential run, introduced legislation to effectively rescind federal approval for the abortion pill mifepristone.

Also this week, Rovner interviews Georgetown Law Center’s Katie Keith about the state of the Affordable Care Act on its 16th anniversary.

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

Julie Rovner: Stat’s “,” by John Wilkerson.��

Shefali Luthra: NPR’s “,” by Tara Haelle.��

Lizzy Lawrence: The Atlantic’s “,” by Nicholas Florko.��

Rachel Cohrs Zhang: The Boston Globe’s “,” by Tal Kopan.��

Also mentioned in this week’s podcast:

• Stat’s “,’” by Jonathan Wosen.
• �鶹Ů�� Health News’ “Rising Health Costs Push Some Middle-Aged Adults To Skip the Doc Until Medicare,” by Sam Whitehead.
• Guttmacher’s “,” by Isaac Maddow-Zimet and Kimya Forouzan.
• United for Medical Research’s “.”

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

Julie Rovner:��Hello,��from �鶹Ů�� Health News and WAMU Public Radio in Washington, D.C. Welcome to��What the Health?��I’m��Julie Rovner, chief Washington correspondent for �鶹Ů�� Health News, and��I’m��joined by some of the best and smartest reporters��covering��Washington.��We’re��taping this week on Thursday,��March 26,��at 10��a.m.��As always, news happens fast, and things might have changed by the time you hear this. So,��here we go.��

Today,��we are joined via video conference by Rachel��Cohrs Zhang��of Bloomberg News.��

Rachel Cohrs Zhang:��Hi,��everybody.��

Rovner:��Shefali Luthra��of��The��19th.��

Shefali Luthra:��Hello.��

Rovner:��And Lizzy Lawrence of Stat News.��

Lizzy Lawrence:��Hello.��

Rovner:��Later in this episode��we’ll��have my interview with Katie Keith of Georgetown University about the state of the Affordable Care Act as it turns 16��—��old enough to drive in most states. But first,��this week’s news.��

So,��it has been another busy week at the Department of Health and Human Services. Last week, a federal judge in Massachusetts blocked the department’s vaccine policy,��ruling it had violated federal administrative procedures��regarding��advisory committees. This week, a federal judge in Portland, Oregon,��ruled the department also��didn’t��follow the required process to block federal reimbursement for transgender-related medical treatment. The case was brought by 21��Democratic-led states. Where does this leave the hot-button issue of care for transgender teens? Shefali,��you’ve��been following this.��

Luthra:��I mean, I think it’s still really up in the air.��A lot of this depends on how hospitals now respond��—��whether they feel confident in the court’s decision,��having staying��power enough to actually resume offering services.��Because a lot of them stopped.��And so that’s something we’re still waiting to actually see how this plays out in practice.��Obviously,��it’s��very symbolic, very legally meaningful, but whether this will translate into changes in practical health care access, I think, is��an open question still.��

Rovner:��Yeah, we will��definitely have��to see how��this one plays��out��— and,��obviously,��if and when��the administration��appeals��it. Well, speaking of that vaccine ruling from last week��—��which,��apparently,��the��administration has not yet appealed, but is going to��—��one of the most contentious members of that very contentious Advisory Committee on Immunization Practices has resigned. Dr.��Robert Malone, a physician and��biochemist, said he��didn’t��want to be part of the��“drama,”��air quotes.��But he caused a lot of��the drama, didn’t he?��

Cohrs Zhang:��He has been��pretty outspoken, and��I think he��isn’t��like a Washington person necessarily��—��isn’t��somebody��who’s��used to,��like,��being on a public stage and having your social media posts appear in large publications.��So��I think��it’s��questionable, like, whether he had a position to resign from.��I think his nomination��was stayed,��too.��But I think it is��…��the back-and-forth,��I think,��there is a good point that this limbo can be frustrating for people when meetings��are canceled��at��the last minute, and people have travel plans,��and it does��…��just changes the calculus for kind of making it worth it to serve on one of these advisory committees.��

Rovner:��And I’m not sure whether we mentioned it last week, but the judge’s ruling not only said that the people were incorrectly appointed to ACIP, but it also stayed any meetings of the advisory committee until there is further court action, until basically, the case is done or it’s overruled by a higher court. So��…��vaccine policy��definitely is��in limbo.����

Well, meanwhile, yesterday was the deadline for the administration to nominate someone to head the Centers for Disease Control and Prevention since Susan��Monarez��was abruptly dismissed, let��go, resigned, whatever, late last summer. Now that that deadline has passed, it means that acting��Director Jay Bhattacharya, who had added that title to his day job as head of the National Institutes of Health,��can no longer��remain��acting��director of CDC.��Apparently, though��he’s��going to��sort of remain��in charge, according to HHS spokespeople, with some authorities reverting to��[Health and Human Services]��Secretary��[Robert F.]��Kennedy��[Jr.].��What’s��taking so long to find a CDC director?����

To quote D.C.��cardiologist and frequent cable TV health policy commentator��,��“The problem here is that��there’s��no candidate��who’s��qualified, MAHA acceptable, and Senate confirmable. Those job requirements are mutually exclusive.”��That feels kind of accurate to me.��Is that actually��the��problem?��Rachel, I see you smiling.��

Cohrs Zhang:��Yeah.��I think it is tough to find somebody who checks all of those boxes.��And though it has been��210 days��since the clock��has started, I would just point out that there has been a significant leadership shake-up at HHS, like among the people who are kind of running this search, and they came in, you know, not that long ago.��It’s��only been, you know,��a��month and a half or so.��So��I think there certainly have been some��new faces��in the room who might have different opinions.��But��I think it��isn’t��a good look for them to miss this deadline when they have this much notice. But I think��there’s��also, like,��legal experts that��I’ve��spoken with��don’t��think that��there’s��going to be a huge��day-to-day��impact on the operations of the CDC. It��kind of reminds��me of that office where there’s,��like,��an��“assistant��to��the��regional��manager vibe”��going on, where, like,��Dr.��Bhattacharya is now acting in the capacity of CDC director, even though he��isn’t��acting��CDC director��anymore. So,��I think I��don’t��know that��it’ll��have a huge��day-to-day��impact, but it is��kind of hanging��over HHS at this point, as they are already struggling with the��surgeon��general nomination,��to get that through the Senate.��So��it just creates this backlog of nominations.��

Rovner:��I’ve��assumed��they’ve��floated some names, let us say, one of which is Ernie Fletcher, the former governor of Kentucky, also a former member of the House Energy and Commerce health subcommittee, with��some certainly medical chops, if not public health chops.��I think��the��head of the health department in Mississippi. There was one other who��I’ve��forgotten, who it is among the names that have been floated��…��

Cohrs Zhang:��Joseph Marine.��He’s��a cardiologist at Johns Hopkins, who has��—��is kind of like in the kind of Vinay Prasad world of critics of the FDA and,��like,��CDC’s covid��booster strategy.��

Rovner:��And yet, apparently, none of them could pass, I guess, all three tests. Do we think it might still be one of them? Or do we think there are other names that are yet��to come?��

Cohrs Zhang:��Our understanding is that there are other candidates whose names have not become public, and I think there’s also a possibility they don’t choose any of these candidates and just drag it on for a while because,��at this point, like, I don’t know what the rush is,��now that the deadline is passed.��

Lawrence:��Yeah, is there another deadline to miss?��

Cohrs Zhang:��I��don’t��think so.��

Lawrence:��I think this��was the only one.��

Cohrs Zhang:��This was the big one that they now have.��It’s��vacant, but it was vacant before as well. Like, I think, earlier in the��administration, when��Susan��Monarez��was nominated.��

Rovner:��But she, well��…��that’s��right, she was the��“acting,”��and then once she was nominated, she��couldn’t��be the acting anymore.��

Cohrs Zhang:��Yeah.��

Rovner:��So��I guess��it��was vacant while she was being considered.��

Cohrs Zhang:��It was.��So��it’s��not an unprecedented situation, even in this administration.��It’s��just not a good��look, I guess. And I think there is value in having a leader that can interface with the White House and with different leaders, and just having a direction for the agency, especially because it’s in Atlanta, it’s a little bit more removed from the everyday goings-on at HHS in general.��So��I think there’s definitely a desire for some stability over there.��

Rovner:��And we have measles spreading in lots more states.��I mean, every time I��…��open up my news feeds, it’s like, oh, now we have measles, you know, in Utah, I think,��in Montana.��Washtenaw County, Michigan,��had its first measles case recently.��So��this is something that the CDC should be on top of, and yet there is no one on top of the CDC. Well, Rachel, you already alluded to this, but it is also apparently hard to find a surgeon general who’s both acceptable to MAHA��and Senate confirmable, which is my way of saying that the Casey��Means nomination still appears to lack the votes to move out of the Senate, Health, Education, Labor��&��Pensions Committee. Do we have any latest��update��on that?��

Cohrs Zhang:��I think the latest update, I mean, my colleagues at Bloomberg Government just��kind of had��an update this week that��they’re��still not to��“yes” —��like,��there are some key senators that still��haven’t��announced their positions publicly.��So��I think a lot of the same things that��we’ve��been hearing��…��like��Sens.��Susan Collins and��Lisa Murkowski and Bill Cassidy obviously have not��stated��their positions publicly on the nomination.��Sen.��Thom Tillis, who you��know��is kind of in a lame-duck scenario and doesn’t really have anything to lose, has, you know, said he’s not really made a decision.��So��I think they’re kind of in this weird limbo where they, like, don’t have the votes to advance her, but they also have not made a decision to pull the nomination at this time. So either, I think,��they have to push harder on some of these senators, and I think senators see this as a leverage point that I don’t know that a lot of��—��that all of the complaints are about Dr.��Means specifically, but anytime that there is frustration with the wider department, then this is an opportunity for senators to have their voice heard, to��…��potentially extract some concessions. And��so��there’s��a question right now, are they going to change course again for this position, or are they going to, you know, sit down at the bargaining��table��and really cut some deals to advance her nomination? I just��don’t��think we know the answer to that yet.��

Rovner:��Yeah,��it’s��worth reminding that,��frequently,��nominations get held up for reasons that are totally disconnected from the person involved. We went��—��I should go back and look this up��— we went, like, four years in two different administrations without a confirmed head of the Centers for Medicare��&��Medicaid��Services because members of Congress were angry about other things, not because of any of the people who had actually been nominated to fill that position. But in this case, it does seem to be, I think,��both Casey��Means and,��you know, her connection to��MAHA,��and the fact that among those who haven’t declared their positions yet,��it’s the chairman of the committee, Bill Cassidy, who’s in this very tight primary to keep his seat.��So��we will keep��on that one.����

Also, meanwhile, HHS continues to push its��Make America��Healthy��Again priority. Secretary Kennedy hinted on the Joe Rogan podcast last month that the FDA will soon take unspecified action to make customized peptides easier to obtain from compounding pharmacies. These��mini-proteins��are part of a biohacking trend that many MAHA��adherents say can��benefit��health,��despite their not having been shown to be safe and effective in the normal FDA approval process. The FDA��has��also��formally��pulled��a proposed rule that would have banned teens from using tanning beds. We know that the��secretary is a fan of tanning salons, even though that��has��been shown to cause potential health problems,��like skin cancer. Lizzy,��is Kennedy just going to push as much MAHA��as he can until the courts or the White House stops him?��

Lawrence:��I guess so. I mean, we do have this new structure at HHS��now that’s trying to��—��clearly��…��there are warring factions with the MAHA agenda and the White House really trying to focus more on affordability and less on��…��vaccine scrutiny and the medical freedom movement that is really popular among Kennedy’s supporters.��…��I’m��very curious about��what’s��going to happen with peptides, because��it’s��a sign of Kennedy’s regulatory philosophy, where��there’s��some products that are good and some that are bad.��It’s��very atypical, of course, for��…��

Rovner:��And that he gets��to decide��rather than the scientists, because he��doesn’t��trust the scientists.��

Lawrence:��Right. Right.��But there has been, I mean, the FDA has kind of been pretty severe on GLP-1��compounders��Hims��&��Hers, so it’ll be interesting to see, you know, how much Kennedy is able to exert his will here, and how much FDA regulators will be able to push back and make their voices heard.��

Rovner:��My favorite piece of FDA��trivia��this week is that FDA is posting the jobs that are about to be vacant at the vaccine center, and one of the things that it actually says in the job description is that you don’t have to be immunized. I��don’t��know if��that’s��a signal or what.��

Lawrence:��Yeah,��I think it��said no telework, which Vinay Prasad famously was teleworking from San Francisco. So,��yeah, I��don’t��know.��But��this��was,��I think it��was for his deputy, although��I’m��sure, I mean, they do need a CBER��[Center for Biologics Evaluation and Research]��director as well.��

Rovner:��Yeah,��there’s��a lot of openings right now at HHS.��All right,��we’re��gonna��take a quick break. We will be right back.��

So��Monday was the 16th anniversary of the signing of the Affordable Care Act, which we will hear more about in my interview with Katie Keith.��But I wanted to highlight a��story by my���鶹Ů����Health��News colleague Sam Whitehead��about older Americans nearing Medicare eligibility putting off preventive and other care until they qualify for federal coverage that will let them afford it. For those who listened to my interview last week with Drew Altman, this hearkens back to one of the big problems with our health system. There are so many quote-unquote��“savings”��that are��actually just��cost-shifting, and often that cost-shifting raises costs overall. In this case, because those older people can no longer afford their insurance or their deductibles,��they put off care until it becomes more expensive to treat. At that point,��because��they’re��on Medicare, the��federal taxpayer will foot a bill��that’s��even bigger than the bill that would have been paid by the insurance company.��So��the savings taxpayers gained by Congress cutting back the Affordable Care Act subsidies are lost on the Medicare end. Is this cost-shifting the inevitable outcome of addressing everything in our health care system except the actual prices of medical care?��

Cohrs Zhang:��I think��it’s��just another example of how people’s behavior responds to these weird incentives. And I think��we’re��seeing this problem, certainly among early retirees,��exacerbated��by the��expiration��of the Affordable Care Act subsidies that��we’ve��talked about very often on this podcast, because it affects these higher earners, and it can dramatically increase costs for coverage. And��I think people��just hope that they can hold on. But again, these��statutory deadlines that lawmakers make up sometimes,��not with a lot of forethought or rational��reasoning,��they have consequences.��And obviously, the Medicare program continues to pay beyond age 65 as well.��And I think��it’s��just another symptom of what the administration talks about when they talk about emphasizing, you know, preventative care and addressing chronic conditions��—��like,��that is a real problem. And,��yeah, I think��we’re��going to see these problems in this population continue to get worse as more people forgo care, as it becomes more expensive on the individual markets.��

Luthra:��I think you��also make a good point, though, Julie, because the increase in costs and cost sharing is not limited to people with marketplace plans, right? Also, people with employer-sponsored health care are seeing their out-of-pocket costs��go up. Employers are seeing what they pay for insurance��go��up as well. And there absolutely is something to be said about��it’s��been 16 years since the Affordable Care Act��passed,��we��haven’t��really had meaningful intervention on the key source of health care prices, right? Hospitals, providers, physicians. And it does seem, just thinking about where the public is and the politics are, that there is possibly��appetite��around this. You see a lot of talk about affordability, but a lot of��this feels, at least as an observer,��very focused��on insurance, which makes sense. Insurance is��a very easy��villain to cast.��But I think you’ve raised a��really good point:��that addressing these really potent burdens on individuals and eventually on the public just requires something��more systemic and more serious if we actually want to yield better outcomes.��

Rovner:��Yeah, there’s just, there’s so much passing the hat that, you know,��I don’t want to do this,��so��you��have to do this.��You know, inevitably, people need health care.��Somebody has to pay for it.��And I think that’s��sort of the��bottom line that nobody really seems to want to address.��

Well, the other theme of 2026 that I feel like I keep repeating is what funding cutbacks and other changes are doing to the future of the nation’s biomedical and medical workforces. Last week was Match Day.��That’s��when graduating medical school seniors find out if and where they will do their residency training. One big headline from this year’s match is that the percentage of non-U.S.��citizen graduates of foreign medical schools matching to a U.S.��residency position fell to a five-year low of 56.4%.��That compares to a 93.5% matching rate for U.S.��citizen graduates of U.S.��medical schools. Why does that matter? Well, a quarter of the U.S.��physician workforce are immigrants, and they are disproportionately represented, both in lower-paid primary care specialties, particularly in rural areas, both of which��U.S.��doctors tend to find less desirable. This would seem to be the result of a combination of new fees for visas for foreign professionals that��we’ve��talked about, a general reduction in visa approvals,��and some people��likely not��wanting to even come to the U.S.��to practice. But that rural health fund that Republicans say will revitalize rural health care��doesn’t��seem like��it’s��really going to work without an adequate number of doctors and nurses, I would humbly suggest.��

Lawrence:��Yeah, absolutely. I mean,��it’s��patients that suffer, right? I mean, you need the people doing the work. And��so��I think that the impacts will start being felt sooner rather than later. That is something that hopefully people will start to feel the pain from.��

Rovner:��I feel like when people think about the immigrant workforce, they think about lower-skilled, lower-paid jobs that immigrants do, and they don’t think about the fact that some of the most highly skilled, highly paid jobs that we have, like being doctors, are actually filled by immigrants, and that if we cut that back, we’re just going to exacerbate shortages that we already know we have.��

Luthra:��And training doctors takes, famously,��a very long��time. And��so��if you are disincentivizing people from coming here to practice, cutting off this key source of supply,��it’s��not as if you can��immediately��go out and say,��Here,��let’s��find some new people and make them doctors. It will take years to make that tenable, make that attractive,��and make that a reality. And it just seems,��to Lizzy’s point,��that even in the scenario where that was possible��—��which I would be somewhat doubtful;��medicine is a hard and difficult career;��it’s not like you can make someone want to do that overnight��—��patients will absolutely see the consequences. I��don’t��know if��it’s��enough to change how people think about immigration policy and ways in which we recruit and engage with immigrant workers, but��it’s��absolutely something that should be part of our discussion.��

Rovner:��Yeah, and I think��it’s��been left out.��Well,��meanwhile,��over at the National Institutes of Health, a��,��Lizzy,��found that more than a quarter have laid off laboratory workers. More than��2��in��5��have canceled research,��and two-thirds have counseled students to consider careers outside of academic research. A separate study published this week found that women and early-career scientists have been disproportionately affected by the NIH cuts, even though most of the money goes to men and to later-career scientists. As I keep saying,��this��isn’t��just about the��future of science. Biomedical research is a��huge piece of the U.S.��economy. Earlier this month, the group��United for��Medical��Research��,��finding��that every dollar invested produced $2.57 for the economy. Concerned members of Congress from both parties last week at an appropriations hearing got NIH Director Jay Bhattacharya to again promise to push all the money that they appropriated out the door.��But��it’s��not clear whether��it’s��going to continue to compromise the future workforce. I feel like, you know, we talk about all these missing people and nomination stuff, but��we’re��not really talking a lot about��what’s��going on at the National Institutes of Health, which is a, you know, almost��$50 billion-a-year enterprise.��

Lawrence:��Right.��In some labs, the damage has already been done. You��know, even if Dr.��Bhattacharya��[follows through],��try spending all the money that has been appropriated. There are young��researchers that have been shut out and people that have had to choose alternative career paths. And��I think this��is one of those things��that’s��difficult politically or, you know, in��the public��consciousness, because it is hard to see the immediate impacts��it’s��measured. And I think my colleague Jonathan wrote��[that]��breakthroughs��are��not��discovered��things, you know.��So��it’s��hard to know what��is being missed.��But the immediate impact of the workforce and��not missing this whole generation of scientists that has decided to go to another country or go to do something else, those impacts will be felt for years to come.��

Rovner:��Yeah, this is another one where you��can’t��just turn the spigot back on and have it��immediately��refill.����

Finally, this week, there is always��reproductive��health��news. This week,��we got the Alan Guttmacher Institute’s����for the year 2025,��which both sides of the debate consider the most accurate, and it found that for the second year in a row, the number of abortions in the U.S.��remained relatively stable, despite the fact that it’s outlawed or seriously restricted in nearly half the states.��Of course, that’s because of the use of telehealth, which abortion opponents are furiously trying to get stopped, either by the FDA itself or by Congress.��Last week, anti-abortion Sen.��Josh Hawley of Missouri introduced legislation that would��basically rescind��approval for the abortion pill mifepristone. But that legislation is��apparently giving��some Republicans in the Senate heartburn, as they really��don’t��want to engage this issue before the midterms.��And,��apparently,��the��Trump administration��doesn’t��either, given what we know about the FDA saying that��they’re��still studying this.��On the other hand, Republicans��can’t��afford to lose the backing of the anti-abortion activists either.��They put lots of time, effort,��and money into turning out votes, particularly in times like midterms. How big a controversy is this becoming, Shefali?��

Luthra:��This is a huge controversy, and��it’s��so interesting to watch this play out. When I saw Sen.��Hawley’s bill, I mean, that stood out to me as positioning for 2028.��He clearly wants to be a favorite among the anti-abortion��movement��heading into a future presidential primary. But at the same time, this is teasing out��really potent��and powerful dynamics among the anti-abortion movement and Republican lawmakers,��exactly what you said. Republican lawmakers know this is not popular. They do not want to talk about abortion, an issue at which they are at a huge disadvantage��with��the public. Susan B Anthony��List and other such organizations are trying to make the argument that if they are taken for granted,��as they feel as if they are, that will result in an enthusiasm gap.��Right? People will not turn out. They will not go door-knocking,��they��won’t��deploy their tremendous resources to get victories in a lot of these contested,��particularly Senate and House,��races. And obviously, the��president cares a lot about the midterms.��He’s��very concerned��about what happens��when��Democrats take control of Congress. But I think what Republicans are wagering, and��it’s��a fair thought, is that where would anti-abortion activists go? Are they going to go to Democrats,��who��largely support��abortion rights? And a lot of them seem confident that they would rather risk some people staying home and,��overall, not alienating a very large sector of the American public that does not support restrictions on abortion nationwide, especially those that many are concerned are not in keeping with the actual science.��

Rovner:��Yeah, I think the White House, as you said, would like to make this not front and center, let’s��put it that way,��for the midterms. But��yeah, and just to be clear, I mean, Sen.��Hawley introduced this bill. It��can’t��pass.��There’s��no way it gets 60 votes in the Senate.��I’d��be surprised if it could get 50 votes in the Senate.��So��he’s��obviously doing this just to turn up the heat on his colleagues, many of whom are not��very happy��about that.��

Luthra:��And anti-abortion activists are already thinking about 2028.��They are, in fact, talking to people like Sen.��Hawley, like the��vice��president, like Marco Rubio, trying to figure out who will��actually be��their champion in a post-Trump landscape. And so far, what��I’m��hearing,��is that they are��very optimistic��that anyone else could be better for them than the��president��is because they are just so dissatisfied with how little��they’ve��gotten.��

Rovner:��Although they did get the overturn of��Roe v.��Wade.��

Luthra:��That’s��true.��

Rovner:��But you know, it goes back to��sort of my��original thought for this week, which is that the number of abortions��isn’t��going down because of the��relatively easy��availability of abortion pills by mail. Well, speaking of which, in a��somewhat related��story, a woman in Georgia has been charged with murder for taking abortion pills later in pregnancy than��it’s��been approved for, and delivering a live fetus who��subsequently��died. But the judge in the case has already suggested the prosecutors have a giant hill to climb to convict her and set her bail at $1.��Are we going to see our first murder trial of a woman for inducing her own abortion?��We’ve��been��sort of flirting��with this possibility for a while.��

Luthra:��It seems possible.��I think it’s a really good question, and this moment certainly feels like a possible Rubicon, because going after people who get abortions is just so toxic for the anti-abortion movement.��They have promised they would not go after people who are pregnant, who get abortions.��And this is exactly what they are doing. And��I think what��really stands out to me about this case is so much of it depends on individual prosecutors and individual judges. You have��the law enforcement officials who decided to make this a case, and��they’re��actually using, not the abortion law, even though the language in the case,��right,��really resonates, reflects with the law in Georgia’s��six-week ban. Excuse me, with the��language��in Georgia’s��six-week ban. But then you have a judge who says this is very suspect. And what feels so significant is that your rights and your protection under abortion laws depend not only on what state you live in, but who happens to be the local prosecutor, the local cop, the local judge, and that’s just a level of micro-precision that I think a lot of Americans would be very surprised to realize they live under.��

Rovner:��Yeah, absolutely. We should point out that the woman has been charged but not yet indicted, because many, many people are watching this case very, very carefully.��And we��will��too.��

All right, that is this week’s news. Now��I’ll��play my interview with Katie Keith of Georgetown University Law Center, and then��we’ll��come back with our extra credits.��

I am pleased to welcome back to the podcast Katie Keith. Katie is the founding director of the Center for Health Policy and the��Law at the Georgetown University Law Center and a contributing editor at Health Affairs, where she keeps all of us up to date on the latest health policy, legal happenings. Katie, thanks for joining us again.��It’s��been a minute.��

Katie Keith:��Yeah.��Thanks for having me,��Julie,��and happy ACA anniversary.��

Rovner:��So��you are my��go-to for all things Affordable Care Act, which is why I wanted you this week in particular,��when the health law turned 16. How would you describe the state of the ACA today?��

Keith:��Yeah,��it’s��a great question. So,��the ACA��remains��a hugely important source of coverage for millions of people who do not have access to job-based coverage. I am thinking of��farmers,��and��self-employed people,��and small-business owners.��And you know, in 2025,��more than��24 million people��relied on the marketplaces all across the country for this coverage.��So��it��remains��a hugely��important place��where people get their health insurance. And we are already starting to see real erosion��in��the gains made under the Biden administration��as a result of, I think, three primary changes that were made in 2025.��So��the first would be Congress’��failure to extend the enhanced premium tax credits, which you have covered a ton,��Julie��and the team,��as having��a huge impact��there. The second is the changes from the��One��Big��Beautiful Bill��Act. And then the third is some of the administrative changes made by the Trump administration that��we’re��already seeing.��So��we��don’t��yet have full data to understand the impact of all three of those��things yet.��We’re��still waiting.��But the preliminary data shows that already enrollments��down��by more than a million people.��I’m��expecting that to drop further. There was some���鶹Ů����survey data out last week that about��1��in 10 people are going uninsured from the marketplace already, and that’s not even, doesn’t even account for all the people who are paying more but getting less, which their survey data shows is about, you know,��3��in 10 folks.��So��you know what makes all of this really,��really tough, as you and I have discussed before, is, I think,��2025, was really a peak year. We saw peak enrollment at the ACA. We saw peak popularity of the law, which has been more popular than not ever since 2017,��when Republicans in Congress tried to repeal it the first time.��And��…��but now it feels like we’re sort of on this precipice for 2026,��watching what’s going to happen with the data into this really important source of coverage for so many people.��

Rovner:��And��…��there’s��been so much news that I think��it’s��been hard for people to absorb. You know, in 2017,��when Republicans tried to repeal the Affordable Care Act, they said��that,��We’re��trying to repeal the Affordable Care Act. Well,��the��2025 you know,��“Big,��Beautiful��Bill,”��they��didn’t��call it a repeal, but it had��pretty much the��same impact, right?��

Keith:��It had��a quite��significant impact. And I think a lot,��like,��you know, there was so much coverage about how Democrats in Congress and the White House learned,��in doing the Affordable Care Act, learned from the failed effort of the Clinton health reform in the��’90s. I think similarly here you saw Republicans in Congress, in the White House, learn from the failed effort in 2017 to be successful here. And��so��you’re exactly right. You did not hear any talk of��“repeal and replace,”��by any stretch of the imagination. I think in 2017 Republicans were judged harshly��—��and appropriately so, in my opinion��—��by the��“replace”��portion��of what,��you know, what they were going to do, and it just��wasn’t��there. And��so��you did not see that kind of framing this time around. Instead, it really is an attempt to do death by��a thousand��paper cuts and impose administrative burdens and a real focus on��kind of who��—��you can’t see me, but air quotes,��you know��—��who��“deserves”��coverage and a focus on immigrant populations. So��…��those changes,��when you layer all of them on��—��changes to Medicaid coverage, Medicaid financing, paperwork burdens, all across all these different programs��—��you know, the��One��Big��Beautiful Bill��Act,��it really does erect new barriers that fundamentally change how Medicaid and the Affordable Care Act will work for people. And��so��it’s��not repealed. I think those programs will still be there, but they will look very different than how they have and,��you know, the CBO��[Congressional Budget Office]��at the time, the coverage losses almost��…��they look quite close to, you know, the skinny repeal that we all remember in the middle of the morning��—��early,��like,��late night,��Sen.��John McCain with his thumbs down.��The coverage losses were almost the same,��and you’ve got��the��CBO now saying,��estimating about 35 million uninsured people by 2028,��which,��you know,��is not��…��it’s just��erasing, I think, not all, but a lot of the gains we’ve made over the past 15, now 16,��years under the Affordable Care Act.��

Rovner:��And now the Trump��administration is proposing still more changes to the law, right?��

Keith:��Yep,��that’s��right.��They’re��continuing, I think, a lot of the same.��There’s��several changes that, you know, go back to the first Trump administration that��they’re��trying to reimpose. Others are sort of��new ideas.��I’m��thinking some of the same ideas are some of the paperwork burdens. So really, in some cases, building��off of��what has been pushed in Congress.��What’s��maybe new��this time around for 2027 that��they’re��pushing is a significant expansion of catastrophic plans. So huge, huge, high-deductible plans that,��you know,��really��don’t��cover much until you hit��tens��of��thousands��of dollars in out-of-pocket costs. You get your preventive services and three primary care visits, but��that’s��it.��You’re��on the hook for anything else you might need until you hit these��really catastrophic��costs.��They’re��punting to��the states on core things like network adequacy. You know, again, some of��it’s��sort of new. Some of��it’s��a throwback to the first Trump administration, so not as surprising. And then on the legislative front, I��don’t��know what the prospects are, but you do continue to see President��[Donald]��Trump call for, you know,��health��savings��account expansions. We think, I think, you know, the idea is to send people money to buy coverage, rather than send the money to the insurers, which I think folks have interpreted as health savings accounts.��There’s��a continued focus on funding cost-sharing reductions, but that issue continues to be snarled by abortion restrictions across the country. So��that’s��something that continues to be discussed, but I��don’t��know if it will ever happen. And you know anything else that’s��kind of under��the so-called��Great��Healthcare��Plan that the White House has put out.��

Rovner:��You mentioned that 2025 was the peak not just of enrollment but of popularity.��And we have seen in poll after poll that the changes that the Trump administration��and��Congress��is��making are not popular with the public, including��the vast majority of��independents and many, many Republicans as well. Is there any chance that Congress and President Trump might relent on some of these changes between now and the midterms?��We did see a bunch of Republicans, you know, break with the rest of the party to try to extend the, you know, the enhanced premiums. Do you see any signs that��they’re��weakening��or��are��we off onto other things entirely��right now?��

Keith:��It’s��a great question.��I think you��probably need��a different analyst to ask that��question to. I��don’t��think my crystal ball covers those types of predictions. But to your point, Julie, I thought that if there would have been time for a compromise and��sort of a��path forward, it would have been around the enhanced premium tax credits. And it was remarkable, you know, given what the history of this law has been��and��the politics��surrounding it, to see 17 Republicans join all Democrats in the House to vote for a clean three-year extension of the premium tax credits. But no, I think especially thinking about where those enhanced tax credits have had the most benefit, it is states like Georgia, Florida, Texas, and I thought that��maybe would,��could have moved the needle if there was a needle to be moved.��So��I,��it seems like��there’s��much more focus on prescription drugs and other issues, but anything can happen.��So��I guess��we’ll��all��stay tuned.��

Rovner:��Well,��we’ll��do this again for the 17th anniversary. Katie Keith, thank you so much.��

Keith:��Thanks,��Julie.��

Rovner:��OK,��we’re��back.��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 will post the links in our show notes on your phone or other mobile device. Lizzy, why don’t you start us off this week?��

Lawrence:��Sure.��So��my extra credit is by��Nick��[Nicholas]��Florko, former��Stat-ian,��in��The Atlantic,��“”��I��immediately��read this��piece, because��this is something��that’s��been driving me��kind of crazy. Just seeing��—��if��you’ve��missed it��—��there have been��…��HHS has been posting AI-generated videos of Secretary Kennedy wrestling a Twinkie,��wearing waterproof jeans,��all of��these things. And this has been, this is not unique to HHS��—��[the]��White House in general has really embraced AI slop as a genre, and I��can’t��look away. And��so��I thought��Nick did��a good job��just acknowledging how crazy this is, and then also what goes��unsaid in these videos.��I think I��personally am just very curious if this resonates with people, or if��it’s��kind of disconcerting��for the average American��seeing these videos like,��Oh, my government is��making��AI slop.��Like I,��you know, social media strategy is so important, so��maybe for��some��people are��really��liking��this. But��yeah,��I’m��just��kind of curious��about public sentiment.��

Rovner:��I know I would say, you know, the National Park Service and the Consumer Product Safety Commission have been��sort of famous��for their very cutesy social media posts, but��not quite to��this extent. I mean,��it’s��one thing to be cheeky and funny. This is��sort of beyond��cheeky and funny.��I agree with you. I have no idea how this is going over the public, but they keep doing it.��It’s a really good story.��Rachel.��

Cohrs Zhang:��Mine is a story in The Boston Globe, and the headline is��“”��by��Tal Kopan.��And this was a really good profile of Tony Lyons, who is Robert F.��Kennedy Jr.’s book publisher, and he’s kind of had the role of institutionalizing all the political energy behind RFK Jr.��and trying to make this into a more enduring political force.��So��I think he��is, like, mostly a behind-the-scenes guy, not really like a D.C.��fixture, more of like a New York book publishing figure.��But I think his efforts and what they’re using, all the money they’re raising for, I think,��is a really important thing to watch in the midterms, and like, whether they can actually leverage this beyond a Trump administration, or beyond however long Secretary Kennedy will be in his position.��So��I think it��was just a good overview of��all the tentacles of institutional MAHA��that are trying to, you know, find their footing here, potentially for the long term.����

Rovner:��I had��never heard of him, so I was glad to read this story.��Shefali.��

Luthra:��My story is from NPR. It is by��Tara��Haelle. The headline is��“.”��Story says exactly what it promises, that if you have an infant, babies��under��6��months, then getting a covid vaccine while you are pregnant will��actually protect��your baby, which is great because there is no vaccine for infants that young. I love this because it’s a good reminder of something that we were starting to see, and now it just really underscores that this is true, and in the midst of so much conversation around vaccines and safety and effectiveness, it’s a reminder that really, really good research can show us that it is a very good idea to take this vaccine, especially if you��are pregnant.��

Rovner:��More fodder for the argument, I guess. All��right,��my extra credit this week is a clever story from��Stat’s John Wilkerson called��“.”��And,��spoiler,��that loophole is that��one way��companies can avoid running afoul of their promise not to charge other countries less for their products than they charge��U.S.��patients is for them to simply delay launching those drugs in those other countries that have price controls.��Already, most drugs are launched in the U.S.��first, and��apparently some��of the companies that have done deals with the administration limited their promises to three years,��anyway. That way they can charge��U.S.��consumers however much they think the market will bear before they take their smaller profits overseas. Like I said,��clever.��Maybe that’s��why so many companies were ready to do those deals.��

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

Luthra:��I am on��Bluesky��.��

Rovner:��Rachel.��

Cohrs Zhang:��On��X��, or��.��

Rovner:��Lizzy.��

Lawrence:��I’m��on��X����and����and��.��

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

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Attorney Nicole Wipp and skate-shop owner Noah Hulsman tell An Arm and a Leg host Dan Weissmann how they tried to balance their financial and physical health when they couldn’t find good options.

Wipp and Hulsman first spoke with �鶹Ů�� Health News senior correspondent Renuka Rayasam for the series “Priced Out,” which tracks how people are responding to skyrocketing health insurance costs.

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan:��Hey there. About a dozen years ago, Nicole Wipp was trying to spend less time running her law firm and more time with her son, who was in preschool. ?It was a work in progress.��

And then she started feeling— a little off. ?Tired. Out of breath. Her doctor thought it was stress.

Nicole didn’t think so, but she soldiered on. And got worse. For months. Until one day— when she told her husband she just couldn’t get off the couch — he was like, you’re going to urgent care. An x-ray showed her whole left lung totally blacked out.?

��Next stop, emergency room.��

Nicole Wipp:��They put a huge needle and shoved it into my back and drew out two liters. Imagine a whole two-liter of pop – I’m from Michigan, so I say pop – from your body. They draw a whole two-liter of liquid. And I felt so much better immediately. I was like, wow, I can breathe. Like, wow, this is so cool. But, um, it was sort of horrifying.

Dan:��Nicole says she eventually got diagnosed with a rare lung condition

Nicole Wipp:��It’s called lymphangioleiomyomatosis — LAMB for short.

Dan:��But not before she’d spent a month in hospitals — hospitals, plural — and had multiple expensive surgeries.

Nicole Wipp:��Minimum — my husband and I tried to like tally it all up, like look at all the bills afterward — and it was, minimum, a half a million dollars.��

Dan:��Which, because her husband’s job at the time provided good health insurance, didn’t break them.

Nicole’s condition hasn’t bothered her for years. But it’s not cured. It’s incurable.

And yet. This year, Nicole and her husband didn’t sign up for health insurance.

For more than 20 million people on Obamacare plans, the price of health insurance changed dramatically this year. Premiums skyrocketed just as subsidies got sharply reduced.��

Some people faced horrifically stark new circumstances:��

People who needed insurance to cover ongoing treatment: for cancer, for diabetes — treatment they literally could not live without — saw premiums jump by thousands of dollars a month, more than they could possibly afford.

And millions more got stuck taking gambles. Making messy, unsatisfying choices.��

Our partners at �鶹Ů�� Health News have been talking with lots of those people.��

They introduced us to Nicole. She and her husband could have paid for health insurance. But when rates went up, they did the math and decided not to. They’re generally healthy, and honestly have more financial cushion than most people.��

If they need medical care — ordinary medical care, anyway— they think they’ll be better off just paying cash.��

But they know they’re gambling: that 2026 won’t be the year Nicole’s condition flares up, or that some other catastrophe hits.

Our pals at �鶹Ů�� Health News also introduced us to this man:

Noah Hulsman:��My name’s Noah Hulsman. I own and operate Home Skateboard Shop here in Louisville, Kentucky.

Dan:��It’s Louisville’s only skateboard shop. It’s kind of a family business, kind of a community center, kind of a place Noah’s spent most of his 37 years.��

Noah’s still paying for insurance — paying for�� protection against catastrophe. But because all he can afford this year is a bare-bones plan, he doesn’t have a way to pay for ordinary medical care. Which he could actually really use.��

Noah Hulsman:��So I’m kind of in a position right now… I need my left shoulder looked at, but I have an $8,400 deductible. Yeah.

Dan:�� We’ll get into that — it sucks. But first: I really want you to hear about this skateboard shop.

Noah Hulsman:��When I tell the story, it almost seems like a movie or something. Like, somebody made this up.

Dan:��Let’s go.��

This is An Arm and a Leg — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you a show that’s entertaining, empowering, and useful.

Here’s how Noah ended up a skater for life.

Noah Hulsman:��So my grandmother, she opened up a skateboard shop in 1988 here in Louisville. It was called Skateboards Unlimited. She had a little skate park also behind it called Ottoman Skate Park.

Dan:��Noah’s grandmother was not a skater. She’d been a nurse — but she had five kids, and Noah says she ended up more of a stay-at-home mom.

Noah Hulsman:��And then with all the commotion that was always occurring, with all the friends in and outta the house, with having five kids and all these skateboarders that just started popping up, she just decided, you know what? Let’s like have a place for you all to go.

Dan:��She opened Skateboards Unlimited — and a skate park behind it.

When her youngest son finished high school — and moved to the West Coast as a professional skateboarder — it was the end of an era. And the beginning of another.��

Noah’s grandma closed up Skateboards Unlimited.��

Noah Hulsman:��And uh, that’s when one of her employees was like, you know what? We gotta keep having a skate shop.��

Dan:��They called it Home Skate Shop. Noah became a regular customer, eventually an employee. And — ten years ago, when he was 27, — he took over the business.��

Noah is as invested as anybody could possibly be.

Noah Hulsman:��It’s everything. It’s my whole life. Yeah.

Dan:��It’s doing OK. There were a few rocky years early on — Noah says he qualified for Medicaid. But things actually picked up when the pandemic started.

Noah Hulsman:��Skateboarding was one of the only things that you do by yourself. You’re doing it outside. If I would’ve been able to get a hold of more product, we would’ve, we would’ve killed it.

Dan:��Noah got an Obamacare plan, and he even bought a building — he leases out a couple of apartments, runs an air bnb in a third one, and says he breaks even on it, right now..

Noah Hulsman:��They say, you know, real estate is a long term game.

Dan:��Noah’s a long-term kind of guy.

\He and his girlfriend have been together for 16 years — even while she was away at veterinary school.

Noah Hulsman:��She just finished up at Auburn this past year and moved back home and yeah, it’s been awesome.

Dan:��Now they live together — with their four cats — in an apartment less than a mile from where his grandma started her skate shop.

But it’s not a cushy living. Noah says he takes odd jobs and gives skateboarding lessons to make ends meet.

Noah Hulsman:��Every single day is a hustle. There is no day, like you can’t get sick, you can’t be–�� no downtime. If you take vacations, you’re still working from your phone, you’re checking in on the shop.

Dan:��Noah says his income — all in — has been holding steady at around $33,000 a year. Last year, with a subsidy, he was able to get a gold plan for about a hundred and five dollars a month.

For 2026 — with premiums jacked up and subsidies cranked down — that gold plan would have cost him an extra $500 a month. That’s $6000 a year. Way more than he could afford.

Instead, he picked a Bronze plan. It leaves him paying pretty much exactly the same every month as he did last year, but it covers so much less.

Noah Hulsman:��I don’t even know why I’m paying that. It’s useless really, unless I get into a car accident and I have $10,000 worth of bills.

Dan:��Or a skateboarding accident. Or a serious illness. Anything.

He’s holding onto the plan as a backstop against a worst-case scenario, against ending up with more debt than he could ever pay back.

But having a backstop is not the same as having access to medical care.

A few months ago, Noah says his left shoulder started bothering him. He says it doesn’t stop him from day-to-day stuff, running the shop. But it does impose limits.��

Noah Hulsman:��It’s those like quick movements. It’s those like blast-off times like when I’m popping on my skateboard or when I’m like turning a certain like front side and like throwing all my weight that way.��

Dan:��His bronze plan — with its $8400 deductible — means he can’t afford to get it checked out.

Noah Hulsman:��To go through, okay first you have to go see primary care, then they gotta do the x-ray. Then once you see the x-ray, oh, we can’t tell anything from the x-ray. Yeah, we know because it’s ligaments and tendons and muscles and things like, I’m not a doctor, but I’ve been through this a few times. So, okay, we’re gonna get you the MRI. All right. Here’s the MRI. None of that’s gonna be covered.

Dan:��It sounds like thousands of dollars to Noah — to me too, really. And that’s before getting it treated, which could mean surgery.

Noah doesn’t have thousands of dollars lying around. If he did, he would’ve paid up for the gold plan.��

So he’s avoiding tricks that could irritate the shoulder,

Noah Hulsman:�� I can still skateboard. I just have to choose what tricks or what obstacles. I don’t have like the freedom that I had when I used to ride my skateboard.

Dan: He’s hoping he can nurse the injury along till next year, when he thinks he could afford better insurance.��

Noah Hulsman:��What I’m kind of planning on doing is my, my shop vehicle is about to be paid off next year or like at, at the, I think it’s like middle of next year. And that payment is basically what that gold plan payment is.

Dan:��Yeah, yeah,

Noah Hulsman:��That’s what’s probably gonna happen. That’s my new car payment. New shoulder payment.

Dan:��Man, that super sucks. I mean, grimly hilarious��

Noah Hulsman:��Yeah. Yeah. I mean, if this, you have to just laugh at how ridiculous the world is these days. There’s, I mean, if you just take it serious, doom and gloom all the time, it’s going to, you’re not gonna make it. You gotta just laugh these days. It’s so ridiculous.

Dan:��It is. Noah is far from alone. A Gallup poll taken in late 2025 found that more than a quarter of all Americans had postponed surgery or medical treatment because of cost.

Being insured and having access to medical care — for lots of people, they haven’t been the same for a long time.

This year, especially for people using Obamacare, that’s accelerating.��

We don’t know yet how many people made choices like Noah’s, and moved to plans that cover less, in order to have a monthly payment they could kind of afford.

Federal numbers won’t be out for a while. But an analyst named Charles Gaba ran some preliminary numbers from a few states.

He found that the number of people in Silver and Gold and Platinum plans was down significantly. And the number of people in Bronze plans, the cheapest, was up dramatically.

And we do know that at least a million people have dropped Obamacare. Some have dropped insurance altogether. Including, of course, Nicole Wipp.

We’re coming back to her story, just ahead.��

This episode of An Arm and a Leg is produced in partnership with �鶹Ů�� Health News. That’s a nonprofit newsroom reporting on health issues in America. The reporters at �鶹Ů�� Health News do amazing work — win all kinds of awards every year. And in a little while, you’ll meet the �鶹Ů�� reporter who introduced me to Noah Hulsman and Nicole Wipp.

Dan:��Before Nicole Wipp knew that her Obamacare rates would be going up, she knew she was pissed at what she calls the insurance industrial complex.��

Nicole Wipp:��So my son. Just for example, we took him— called in advance, ‘do you take our insurance?’ Took him to get basic well child vaccines. Well, next thing I know, I got a bill for $4,000. I called them up and was��like, what is this?��

Dan:��She says that was early 2025, and she’s been fighting ever since.��

Nicole Wipp:��They’ve cut it down to like 1200, but I’m like, no, no, no, no, no. It should be a hundred percent covered under our insurance, So that’s the thing is like, why would I participate in this?

Dan:��And at least since her half-a-million-dollar medical adventure Nicole Wipp has been pretty determined to live life on her own terms.

Even before her illness, she had already been trying to spend less time running her law practice and more time with her family.

Then, after the illness, she more than doubled down on that. On her website, she says she went from working 80 hours a week to working just five days a month.

That’s the website for a new business she started after her recovery: a consulting and coaching practice that offers to help people achieve financial success on their own terms.��

Nicole Wipp:��Financial success for me is very much not just about money, it’s really more about quality of life and having enough money to have that quality of life.

Dan:��So, for instance, about four years after her illness, Nicole’s family moved from Michigan to Hawaii.

Nicole Wipp:��We said, we want to live in Hawaii because we wanna have a quality of life. And of course, living in Hawaii is not cheap. It’s one of the most expensive places in the United States to live.

Dan:��But that’s what they wanted. And they made it work.��

And then their son got into polo. Like, with horses. Which is harder to do in Hawaii— to do seriously, competitively — without a lot of traveling to the mainland. So they moved again, to South Carolina.

Nicole Wipp:��And we did, by the way, when we moved back to the mainland, FedExed four horses from Hawaii

Dan:��Oh my God.

Nicole Wipp:��I know, and like when you say, all these things, it sounds insane, right? It is insane.��

Dan:��Since then, she says they’ve picked up another four horses.

Nicole Wipp:��Now we have a total of eight, which is a lot, a lot by the way. Um, and so, you know, I say it out loud and I’m like, oh, I’m not proud of this, to be honest with you. But, but we have also though made other choices like we live in a smaller home than we would otherwise, so that we can do that.

Dan:��And that home is in a part of South Carolina where houses aren’t super- expensive. So Nicole says the mortgage on their house is less than the $1400 they would’ve been paying if they’d kept their insurance this year.��

The expensive horses, the less-expensive home…

Nicole Wipp:�� Like these are choices that we’ve made as a family that I understand very much that most people would never make these choices, but we’re doing it in as responsible of a fashion as we possibly can.

Dan:��A few years ago, her husband changed careers— no more job-based health coverage. They started buying insurance on the Obamacare exchange.

But by mid-2025, it started looking like that insurance could get a lot more expensive. Not because they’d lose a subsidy — they hadn’t qualified for a subsidy to start with.��

But if subsidies went away, she figured rates would go way up.����

Nicole Wipp:��I started bringing it up to my husband. Like, I don’t know what this is gonna look like. I’m very worried about it. And we may be in a situation where we need to make a choice��

Dan:��Could they contemplate doing without insurance?

Nicole Wipp:��And so we had probably, you know, 20 conversations, at least, about it.

Dan:��Before making a decision — even before 2026 rates got posted — Nicole and her husband started taking some steps. She scheduled a colonoscopy, and went to the dermatologist for a skin check. Her husband got some tests too.

If they didn’t have insurance next year, those tests wouldn’t be covered. And if any tests came back with scary results, insurance would be more important.

Obamacare premiums for 2026 got published. Their family’s rate would go up by about 50 percent.��

Nicole Wipp:��Once the numbers came out, I was like, I just don’t know if this makes sense.?But we were like, okay, we need to gather more information. We need to think about it some more.��

Dan:��Their tests had come back OK. And they felt fine. Maybe they wouldn’t need any medical care in 2026, or not much. But maybe they would. How might they pay the bills? They kept talking. And they identified some ideas.

For one thing, Nicole found some money socked away in a health savings account from her husband’s old job.��

Nicole Wipp:��It’s not a lot, but it was like, oh, that’s a nice little cushion. Like we could use that if we needed it.��

Dan:��Nicole figured, if they were paying cash, she’d be in a good position to negotiate with providers for discounts.��

Nicole Wipp:��Because I’m a lawyer and I’ve been around the block on these things, so I had a lot of faith that I could negotiate a bill.

Dan:��And she had other ideas for finding deals.��

Nicole Wipp:��I was like, you know, depending on what the situation is, we could fly to another country, receive healthcare quality healthcare. It still would be less. And I am not above doing that.

Dan:��And if all of that required more cash than they had lying around, Nicole figured, they still had options.��

Nicole Wipp:��We have certain assets that in an extreme emergency we could sell – I mean, because it’s not just the horses. We have horse trailers and like, you know, there’s a lot that goes along with all of that that isn’t just the horses by the way.

Dan:��None of which made the decision easy. Nicole says she and her husband didn’t fully decide until the actual deadline came for signing up. Even then, they knew they were gonna keep their son insured.

Nicole Wipp:��I would be in my opinion, not responsible as a mom, so… because he does play a very dangerous sport.

Dan:��But for the adults, they weighed the risks, and decided to gamble.

Nicole Wipp:��If I take that money and invest it instead of putting, I don’t know, am I gonna be out further ahead? I will if I don’t have a massive emergency and a half a million dollar illness. Um, right? And so it’s a gamble, like, right? All of this is a gamble, but it was a gamble that I was like, I just don’t want to participate in this any longer because this is not workable for almost anybody, but it certainly isn’t workable for me anymore mentally or emotionally.

Dan: Not workable for almost anybody.��

[Music transition]

Renu Rayasam:��I mean, I also think about this as a reporter. We have these individual stories. What do they mean? First of all, why is this system like this and what does it mean for everyone?

Dan:��That’s Renu Rayasam. She’s a senior correspondent with our partners at �鶹Ů�� Health News. She introduced me to Nicole and to Noah. She and her colleagues have been talking with dozens of people about the choices they’ve been forced to make about insurance this year.

?And thinking about what those individual stories mean has led Renu to some big reflections.��

Renu Rayasam:��I think sometimes in the US you take for granted the way things are. Just you don’t, you don’t realize there is another way, you know? There is another way! And um, and that’s where everybody has health insurance and those costs are better spread out.��

Dan:��Renu is speaking in part from experience. She spent a half-dozen years living in Germany. We talked about her experience— and how it affects the way she sees stories like Nicole’s and Noah’s.��

Renu Rayasam:��?Well first of all, it was kind of amazing to like never get a medical bill. Like that was like, like so mind blowing that you just, like, you go to the doctor and you never get a bill.��

Dan:��Not because the government pays for health care. But because the government requires everybody to have health insurance.��

Renu Rayasam:�� People pay premiums. ?You have to pay into the system. And it’s not necessarily cheap either.??But then on the back end, you’re never worried about, oh, my shoulders hurt, I have to get this MRI and I’m gonna get a bill.

Dan:��?Most people pay a government-set rate — about 15 percent of their income. Most insurance funds are non-profit. Everything’s highly regulated, and everybody gets the same benefits. Here, things are … more chaotic. Less predictable. People have to make hard choices— and those choices feed back into the chaos.��

Renu Rayasam:��So if somebody like Nicole opts out of health insurance, they’re not paying into this system and the people who are paying into the system are people who need care. And so that makes health insurance more expensive generally.��

Dan:��Because insurers set their rates based on how much they expect to pay out. When healthy people bail, the rates go up. And when rates go up, healthy people bail. They reinforce each other. It’s what experts call a death spiral.

As some of those experts told Renu, a version of that happened over the last year. ?It wasn’t a coincidence that insurers jacked up prices when subsidies were on the chopping block.��

Renu Rayasam:��Part of the reason that insurers raised their prices was because they expected people to drop plans and that fewer people would be paying their premiums and be paying into the system.

Dan:��And people like Nicole and Noah ended up with lousy choices to make.��

Noah chose to keep paying for insurance as a backstop against absolute financial catastrophe — even though the insurance he can afford doesn’t give him access to medical care he needs.��

Nicole and her husband think they’ve got the resources to pay for ordinary medical care. Even maybe a big medical deal — as long as there was time to hop on a plane and get to a country where they could afford treatment.

But they’re not protected against the worst. Nicole knows bankruptcy is a real possibility.��

Nicole Wipp:��We don’t have a guarantee. And it still weighs on me every day that I made this choice because it feels fraught. Do I regret it? No, not at the moment. I don’t. Will I regret it? I hope not.

Dan:��Hmm.

Nicole Wipp:��I don’t know though.

Dan:��Yeah, you’re not like, I did it. I’m free, you know, this is the best. It’s like, no, you’re not free of it.

Nicole Wipp:��No, I don’t feel free at all.

Dan:��I wish I had a snappier ending to this story. We are more stuck than ever — all of us — making messy choices, hoping for the best. So I’m gonna give Noah the last word here.��

He’s taking his own advice: Taking things as they come, recognizing what’s ridiculous, and aiming to hang in there for the long term.

Noah Hulsman:��?Hopefully we, you know, get enough equity in this building that once it’s time to pass the skateboard shop on, maybe sell the building and hopefully that’s when we get to maybe cash out and go to the beach.��

Dan: Wow.��

Noah Hulsman:��?Maybe. Or maybe I’ll just get to pay off my medical debt that I’ve accrued over however many years at that point.

Dan:��We’ll be back in a few weeks with a new episode. Till then, take care of yourself.��

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss.��

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.��

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations.��

An Arm and a Leg is produced in partnership with �鶹Ů�� Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at �鶹Ů��, an independent source of health policy research, polling, and journalism.

��Zach Dyer is senior audio producer at �鶹Ů�� Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,��“.” You can also follow the show on��,��,��, and��. And if you’ve got stories to tell about the health care system, the producers would love to��.

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Estaba pensando en retrasar el estudio, contó, porque este año la prima mensual del seguro de Obamacare se le triplicó a $2.460, lo que es igual a cerca de un tercio de sus ingresos.

Con un deducible de $2.700, habría tenido que pagar de su propio bolsillo la mayor parte del examen diagnóstico, un golpe económico que aseguró no poder asumir.

Galvin vive en North Kingstown, Rhode Island, y se retiró recientemente como director de una empresa de equipos médicos. “La colonoscopía me iba a costar cerca de $3.000. Así que decidí postergarla”, explicó.

También Nancy, la esposa de Galvin, está retrasando una costosa tomografía computarizada por unos años, hasta que pueda aplicar a Medicare y que el programa federal de salud cubra el costo. Medicare ofrece cobertura para todos los estadounidenses de 65 años en adelante.

Las personas con planes de la Ley de Cuidado de Salud a Bajo Precio (ACA) que están cerca de la edad de jubilación fueron de las más afectadas por los aumentos de precios luego de la suspensión de los subsidios federales mejorados, a finales de diciembre.

Quienes tenían ingresos superiores al 400% del nivel federal de pobreza para una familia de dos miembros— habían estado recibiendo ayuda para pagar los planes desde que la administración Biden amplió los subsidios durante la pandemia de covid-19. Los adultos de 50 a 64 años representaban alrededor de en ACA.

Ahora, sin esa ayuda financiera, algunas personas en este grupo de edad dicen que están pensando si no les conviene retrasar la atención médica hasta que califiquen para Medicare.

Según defensores de pacientes, médicos y expertos en políticas de salud, esta decisión no solo puede poner en riesgo la salud, sino también generar mayores costos para el sistema. Al postergar la atención médica hasta alcanzar la elegibilidad para Medicare, muchas afecciones se pueden agravar, lo que termina trasladando el gasto a los contribuyentes.

“Habrá mucha demanda acumulada y necesidades no atendidas”, dijo , consultora de políticas de salud que trabajó en las administraciones de Barack Obama y Joe Biden. “Medicare va a tener que gastar mucho dinero cubriendo y manejando esos tratamientos”.

ACA ha sido una fuente clave de cobertura médica para personas de 50 a 64 años. El acceso a los planes del Obamacare ayudó a reducir a la mitad la tasa de personas sin seguro en este sector, un grupo de defensa que representa a adultos mayores.

Esto permitió que algunas personas se jubilaran antes manteniendo cobertura. También ha servido como red de seguridad para los dueños de pequeños negocios y para quienes tienen empleos que no ofrecen seguro médico.

El otoño pasado se produjo el cierre del gobierno más largo de la historia, en medio de un intento fallido de los demócratas por extender los subsidios mejorados. Los republicanos que se opusieron a la medida argumentaron que la ayuda beneficiaba a las aseguradoras e incentivaba el fraude y la oferta de cobertura innecesaria.

El tema seguirá siendo relevante en la política, especialmente ante las elecciones de medio término de este año, incluso entre los estadounidenses mayores, que votan de manera regular, dijo el estratega republicano , quien dirige Atlas Strategy Group.

“¿El costo de la atención médica va a ser un tema? Sin duda”, dijo. “¿Los precios de la atención médica influirán? Sí”.

Incluso antes de que expiraran los subsidios, los costos de la atención médica, los hogares de adultos mayores y los medicamentos recetados eran algunas de las principales preocupaciones de salud entre las personas mayores de 50 años, según .

Los adultos de mediana edad con planes del Obamacare sienten con más fuerza el impacto de la eliminación de estos subsidios, porque primas hasta tres veces mayores que a las de 20, ya que estas últimas, por lo general, usan menos servicios médicos.

Y muchos adultos de mediana edad ya estaban inscriptos en los planes de menor costo disponibles, lo que los deja sin opciones más baratas, señaló , analista de políticas en �鶹Ů��, una organización sin fines de lucro de información en salud que incluye �鶹Ů�� Health News.

“Esto es muy grave para las personas mayores inscriptas en el mercado de seguros”, dijo.

Quienes ganan apenas unos dólares por encima del 400% del nivel federal de pobreza ahora quedan fuera de los subsidios, y en algunos estados las primas promedio para este grupo .

��Muchas personas están viendo aumentos anuales de miles de dólares, con primas que pueden representar hasta una cuarta parte de sus ingresos.

, médico de atención primaria e investigador de políticas de salud en la Universidad de Michigan, contó que con frecuencia sus pacientes mayores le hablan de sus esfuerzos para afrontar el pago de su atención médica. Algunos, de poco más de 60 años, probablemente abandonen la cobertura de ACA debido al aumento, dijo.

“Es una apuesta arriesgada”, opinó.

Marci Heinbaugh podría verse obligada a asumir ese riesgo. La trabajadora social de 63 años, que vive en una zona rural de Illinois, contó que su prima mensual superó el doble de su valor, pasando de unos $1.100 a $2.333, por un plan con gasto máximo de bolsillo de $10.150.

Sabía que tendría que pagar más, dijo, pero no imaginaba un aumento de esa magnitud. Después de unos meses, ya no está segura de poder mantener el plan durante el resto del año y dijo que incluso podría quedarse sin seguro. “Me da pánico siquiera pensarlo”, confesó Heinbaugh.

Las personas quieren comprar su propio seguro en el mercado y muchos adultos de mediana edad podrían pagarlo con un poco de ayuda financiera federal, dijo , vicepresidente senior de políticas públicas en AARP. Quienes abandonan la cobertura o retrasan la atención hasta cumplir 65 años pueden estar ahorrando dinero ahora, pero eso podría resultar más costoso para ellos —y para los contribuyentes— más adelante.

“Existe una probabilidad significativa de que los supuestos ahorros por reducir los subsidios a medida que las personas se acercan a la jubilación terminen convirtiéndose en mayores costos para Medicare”, señaló Weil.

Los afiliados a Medicare no están protegidos de los aumentos de costos. Por ejemplo, en enero, las primas estándar de la subieron de $185 al mes a casi $203.

Hasta que Galvin pueda inscribirse en Medicare, prevé gastar los $30.000 de su cuenta de jubilación para cubrir los pagos de primas y el deducible de su plan del mercado.

reveló que 1 de cada 5 adultos mayores de 50 años no tiene ahorros para la jubilación y que a 3 de cada 5 les preocupa no tener suficientes fondos para mantenerse.

La expiración de estos subsidios del Obamacare ejerce una presión financiera adicional sobre los estadounidenses a medida que se acercan a la jubilación, dijeron investigadores de políticas de salud.

“Están obligando a las personas a tomar decisiones imposibles”, dijo , directora de defensa federal en salud de la organización sin fines de lucro Justice in Aging.

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He was already thinking about delaying it — then his monthly Obamacare insurance premium payment tripled this year to $2,460, about a third of his income, he said. And with a $2,700 deductible, he’d be on the hook for most of the diagnostic exam, a financial hit he said he couldn’t stomach.

“It was going to cost close to $3,000,” said Galvin, who lives in North Kingstown, Rhode Island, and recently retired as director of a durable medical equipment company. “I put it off.”

Galvin said his wife, Nancy, is delaying a costly CT scan for a few years until she too qualifies for Medicare, so it can foot the bill. The federal health program offers coverage for all Americans 65 and older.

People on Affordable Care Act plans nearing retirement age experienced some of the largest price increases following the expiration of enhanced federal subsidies at the end of December. Those with incomes above 400% of the federal poverty level — — had been getting help paying for the plans since the Biden administration expanded the subsidies during the covid-19 pandemic. Adults ages 50 through 64 of those ACA enrollees.

Now, without that federal financial help, some in this age group say they’re wrestling with whether to delay care until they qualify for Medicare. Not only does that put their physical health at risk, said patient advocates, doctors, and health policy researchers, but it potentially just shifts the costs — and could lead to taxpayers’ footing even bigger bills to fix health issues that worsen amid the delays.

“There’s going to be a lot of pent-up demand and unmet need,” said , a health policy consultant who worked in the Obama and Biden administrations. “Medicare is going to have to spend a whole heck of a lot of money covering and dealing with their treatment.”

The Affordable Care Act has been a key source of health care coverage for people 50 through 64. Access to Obamacare plans helped cut the uninsured rate for this age group by half, , a lobbying group that represents older adults. That allowed some people to retire early while keeping coverage. It also has provided a safety net for small-business owners and those with jobs that don’t offer health insurance.

Last fall, the longest-ever government shutdown occurred amid an unsuccessful effort by Democrats to extend the enhanced subsidies. Republicans opposing the extension had said the assistance went to insurers, incentivizing fraud and wasteful coverage.

Waiting for Medicare

John Galvin, 64North Kingstown, Rhode Island

John Galvin knows he needs a colonoscopy. But he’s waiting until he turns 65 in December to schedule it, so that Medicare will pick up the tab. His monthly Obamacare premium payment jumped this year — from $800 to more than $2,400 — so he’s burning through a $30,000 retirement account to cover the additional costs. And that’s for a plan with a $2,700 deductible, which means he’d be on the hook for most of the pricey diagnostic exam. “It was going to cost close to $3,000,” Galvin says. “I put it off.”

— Sam Whitehead

The issue will continue to have political relevance, especially in this year’s midterm elections, including among older Americans who reliably show up to the polls, said Republican strategist , who runs the Atlas Strategy Group.

“Is affordability going to be an issue? Absolutely,” he said. “Are health care prices going to factor into that? Yes.”

Even before the subsidies expired, the costs of medical care, nursing homes, and prescription drugs were among the top health-related concerns for people over 50, a found.

Middle-aged adults with Obamacare plans acutely feel the pinch of the expired subsidies, because to charge adults in their 60s up to three times as much for premiums as those in their 20s, who generally use fewer medical services.

And many middle-aged adults were already enrolled in the lowest-cost plans available, which leaves them without cheaper options to fall back on, said , a policy analyst with �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News.

“This is very dire for the older marketplace enrollees,” he said.

Someone making a few dollars over 400% of the federal poverty level earns too much to get a subsidy now, and in some states average premium payments were due to for this group. Many people are seeing yearly rate increases of thousands of dollars, with premium payments totaling as much as a quarter of their incomes.

, a primary care physician and health policy researcher at the University of Michigan, said he has regular conversations with older patients who are trying to figure out how to afford their medical care. Some in their early 60s are likely to drop ACA coverage because of rising premiums, he said.

“That’s a gamble,” he added.

Marci Heinbaugh may take that bet. The 63-year-old social services worker, who lives in rural Illinois, said her monthly premium payments more than doubled, from roughly $1,100 to $2,333, for a plan with a $10,150 out-of-pocket maximum.

She knew she’d be paying more, she said, but wasn’t anticipating that kind of increase. A few months in, she’s not sure if she’ll stick with the plan for the rest of the year. She said she may go uninsured.

“I’m petrified to even think about that,” Heinbaugh said.

People want to buy their own insurance on the marketplace, and many middle-aged adults could afford it with just a little federal financial help, said , senior vice president of public policy at AARP. Those who drop coverage or delay care until they reach age 65 might save money now, but that could be more costly for them — and taxpayers — later.

“There’s significant possibility that the purported savings associated with reducing subsidies as people approach retirement end up turning into higher utilization costs for Medicare,” Weil said.

And Medicare enrollees aren’t insulated from rising costs. In January, for example, standard Medicare from $185 per month to almost $203.

Until Galvin joins Medicare, he said, he expects to burn through a $30,000 retirement account to cover his marketplace plan’s premium payments and deductible.

A found that 1 in 5 adults over 50 had no retirement savings and 3 in 5 were worried they wouldn’t have enough retirement savings to support themselves.

The expiration of these Obamacare subsidies puts additional financial pressure on Americans as they approach retirement, health policy researchers said.

“It’s forcing people to make impossible choices,” said , director of federal health advocacy for the national nonprofit Justice in Aging.

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

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This story can be republished for free (details).