Out-Of-Pocket Costs Archives - �鶹Ů�� Health News

Cheaper, Alternative Health Plans Are Having a Moment, but Critics Urge Caution

Sarah Kwon — Tue, 26 May 2026 09:00:00 +0000

When Melanie Miller saw that her health insurance premium payment was set to nearly triple to $914 a month this year, she stopped shopping on the Affordable Care Act marketplace.

The 59-year-old retired teacher, who recently moved from Ohio to Michigan, now pays $341 a month for a pair of plans, one that covers routine and urgent care and another that pays fixed amounts for hospital stays. Neither meets federal standards for comprehensive coverage.

Though she practices yoga and is healthy, Miller said she still feels “vulnerable.” If she lands in the hospital, her plan pays a flat $2,000, a fraction of the of an average hospital stay.

“I don’t gamble. But I may as well,” she said. “This is gambling.”

Congress’ decision late last year not to extend enhanced marketplace tax credits has boosted the appeal of alternatives to comprehensive insurance — plans like Miller’s, which have lower premiums but don’t meet ACA standards for coverage or consumer protections. Unlike plans sold on the exchanges, these options — some sold by major insurers, others by small companies or nonprofits — can deny claims with few or no legal rights for consumers to appeal. The plans are not required to cover “essential health benefits,” such as preventive care, and can impose annual or lifetime caps on benefits.

There is debate over whether these options help or harm patients. Consumer advocates dismiss them as “junk insurance,” while proponents say restricting alternatives to pricey marketplace plans risks driving up the number of uninsured. Some states, including Kansas and Florida, and the federal government itself have eased regulations on such plans or created incentives to join them, while other states, including California and Massachusetts, have tried to deter enrollment in alternative insurance. Those regulatory guardrails, however, are now being stress-tested as premiums blow out household budgets.

Alternative insurance takes many forms, including short-term policies, which were designed to bridge temporary gaps in coverage and often exclude preexisting conditions, and fixed-indemnity plans, which pay a flat rate per service regardless of how high costs go and are intended for supplemental use. Arrangements in which people pool their money to cover one another’s bills, including faith-based “healthcare sharing ministries,” also provide a cheaper alternative to the marketplace options. Because they are not considered insurance under federal or state law, they are not legally bound to pay for even .

Enrollment data for alternative plans is mostly confidential, but several indicators point to shifts in the market. Recent estimates suggest marketplace enrollment from 2025, and a of people on the exchanges last year found that 5% switched to private, nonmarketplace individual coverage, including plans that don’t comply with the ACA. Covered California, the state’s marketplace, plans to survey former enrollees to find out where they went.

Insurance industry insiders also report that, amid the expiration of subsidies, alternative plans are making a marketing push. Colorado insurance broker Samantha Albritton said that before ACA open enrollment, she saw more marketing from fixed-indemnity plans than in previous years. One healthcare sharing plan, Zion HealthShare, had more than 75,000 members in February — a 50% increase since last June, it said in a statement.

Critics of these alternative plans say the major issues occur when people use them as primary insurance and don’t realize the coverage is inadequate until they need it most. “Humans have bodies that can fail them,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms.

A Premium Spike Drove Her From the Marketplace. An Alternative Left Her Exposed.

Melanie Miller, 59
Harbor Springs, Michigan

To avoid a $553 monthly premium hike this year, retired teacher Melanie Miller replaced her Affordable Care Act coverage with two alternative plans, one that covers preventive services and another that pays fixed amounts for hospital care. She considers her limited hospital coverage a calculated risk given her good health but is now weighing whether to drop the preventive care policy, given her struggles to find in-network providers in her area. “I have not had a good experience with it,” she said.

Killelea and other health insurance experts say that the fine print on these plans can be difficult to parse and that enrollees don’t have the protections of traditional insurance to fall back on. A found that after reading a summary of a sample short-term policy’s benefits and a disclosure that the plan was not ACA-compliant, only half of participants understood that prescription drugs were not covered.

When Jade Ramsey was 24, she declined insurance from her employer due to the cost of the premiums. After experiencing fatigue and unexplained bruising, she sought low-cost coverage from Southern Guaranty Insurance Company through a policy similar to a fixed-indemnity plan.

Two weeks after enrolling, Ramsey, who lives in Arizona, was unable to walk. An emergency room visit led to a six-day hospital stay and a $143,823 bill in 2021. She was diagnosed with acute lymphoblastic leukemia. Her insurer denied coverage for this and other bills, labeling the cancer a preexisting condition and offering no other recourse after rejecting her appeal, she said.

Those bills landed in collections, and her credit score nose-dived. Ramsey said she once visited the ER with chest pain she attributed to the stress of the six-figure debt. She eventually qualified for Medicaid, and her credit score has since recovered even though she never paid off the debt. She said collection agencies still call, but she ignores them.

Southern Guaranty Insurance Company did not respond to requests for comment.

Proponents of alternative insurance argue that stifling these more affordable options will just increase the ranks of those without any coverage.

“People should be able to spend their own money financing healthcare the way that works best for them,” said Brian Blase, president of Paragon Health Institute, an influential conservative think tank. Paragon pushed for ending the enhanced marketplace tax credits, arguing they fueled improper enrollment by heightening incentives for unscrupulous brokers to sign people up without their knowledge.

Robert Godfrey of Clearwater, Florida, appreciates having choices. When Godfrey’s monthly premium payment was slated to jump from $879 to around $1,250 this year, the 64-year-old hair salon owner switched to a $320-a-month membership with Zion HealthShare. Rarely needing medical care, Godfrey viewed the shift to a cheaper plan as a pragmatic choice. “Thank God I’m healthy,” he said.

Healthy and Outraged by Rising Premiums, He’s Betting on Alternative Insurance

Robert Godfrey, 64
Clearwater, Florida

Robert Godfrey, a hair salon owner, says he doesn’t need healthcare beyond preventive services and has never hit his deductible. So last year, when the expiration of enhanced federal subsidies was going to push his marketplace premium payment up 40% — to around $1,250 a month — he walked away. He called it an “outrageous increase.” Just months away from becoming eligible for Medicare, Godfrey opted for a cheaper alternative: a $320-a-month healthcare sharing plan. These arrangements, in which members pool their funds to cover one another’s medical costs, aren’t legally obligated to pay for expenses.

The Trump administration has relaxed regulations on some alternative plans. Last year, federal agencies Biden-era rules on how long short-term plans could last and how they could be marketed, then a marginal advantage in the competition for a share of $50 billion in federal rural health funding if they followed suit.

In a statement, CMS spokesperson Christopher Krepich said the administration is focused on ensuring “access to affordable coverage options, strengthening competition, and reducing unnecessary regulatory burdens, while maintaining appropriate consumer protections.”

State oversight of alternative insurance is a patchwork. In much of the nation, these plans face few restrictions. Many states, including , , and , have eased limits on short-term plans in the wake of the Trump administration’s moves, allowing them to be renewed for up to three years in total.

In Kansas, lawmakers overrode the governor’s veto to in March providing a tax break for people who enroll in healthcare sharing ministries. In her veto, Democratic Gov. Laura Kelly warned that these ministries are unregulated, “which opens the door to all sorts of fraud and abuse.” Kansas House Speaker Daniel Hawkins countered in a news release that “House Republicans believe families should have more flexibility and more control over their healthcare decisions, not fewer options and higher costs.”

Oklahoma weighed a earlier this year, though it did not pass.

Not all states are friendly toward alternative plans. ban short-term policies or have rules restrictive enough to deter insurers from selling them. California and Massachusetts are among the states with the most stringent rules, banning short-term plans and requiring clear warnings to people considering a healthcare sharing ministry in certain circumstances. Both also tax adults who forgo comprehensive coverage, while subsidizing marketplace premiums to encourage enrollment.

Still, the higher premiums will test these guardrails, said Héctor Hernández-Delgado, a director at the National Health Law Program, which advocates for quality healthcare for low-income people. He worries that consumers lured by the plans’ low prices could “be worse off down the road,” saddled with burdensome medical debt.

Now in remission, Ramsey urges those considering cheaper insurance to do careful research. “Make sure it’s covering what you need to be covered,” she said. “It could be too good to be true.”

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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Watch: 8 Health Insurance Terms You Should Know

Mon, 11 May 2026 09:00:00 +0000

Health insurance in the U.S. is notoriously confusing. So we’re covering the basics to make navigating your plan a little easier. We explain the difference between a deductible and an out-of-pocket limit, define copay and coinsurance, and point out where surprise bills can get you in trouble, from out-of-network providers to prior authorizations.

Read more coverage from our “Bill of the Month,” “Health Care Helpline,” and “Priced Out” series:

“How To Make a High-Deductible Health Plan Work for You,” by Jackie Fortiér.
“To Avoid Care Disruptions, Know When the Clock Runs Out on Your Prior Authorization,” by Sarah Boden.
“So Your Insurance Dropped Your Doctor. Now What?” by Bram Sable-Smith.

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That Discount at the Pharmacy Counter May Pack Hidden Costs

Rachel Spears — Thu, 07 May 2026 09:00:00 +0000

Next time you go to the pharmacy, you might be offered a coupon on your prescription drugs. While it may sound like a great deal — with the prospect of saving hundreds of dollars — the decision to accept it is complicated, especially for people with insurance.

Even as prescription drug costs rise, patients with commercial insurance have slowed their use of manufacturer-sponsored drug coupons in recent years, according to April 6 by the Journal of the American Medical Association.

Manufacturers are offering just as many of them, “but still, we see a lot of affordability issues among this commercially insured population,” said So-Yeon Kang, the study’s main author, who is an assistant professor of health management and policy at Georgetown University.

“Patients are at the intersection and battle place between these payers and manufacturers,” she said.

Drug manufacturers distribute copay coupon cards to consumers online or in person at the pharmacy counter. These manufacturer-sponsored coupons are not the same as discount card services from companies like GoodRx, which negotiate lower bulk pricing for prescription drugs, then pass those savings along to the consumer.

Manufacturers issue the coupons to keep their drugs competitive by offering patients short-term savings. Consumers pay less out-of-pocket, often for brand-name drugs. This encourages patients to use the brand-name version of the drug, even when a cheaper, generic version might be available.

Some insurers say this unfairly puts them on the hook for pricier drugs. They say monthly premiums are higher as a result, punishing consumers and patients, not the manufacturers.

So, should you use manufacturer-sponsored prescription drug coupons when they are offered?

The short answer: It depends.

Here are five things to consider:

1. What if you do not have insurance?

If you are uninsured, using a coupon can be a great way to save money, especially if there is no generic version of the drug.

TrumpRx is a new federally funded initiative that acts as a prescription drug coupon dashboard for patients. Some of the coupons come from manufacturers, while others do not. Not every drug has a coupon offer, but the portal will save consumers money on drugs for those that do, especially in the short term.

Michelle Long, a senior policy manager at �鶹Ů�� who studies patient and consumer protections, said people without insurance can save money by using TrumpRx or manufacturer coupons. (�鶹Ů�� is the health policy research, polling, and news organization that includes �鶹Ů�� Health News.)

“I wouldn’t brush it off entirely because it’s got Trump’s name on it,” Long said. “For a lot of people who take certain medications, there really could be some real savings.”

Still, Long said, TrumpRx lists only about 85 drugs, among thousands approved by the FDA. It is important to note that drug coupons have limitations and guidelines. They do not last forever. When they are exhausted, uninsured consumers may have to pay full price for the drug.

2. What if you have commercial health insurance?

For people with insurance, the answer is a little more complicated.

If the drug isn’t covered by your insurance plan or if you intend to pay cash, then the coupon may be the way to go. If not, be wary.

Insurance coverage varies for certain kinds of drugs, such as GLP-1 obesity drugs. Kang’s study found that coupon use by commercial insurance holders on obesity drugs dropped from 54.6% of prescriptions in 2017 to only 2.5% in 2024, even though use of the drugs has been rising in the United States.

She said this reflects the growing number of patients paying cash for the drugs as prices decline, along with insurers’ reluctance to cover them and manufacturers’ shifting focus from coupon distribution to marketing campaigns.

3. What should you do if you expect high medical costs this year?

If you have insurance and anticipate meeting your deductible for the year through health care visits and treatments, consider using the coupons.

Coupons let you pay less out-of-pocket when you visit the pharmacy, but your insurer likely won’t count the value of the coupon toward your deductible. Only use a coupon if there is no generic option available and if you know you’d otherwise hit your deductible.

4. What if you have insurance but low overall medical costs?

The answer will almost always be: Don’t use the coupon.

Unless the drug you are looking for is not covered by your insurance plan, using coupons will put you at risk for higher indirect costs. It’s also often more advantageous to spend toward your deductible.

Watch out for copay adjustment programs that insurers use to discourage the use of drug coupons. They come in two common forms, Long said.

“” allow the use of drug coupons up to their full value, but the amount of the coupon won’t count toward patients’ deductibles or out-of-pocket maximums. That makes it harder for them to reach the threshold at which insurers will pitch in on prescriptions and other medical care. It can also mean a patient will eventually start paying the full cost of the drug because they haven’t yet met their annual deductible.

“Copay maximizers” use a similar technique that also prevents the coupon value from counting toward deductibles. Maximizer programs use a third party to over the course of a year to match the amount of the manufacturers’ coupons.

Insurers sometimes offer the programs to consumers under euphemistic names like “Employee Savings Program” that sound good in theory, but, in reality, take away some of the value of the coupons, Long said.

Initially, consumers will see savings at the pharmacy counter, but they may end up paying more in the long run.

5. What if you’re on Medicaid or Medicare?

Medicare and Medicaid beneficiaries are prohibited from using manufacturer-sponsored coupons.

A federal anti-kickback law makes it illegal to give someone anything of value to influence their decision to purchase something that will ultimately be paid for by a federal health care program. The law also prevents remuneration, which includes waiving copays and charging less than fair-market value for a product.

Manufacturer drug coupons categories.

Some states, notably California and Massachusetts, prohibit or limit the use of manufacturer drug coupons when a generic version of the drug is available — highlighting the tension among manufacturers, health plans, and the government.

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Listen: Cheap Health Insurance Isn’t Always Cheap

Jackie Fortiér — Tue, 21 Apr 2026 09:00:00 +0000

A lot of people choose their health insurance the way they shop for a flight — sort by the lowest price and click “buy.” But what looks like a bargain upfront can come with costly consequences later.

After some federal financial aid expired, many Americans found that high-deductible health plans were the only option they could afford.

In a new episode of NPR’s Life Kit podcast, �鶹Ů�� Health News reporter Jackie Fortiér and podcast host Marielle Segarra discuss what these plans are, and why they can feel so confusing. Imagine paying $100 out-of-pocket for a routine doctor visit that used to cost you $20. Imagine shouldering thousands of dollars in bills before your insurance pays a cent.

Still, for some people — especially those who rarely need medical care — high-deductible plans work. Listen to the episode to explore how timing your care and taking advantage of free preventive services can help you make the most of your coverage.

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Even With Dental Insurance, You Still Could Face a Large Bill

Blake Farmer, Nashville Public Radio — Mon, 23 Mar 2026 09:00:00 +0000

LISTEN: Your dental insurance might not cover what you expect.

Russell Anthony made eight trips to the dentist last year. The 65-year-old retiree in Nashville, Tennessee, hopes to go less often in 2026, but he’s already made a few visits.

“I had a root canal just last week that was like $500,” he said. “The week before that, I had a crown that cost me several hundred dollars. And as we speak, I have a broken tooth, and I have to go and see the dentist soon.”

In all, Anthony — uncle of HealthQ host Cara Anthony — expects to pay about $2,000 for dental care this year, even though he has dental insurance.

“Trying to weigh the cost of when to go to get dental care and paying for it, versus the other needs that I have, is something that’s very important,” Russell Anthony said.

The American Dental Association reported that had dental insurance in 2021. But that coverage does not necessarily protect against large bills. In fact, 1 in 4 adults with dental insurance reported costs as a barrier to care, according to a by �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News.

Here are three things to know to better understand your insurance plan and keep your dental costs as low as possible:

1. Even With Dental Insurance, You’ll Have To Pay for Procedures

Dental plans typically cover routine care in full but pay only a portion of additional work. Benefits vary, but many plans follow the “100/80/50” rule, covering 100% of preventive care like cleanings and exams, 80% of basic procedures like fillings and root canals, and 50% of other major procedures.

Plus, dental plans often have a maximum annual payout, usually between $1,000 and $2,000. Patients are responsible for any costs above that. For example, if your plan maxes out at $1,500 and you need $4,000 of dental treatments, you will be on the hook for the difference of $2,500.

2. Facing a Big Dental Bill? You Have Options

It might feel uncomfortable to talk about finances directly with a dentist, but it’s helpful to be up-front about what you can afford.

Many dentist offices offer financial options to help patients manage the cost of care, including pretreatment estimates and payment plans. If you get an estimate that seems especially high, talk through the items and consider getting a second opinion. It never hurts to ask the office for a discount.

If you need a lower-cost alternative, consider looking into dental schools, which often offer discounted care, or , which use sliding scales based on a patient’s income.

3. Seeing Your Dentist Regularly Can Help Keep Costs Low

Sarah Olim, a general dentist in Katy, Texas, encourages her patients to come in for visits every six months.

“The best thing that you can do to mitigate the cost of going to the dentist is make sure that you are going regularly and trying to take care of things early,” she said.

Olim welcomes patients no matter how long it’s been since their last visit. But she cautioned that patients who wait a few years between visits may find their appointments are more expensive and more uncomfortable.

The reason? Dental problems often don’t resolve on their own. For example, a small cavity that needs a quick filling might cost $200. If left untreated, it could turn into a larger issue requiring a root canal and crown — and cost thousands.

Your dentist will also encourage you to follow the best preventive maintenance: brushing your teeth for two minutes twice a day. Olim tells her patients to use a timer or listen to a favorite song to make sure they brush long enough.

People and Policy

Federal lawmakers have tried to increase children’s access to dental insurance. Under the Affordable Care Act, dental care is considered , so health insurance plans on the individual marketplace must offer dental coverage for those 18 or younger. State Medicaid programs are also for children.

Emily Siner at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and �鶹Ů�� Health News.

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Millions of Americans Are Expected To Drop Their Affordable Care Act Plans. They’re Looking for a Plan B.

Blake Farmer, Nashville Public Radio — Mon, 12 Jan 2026 10:00:00 +0000

Robert Sory feeds a treat to a blind, albino raccoon named Cricket. Russian foxes, African porcupines, emus, bobcats, and goats are also part of his menagerie. (Blake Farmer/WPLN)

It’s feeding time for the animals on this property outside Nashville, Tennessee. An albino raccoon named Cricket reaches through the wires of its cage to grab an animal cracker, an appetizer treat right before the evening meal.

“Cricket is blind,” said Robert Sory, who is trying to open a nonprofit animal sanctuary along with his wife, Emily. “A lot of our animals come to us with issues.”

The menagerie in Thompson’s Station includes Russian foxes, African porcupines, emus, bobcats, and some well-fed goats.

The Sorys are passionate about their pets and seem to put the animals’ needs before their own.

Both Robert and Emily started 2026 without health insurance.

Robert had been covered through a marketplace plan subsidized through the Affordable Care Act. His share of the monthly premiums was $0. When he looked up the rates for 2026, he saw that a barebones “bronze”-level plan would cost him at least $70 a month. He decided to forgo coverage altogether.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” he said. “It’s not affordable.”

Emily and Robert Sory are trying to open a nonprofit animal sanctuary at their home in Thompson’s Station, Tennessee. They have forgone health insurance this year and are looking for ways to pay for their care without coverage. (Blake Farmer/WPLN)

Dumping Coverage

Marketplace plans from the Affordable Care Act no longer feel very affordable to many people, because Congress did not extend a package of enhanced subsidies that expired at the end of 2025. Last week, the House did pass legislation to extend the expired subsidies, and negotiations have moved to the Senate. Without a deal, an estimated will go without coverage this year.

But even without a health plan, people will still need medical care. Many, like the Sorys, have been thinking through their plan B to maintain their health.

The Sorys both lost jobs in November, within days of each other. Robert worked as a farmhand. Emily worked at a staffing firm and lost her insurance along with her position.

“It’s a horrible, horrible market right now. Really tough,” she said.

The first time she had to pay out-of-pocket for her three monthly prescriptions, the cost was $184.

“To equate that to kind of how we think about it, you’re talking about 350 pounds of food for these animals,” Robert said. He pointed to his bobcats, who eat only meat.

A bobcat waits for a meaty meal served by Robert Sory. (Blake Farmer/WPLN)

Workarounds for the Newly Uninsured

To keep kibble in the food bowls, the Sorys are prepping for an uninsured future. They see the same psychiatrist and met with him to make a plan. He was willing to work with them by charging $125 per visit. They’ll have to go every three months to keep their prescriptions current.

And if other medical problems emerge? They’re hoping for the best.

“I’m not somebody who gets sick super often, thank God,” Robert said. “And if I do, generally I go to an emergency room where they’re going to bill me later.” Robert said he would arrange a repayment plan for bills like that.

Emily has costly health conditions and has already taken on substantial medical debt. “It’s just sitting there, and I’ve racked up money,” she said. “But I’ve had to go to the doctor.”

Donated Drugs and Sliding Scales

Hospitals and clinics are of newly uninsured patients. They’re also concerned that people won’t know about alternative ways to get medical care.

“We don’t have marketing dollars, so you’re not going to see big billboards or radio ads,” said , CEO of in Nashville. It’s one of the country’s 1,400 federally qualified health centers, also called FQHCs.

FQHCs are by the federal government. Although they do not usually offer free care, their fees tend to be lower or on a sliding scale.

Uninsured people who get care receive a bill, Beard said, “but the bill will be based on their ability to pay.”

FQHCs often have on-site pharmacies, and some offer prescription medications free of charge through a partnership with the , a Nashville-based nonprofit.

Many hospital pharmacies also partner with the nonprofit, which has donated by pharmaceutical companies to 277 sites in 38 states. must make the medicine available free of charge to people without insurance who have annual incomes below 300% of the federal poverty limit.

The organization primarily sources medications for chronic conditions such as high blood pressure, diabetes, and mental health. Demand is expected to outstrip supply in the new year, according to .

“We’re projecting and engaging with our manufacturers and asking them, ‘Are you willing to help support, for this future status that we are anticipating?’” he said. “By and large,” he said, pharmaceutical companies have said they’re willing to step up.

“It’s a continuous conversation that we’re having,” Cornwell said.

Emily Sory readies the foxes’ supper. (Blake Farmer/WPLN)

A Medicaid ‘Gap’ in 10 States

Hospitals will also have to find a way to care for more patients who cannot pay. Industry groups such as the have been vocal about the threat to hospitals’ financial health and have urged Congress to extend the enhanced subsidies, which take the form of tax credits.

The impact might be most acute in states like Tennessee that have not expanded Medicaid to cover people who work but do not have job-based insurance and cannot afford it on their own.

Ten states have chosen not to expand Medicaid to uninsured, low-income adults — an optional provision of the ACA that is mainly paid for by federal funds.

This Medicaid “gap” is , at the high end of the spectrum, by as much as 65% in Mississippi and by 50% in South Carolina, according to the Urban Institute.

As Emily Sory pets a Russian fox, she admits she is keenly aware that she will soon become part of this growing population. After all, her last job involved health care staffing. Her mother is a nurse.

“I understand the system. And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad,” she said. “But at the same time, I don’t have the money to pay it.”

This article is from a partnership that includes , , and �鶹Ů�� Health News.

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New Year, Same Health Fight

Thu, 08 Jan 2026 21:15:00 +0000

The Host

Julie Rovner �鶹Ů�� Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of �鶹Ů�� Health News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

Congress returned from its holiday break to the same question it faced in December: whether to extend covid-era premium subsidies for health plans sold under the Affordable Care Act. The expanded subsidies expired at the end of 2025, leaving more than 20 million Americans facing dramatically higher out-of-pocket costs for insurance.

Meanwhile, the Robert F. Kennedy Jr.-led Department of Health and Human Services announced an overhaul of the federal vaccine schedule for children, reducing the number of diseases for which vaccines are recommended from 17 to 11.

This week’s panelists are Julie Rovner of �鶹Ů�� Health News, Sarah Karlin-Smith of Pink Sheet, Alice Miranda Ollstein of Politico, and Lauren Weber of The Washington Post.

Panelists

Sarah Karlin-Smith Pink Sheet

Alice Miranda Ollstein Politico

Lauren Weber The Washington Post

Among the takeaways from this week’s episode:

The conservative movement to end abortion access nationwide has ensnared a last-ditch effort in Congress to help millions afford their health plans. As lawmakers consider a compromise to revive enhanced federal tax credits for ACA plans, some Republicans are arguing that the tax credits should be barred from subsidizing any plan that covers abortion care — even though the federal dollars would not be used to pay for abortions anyway. That change would force some states to choose between dropping their requirements for insurance coverage for abortion care or forgoing that federal assistance.
President Donald Trump this week urged Republicans in Congress to be “flexible” about abortion restrictions. Meanwhile, his health policies so far are not yielding notable benefits for Americans, with most of the savings from his high-profile pharmaceutical deals going to the federal and state Medicaid programs. And the $50 billion federal funding boost for rural health — intended to counterbalance nearly $1 trillion in expected Medicaid spending cuts — is unlikely to make a meaningful dent, in no small part because rural facilities are barred from using the money for general expenses.
While Kennedy announced an overhaul of federal recommendations for childhood vaccines, the action’s impact on vaccination rates and insurance coverage will depend in large part on how various states react, since states are the ones that impose mandates — such as for school enrollment — and regulate some insurers. Nonetheless, it is likely to result in a patchwork of state policies, which is problematic for public health efforts.
Federal health officials also unveiled new nutritional guidelines, turning the decades-old food pyramid upside down. Some of the recommendations adhere to scientific findings, such as cutting added sugar from one’s diet. Others are more controversial, particularly the suggestion that Americans should eat more red meat and the softening of guidelines on saturated fats.

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

Julie Rovner: �鶹Ů�� Health News’ “,” by Fred Schulte.

Alice Miranda Ollstein: SFGate’s “,” by Lester Black and Stephen Council.

Sarah Karlin-Smith: ProPublica’s “” by Anna Maria Barry-Jester and Brett Murphy.

Lauren Weber: The Washington Post’s “,” by Rachel Roubein, Lena H. Sun, and Lauren Weber.

Also mentioned in this week’s podcast:

NBC News’ “” by Berkeley Lovelace Jr.
Stat’s “,” by Isabella Cueto and Sarah Todd.
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Click to Open the transcript Transcript: New Year, Same Health Fight

To Knock Down Health-System Hurdles Between You and HIV Prevention, Try These 6 Things

Zach Dyer — Mon, 05 Jan 2026 10:00:00 +0000

(Oona Zenda/�鶹Ů�� Health News)

When Matthew Hurley was looking to take PrEP to prevent HIV, the doctor hadn’t heard of the medicine, and when he finally did prescribe PrEP, the bills sent to Hurley were expensive … and wrong. “I decided to write in because the process was really super frustrating.” At one point, Hurley asked, “Am I just going to stop this medication to stop having to deal with these coding issues and these scary bills?”

— Matthew Hurley, 30, from Berkeley, California

A couple of years ago, Matthew Hurley got the kind of text people fear.

It said: “When was the last time you were STD tested?”

Someone Hurley had recently had unprotected sex with had just tested positive for HIV.

Hurley went to a clinic and got tested. “Luckily, I had not caught HIV, but it was a wake-up call,” they said.

That experience moved Hurley to seek out PrEP, shorthand for preexposure prophylaxis. The antiretroviral medication greatly reduces the chance of getting HIV, the virus that causes AIDS. The therapy is at protecting people against sexual transmission when taken as prescribed.

Hurley started PrEP and all was well for the first nine months — until their health insurance changed and they started seeing a new doctor: “When I brought PrEP up to him, he said, ‘What’s that?’ And I was like, oh boy.”

Hurley, who is a librarian, went into teaching mode. They explained that the PrEP regimen they’d been on required daily pills and lab work every three months to look out for breakthrough infections or other health issues.

Hurley was surprised they knew more about PrEP than the physician. The FDA approved the first drug, Truvada, , and Hurley lives in the San Francisco Bay Area, a place with one of the of LGBTQ+ people in the nation and a of HIV and health care activism. Hurley said older friends and acquaintances who survived the AIDS epidemic shared the horror of living through a time when there was no effective treatment or drugs for prevention. Deciding to take PrEP felt like an empowering way to protect their health and their community.

So Hurley pushed the doctor, and after the physician did his own research, he agreed to prescribe PrEP.

Hurley got the care they needed, but they had to be the expert in the exam room.

“That’s a big burden,” said Beth Oller, a family medicine physician and board member of GLMA, a national organization of LGBTQ+ and allied health care professionals focused on health equity. “You really want someone you can just go in and talk [to] about your health concerns without feeling like you are having to educate and advocate for yourself at every turn.”

Oller said many queer people have had during health care visits.

“I have a lot of patients who had not done preventive care for years because of the medical stigma,” she said.

Billing Headaches

Clearing the access hurdles to HIV prevention medicine was just the beginning. Hurley started receiving a string of bills for PrEP-related care. Blood test: $271.80. Office visit: $263.

Again, Hurley was surprised. They knew — even if the billing office didn’t — that under the most private insurance plans and Medicaid expansion programs are PrEP and ancillary services, , as preventive with no cost sharing.

The bills for doctor visits and blood draws piled up.

Hurley would appeal the bill and get a denial almost every time. Then, they would appeal again.

Hurley shared a series of appeal letters for one service, in which the billing office acknowledged that blood work had been initially incorrectly coded as diagnostic. Once that was corrected, Hurley said, the insurer paid for the service.

That might sound quick or easy to resolve, but Hurley said it took “forever to get through the process.” They dealt with at least six incorrect bills over several months. Hurley estimated they spent more than 60 hours contesting the bills.

During that time, Hurley said, the billing department “is continuing to send me emails and bills that are saying, You’re overdue. You’re overdue. You’re overdue.”

Fed up with the hassles, Hurley decided to find a health provider (and billing office) better informed about PrEP. They settled on the AIDS Healthcare Foundation. The care team there was able to discuss the pros and cons of different PrEP regimens and knew how to navigate the formulary for Hurley’s insurance.

Hurley hasn’t gotten an unexpected bill since.

But siloing sexual health care and PrEP off from primary care hasn’t been ideal.

“I have multiple organizations that I have to deal with to get my holistic health dealt with,” Hurley said.

A provider doesn’t need to be an HIV specialist, an infectious disease expert, or a physician to prescribe PrEP. The Centers for Disease Control and Prevention encourages primary care providers to treat PrEP like .

To avoid some of the headaches Hurley faced, try these tips:

1. Find out if PrEP is right for you.

The CDC estimates Americans could benefit from HIV prevention drugs, but just over a quarter of that group have been prescribed them.

“Not enough people know about PrEP, and there are a number of people who know about PrEP but do not realize it’s for them,” said Jeremiah Johnson, executive director of PrEP4All, an organization dedicated to universal access to HIV prevention and medication.

According to the CDC’s clinical guidelines, PrEP can be prescribed as part of a preventive health plan to . It’s especially recommended for people who don’t use condoms consistently, intravenous drug users who share needles, men who have sex with men, and people in relationships with partners living with HIV or whose HIV status is unclear.

The vast majority of PrEP users are men. There are big race, gender, and geographical of HIV and the populations taking the prevention medicine. For example, based on the patterns of new infection in the U.S., a group that would benefit from PrEP is cisgender Black women, whose gender identity aligns with their sex assigned at birth.

2. Don’t assume your provider knows about PrEP.

If your doctors aren’t well informed, start by . There are also clinical guidelines and information you can share with your provider. Check your state or local health department for a how-to guide for prescribing PrEP. For example, the New York State Department of Health AIDS Institute has information .

The , but many of the agency’s websites dealing with LGBTQ+ health are in flux. Under the Trump administration, some HIV/AIDS resources have been taken down from federal websites. Others now have : “This page does not reflect biological reality and therefore the Administration and this Department rejects it.”

3. Get lab work in-network.

Johnson said Hurley’s experience with billing mistakes is common. “The lab expenses in particular end up being very tricky,” Johnson said.

For example, a doctor’s office may mistakenly code the lab work required for PrEP as a instead of preventive care. Patients like Hurley can end up with a bill they shouldn’t have to pay. If your doctor’s office is making mistakes, share the from NASTAD, an association of public health officials who administer HIV and hepatitis programs.

Try to get your lab work done in-network. If the lab is out-of-network, Johnson said, it can be difficult to appeal.

If the bills keep coming, appeal them. And if you can’t resolve the dispute, Johnson said, file a complaint with the agency that regulates your insurance plan.

4. Look for ways to save.

There are different kinds of PrEP. There are lower-cost, generic versions of Truvada, for example, sold as emtricitabine/tenofovir disoproxil fumarate, often shortened to FTC/TDF. Newer PrEP drugs have list prices in the thousands of dollars. Check your insurance formulary and ask your doctor to prescribe medicine your plan will cover.

With many health care premiums dramatically increasing and millions at risk of losing Medicaid coverage, many people may go without health insurance this year. Drug manufacturers such as and have assistance programs for qualifying patients. If you have to pay out-of-pocket, prescription price comparison websites, like GoodRx, can help you find the pharmacies with the cheapest price.

5. Consider telehealth.

Telehealth is an option if you don’t live near an affirming provider or are looking for a more private way to get PrEP. In 2024, roughly 1 in 5 people on PrEP used telemedicine. Online pharmacies like and offer PrEP without an in-person appointment, and lab work can be done at home. Some telehealth options have ways to if you’re uninsured.

Telehealth can also broaden the number of doctors who are ready to prescribe PrEP. And some patients say speaking with a remote provider feels like a safer setting to talk about sexual health. “They’re in the comfort of their own bedroom or living room but can interface virtually with a provider. It can open up a lot of doors for honesty and trust,” said Alex Sheldon, executive director of GLMA.

6. Seek out affirming care.

GLMA created the , a searchable database of health care providers across the nation who identify as queer-friendly. As Hurley discovered, living in a major metro area is no guarantee your doctor is up to date on LGBTQ+ health care.

Ask locals you trust for recommendations. You might be surprised to find good options nearby.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and �鶹Ů�� Health News.

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Out-of-Pocket Pain From High-Deductible Plans Means Skimping on Care

Charlotte Huff — Tue, 09 Dec 2025 10:00:00 +0000

David Garza sometimes feels as if he doesn’t have health insurance now that he pays so much to treat his Type 2 diabetes.

His monthly premium payment of $435 for family coverage is roughly the same as the insurance at his previous job. But the policy at his current job carries an annual deductible of $4,000, which he must pay out-of-pocket for his family’s care until he reaches that amount each year.

“Now everything is full price,” said the 53-year-old, who works at a warehouse just south of Dallas-Fort Worth. “That’s been a little bit of a struggle.”

To reduce his costs, Garza switched to a lower-cost diabetes medication, and he no longer wears a continuous glucose monitor to check his blood sugar. Since he started his job nearly two years ago, he said, his blood sugar levels have inched upward from an A1c of 7% or less, the target goal, to as high as 14% at his most recent doctor visit in November.

“My A1c is through the roof because I’m not on, technically, the right medication like before,” Garza said. “I’m having to take something that I can afford.”

Plans with high deductibles — the amount that patients must pay for most medical care before insurance starts pitching in — have become increasingly common. In 2024, participating in medical care plans were offered this type of insurance, up from 38% in 2015, according to federal data. Such plans are also offered through the Affordable Care Act marketplace.

With and many of the subsidies to help people pay for them poised to expire at year’s end, more people face tough choices as they weigh monthly premium costs against deductibles. To afford insurance at all, people may opt for a plan with low premium payments but with a high deductible, gambling that they won’t have any medical crises.

But high-deductible plans pose a particular challenge for those with chronic conditions, such as the who live with Type 1 or Type 2 diabetes. Adults with diabetes who are involuntarily switched to a high-deductible plan, compared with adults on other types of insurance, face an 11% higher risk of being hospitalized with a heart attack, a 15% higher risk of hospitalization for a stroke, and that they’ll go blind or develop end-stage kidney disease, according to a study published in 2024.

“All of these complications are preventable,” said , the study’s lead author.

Care vs. Cost

The initial rationale behind such high-deductible plans was to encourage people to become wiser health care shoppers, said McCoy, an associate professor of medicine at the University of Maryland School of Medicine in Baltimore. And they can be a good fit, proponents say, for people who don’t use a lot of medical care or who have cash on hand for a health crisis.

But while people with an excruciating earache will seek care, McCoy said, those with unhealthy blood sugar levels might not feel as urgent a need to seek treatment — despite the potential long-term damage — given the acute financial pain.

“You have no symptoms until it’s too late,” she said. “At that point, the damage is irreversible.”

Overall, medical care for people with diabetes costs insurers and patients an average of the disease, according to an analysis. Type 2 diabetes, the more common form, is diagnosed when the body can no longer process or produce enough insulin to adequately regulate blood sugars. With Type 1, the body can’t produce insulin. Those with the disease may end up on the financial hook not just for insulin and other types of medication but for related equipment.

Mallory Rogers, whose 6-year-old daughter, Adeline, has Type 1, calculates that it costs roughly $1,200 a month for insulin, a pump, and a continuous glucose monitor. That figure doesn’t include the cost of emergency supplies needed in case Adeline’s technology malfunctions. Those include another type of insulin, blood-testing strips, and a nasal spray that’s nearly $600 for a two-pack of vials — supplies that must be replaced once a year or more frequently.

“If she doesn’t have insulin, it would become an emergency situation within two hours,” said Rogers, a technology consultant who lives in Sanford, Florida. Rogers has been saving for the coming year when her daughter moves to the high-deductible health plan offered by Rogers’ employer, which has a $3,300 deductible for family coverage.

To treat her diabetes, Adeline relies on insulin, a pump, and a continuous glucose monitor that together cost about $1,200 a month, not including emergency supplies in case her technology malfunctions. (Mallory Rogers)

Taxing Decisions

Many insurance plans carry increasingly high deductibles. But to be defined as a high-deductible health plan — and thus be eligible to offer a health savings account — a plan’s deductible for 2026 must be , according to IRS rules.

Health savings accounts enable people to squirrel away money that can be rolled over from year to year to be used for eligible medical expenses, including prior to meeting a deductible. Such accounts, available through a plan or employer, can provide tax benefits. The contributions are limited to $4,400 individually and $8,750 for a family in 2026, and employers may contribute toward that total. Rogers’ employer pays $2,000 spread out over the year, and Garza’s contributes $1,200.

Rogers recognizes that she’s fortunate to have accumulated $7,000 so far in her health savings account to prepare for her daughter’s insurance shifting to Rogers’ plan.

“Adding a financial burden to an already very stressful medical condition, it hurts my heart,” she said, reflecting on those who can’t similarly stockpile. “Nobody asks to have diabetes, Type 1 or Type 2.”

The median deductible for employer health insurance plans was $2,750 in 2024, but deductibles can run $5,000 or higher, said George Huntley, CEO of both the and .

When deductibles are too high, Huntley said, routine maintenance is what patients skimp on: “You don’t take the drug that you’re supposed to take to maintain your blood glucose. You ration your insulin, if that’s your scenario. You take pills every other day.”

Garza knows he should do more to control his blood sugar, but financial realities complicate the equation. His previous health plan covered a newer class of diabetes medication, called a GLP-1 agonist, for $25 a month. He wasn’t charged for his remaining medications, which included blood pressure and cholesterol drugs, or his continuous glucose monitor.

With his new insurance, he pays $125 monthly for insulin and several other medications. He doesn’t see his endocrinologist for checkups more than twice a year.

“He wants to see me every three months,” Garza said. “But I told him it’s not possible at $150 a pop.”

Plus, he typically needs lab testing before each visit, an additional $111.

In 2026, the deductible for a “silver”-level plan on the marketplace will average $5,304 without cost-sharing reductions, according to an analysis from �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News. For a . An annual visit and some preventive screenings, such as a mammogram, would be covered free of cost to the patient.

Moreover, people , whether through their employer or the marketplace, should figure out their annual out-of-pocket maximum, which still applies after the deductible is met, Huntley said.

Garza’s family policy requires him to pay 20% until he reaches $10,000, for example.

Given Garza’s high blood sugar levels, his doctor prescribed a fast-acting form of insulin to take as needed with meals, which costs an additional $79 monthly. He planned to fill it in December, when he’s responsible for only 20% of the cost after he has hit his deductible but not yet reached his out-of-pocket maximum.

Garza likes his job despite its health plan, saying he’s never missed a day of work, even recently when he had a stomach bug. As of late 2025, he remained conflicted about whether to sign up for health insurance when his company’s enrollment period rolls around in mid-2026.

He worries that dropping insurance would place his family too much at risk if a major medical crisis struck. Still, he pointed out, he could then use the money he now spends on monthly premiums to directly pay for care to better manage his diabetes.

“I’m just stuck, to be honest with you,” he said.

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Medicaid Work Rules Exempt the ‘Medically Frail.’ Deciding Who Qualifies Is Tricky.

Samantha Liss — Mon, 01 Dec 2025 10:00:00 +0000

Eliza Brader worries she soon will need to prove she’s working to continue receiving Medicaid health coverage. She doesn’t think she should have to.

The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to �鶹Ů��.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Brader worries the additional red tape will cause her to lose her Medicaid coverage. “It’s terrifying,” she says. “I already have fought so hard to get my health care.” (Chris Bergin for �鶹Ů�� Health News)

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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