Federal Exchange Archives - ýҕl Health News /news/tag/federal-exchange/ Fri, 16 Jan 2026 21:36:10 +0000 en-US hourly 1 https://wordpress.org/?v=6.8.5 /wp-content/uploads/sites/2/2023/04/kffhealthnews-icon.png?w=32 Federal Exchange Archives - ýҕl Health News /news/tag/federal-exchange/ 32 32 161476233 What the Health? From ýҕl Health News: Culture Wars Take Center Stage /news/podcast/what-the-health-429-obamacare-abortion-pill-mifepristone-hhs-january-15-2026/ Thu, 15 Jan 2026 20:20:00 +0000 /?p=2143097&post_type=podcast&preview_id=2143097 The Host Julie Rovner ýҕl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ýҕl 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.

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

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

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

Panelists

Anna Edney Bloomberg News Joanne Kenen Johns Hopkins University and Politico Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

  • The Washington Post’s “,” by Paul Kane.
  • HealthAffairs’ “,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
  • Politico’s “,” by Alice Miranda Ollstein.
  • JAMA’s “,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.
click to open the transcript Transcript: Culture Wars Take Center Stage

[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 ýҕl Health News and WAMUpublicradio in Washington, D.C., and welcome toWhat the Health?I’mJulie Rovner, chief Washington correspondent for ýҕl Health News, andI’mjoined by some of the best and smartest health reporters in Washington.We’retaping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go.

Today,we are joined via video conference by Anna EdneyofBloomberg News.

Anna Edney:Hi, everyone.

Rovner:Alice [Miranda]Ollsteinof Politico.

Alice MirandaOllstein:Hello.

Rovner:AndJoanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.

Joanne Kenen:Hi, everybody.

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

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

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

Ollstein:Yeah, so itwasn’ta good sign when the person who hassort of comeout as a leader of these bipartisan negotiations,Ohio Sen.BernieMoreno, at first came outvery strongand said,We’rein the end zone.We’reverycloseto a deal.We’regoing to havebilltext.And that was several days ago, and nowthey’resaying thatmaybethey’llhave something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and,from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before.There isnotagreement on how Obamacare currently treats abortion, and thus there can be no agreement on how itshouldtreat abortion.

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

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

Ollstein:Well,you’rehearing a lot more optimism from lawmakers about the spending bill than you are about a[n]Obamacare subsidy deal or any of the other things thatthey’refighting about. And I would say,on thespending,I think the much bigger fightsare going to be outside the health care space. I thinkthey’regoing to be about immigration, with everythingwe’reseeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts.On health,yes, I thinkyou’veseen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, itimpactstheir districts and their voters too. So that makes sense.

Kenen:We’vealso seen the Congress vote for spending that the administrationhasn’tbeen spent.SoCongress has just voted on a series of things about science funding and otherhealth-relatedissues, including global health. But it remains to be seen whether this administration takes appropriations as law orsuggestion.

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

Edney:I thinkit’scertainly looking more likely than the subsidies thatwe’vebeen talking about. But I do thinkwe’vebeen here before several times, not just at the end of last year—but,like with these PBM reforms, I feel like they have certainly gotten to a point whereit’slike,Thisis happening.It’sgonnahappen.And, I mean,it’sbeen years, though, thatwe’vebeen talking about pharmacy benefit manager reforms in the space of drug pricing.So basically, youknow, fromwhen[President Donald]Trump won. And so, you know, I say this with, like, a huge amount of caution:Maybe.

Rovner:Yeah, we will, butwe’llbelieve it when…we get to the signing ceremony.

Ollstein:Exactly.

Rovner:Well, back to the Affordable Care Act, for which enrollment in most statesendtoday.We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies.Sign-ups on the federal marketplace are down about1.5million from the end of last year’s enrollment period, andthat’sbefore most peoplehave topay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans.I’mwondering if these early numbers—which areactually strongerthan many predicted, with fewer peopleactually droppingcoverage—reflect people who signed up hoping that Congress mightactually renewthe subsidies this month. Since we kept saying that waspossible.

Ollstein:I would bet that most people are not following theminutiae ofwhat’shappening on Capitol Hill and have noideathe messwe’rein,andwhy,andwho’sresponsible. I would love to be wrong about that. I wouldlove foreveryone to be super informed.Hopefullytheylistento this podcast. But you know, I think that a lot of people justsign upyear after year andaren’tsure ofwhat’sgoing on untilthey’rehit with the giant bill.

Rovner:Yeah.

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

Kenen:But… I think what Julie saidisit’s…the follow-up is less than expected. But for the reasons Julie justsaidis that you haven’t gotten your bill yet.Soeither youhaven’tbeen paying attention, oryou’rean optimist and thinkthere’llbe a solution.So, andpeople might even pay their first bill thinking thatthere’llbe a solution next month, or thatwe’reclose. I mean, I would thinkthere’dbe drop-off soon, but there might be a steepercliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just becausethey’renot as bad as somepeopleforecastdoesn’tsay that this is going to be a robust coverage year.

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

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

Kenen:This 17%-18% of GDP has beenpretty consistent, whichdoesn’tmeanit’sgood;it just meansit’sbeen around that level for many, many, many years. Despite all the talk abouthow it’sunsustainable,it’sbeen sustained,with pain, but sustained.$5.7 trillion,even ifyou’vebeen doingthisa long time…

Rovner:It’s$5.3 trillion.

Kenen:$5.3 trillion.It’sa mind-bogglingnumber.It’sa lot of dollars!So the ACA made insurance more—the out-of-pocket cost of insurance for millions of Americans, 20-ish million—but the underlying burden we’ve not solvedthe — to use the word of the moment, the“affordability”crisis in healthcare is still with us and arguably getting worse. But like, I thinkwe’resort of numb. These numbers are just so insane, and yet you sayit’sunsustainable, but…I think itwasUwe’sline, right?

Rovner:It was, it was a famousUweReinhardt line.

Kenen:No,it’ssustainable, ifwe’resustaining it at a high—ineconomically—zany price.

Rovner:Right.

Kenen:And, like, the other thing is, like, where is the money?Right? Everybody in healthcare says theydon’thave any money, so Ican’tfigure out who has the$5 trillion.

Rovner:Yeah, well, it’s not…it does not seem to be the insurance companies as much as it is,you know, if you look at these numbers—and I’ll post a link to them—you know, it’s hospitals and drug companies and doctors and all of those who are part of the healthcare industrial complex, as I like to callit.

Kenen:Allof them say theydon’thave enough.

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

Ollstein:So, you know, in a sense, this was a show hearing. Therewasn’ta bill under consideration. Theydidn’thave anyone from the administration to grill. Andsothis is justsort of yourtypicaleach sidetries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside—they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill.Their bigger goal is outlawing all abortion,but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting.Andsothey’refrustrated that, you know, both[RobertF.]Kennedy[Jr.]and[Marty]Makary have promised some sort of review or action on the abortion pill, and they say,Wewant to see it.Why haven’t you done it yet?AndsoI think that pressureis only going to mount, and this hearing was part of that.

Rovner:I was fascinated by the Louisianaattorneygeneral saying,basically,thequiet partout loud, which is thatwe banned abortion, but because of these abortion pills, abortions are still going up in our state.That was the first time IthinkI’dheard an official say that. I mean that,if you wonder whythey’regoing after the abortion pill,that’swhy—because theystruck downRoe[v. Wade]and assumed that the number of abortions would go down, and it really has not, has it?

Ollstein:That’sright. And so not only are people increasingly using pills toterminatepregnancies, butthey’reincreasingly getting them via telemedicine.And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal.You know, a lot of people just really prefer the telemedicine option,whether becauseit’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons.Sothe right—you know, again, including senators like Cassidy, but also these activist groups—they’resaying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. Andthey’repretty openabout saying that.

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

Ollstein:Well, just likeI’mskeptical thatthere’sany compromise that can be found on the Obamacare subsidies,there’sjust no compromise here. You know, you have the groups that are making these arguments about the pills’safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say itcan’tbe health care ifit’sdesigned to end a life, and that kind of rhetoric. Andsothe focus on the rate of complication…I mean,I’mnot sayingthey’renot genuinely concerned. They may be, but, you know, this is one of many tacticsthey’reusing to try to curb access to the pills.Soit’sjust one argument in their arsenal.It’snottheir,like,primary driving, overriding goal is, is the safety which, like you said, has been wellestablishedwith many, many peer-reviewed studies over the last several years.

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

Ollstein:It was one pot of moneythey’refighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over lastsummer,those are still in place. And sothat’san order of magnitude more than this pot ofTitleXfamily planning money that they just got back. So that aside,I’veseen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, andit’sa lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to apatient,you can thensubmitfor reimbursement. Andsoif the clinic’s not there,it’snot like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.

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

OK,we’regoing to take a quick break. We will be right back.

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

Edney:Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here thatwe’reeven talking about. And so those who are against it have done an effective job of making thatthe issue. And so there…who support gender-affirming care, who havelooked intoit, would see that a lot of this is hormone treatment, things like that, to drugs…

Rovner:Puberty blockers!

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

Kenen:I think,like,from the beginning, because, like, five or six years ago was the first time I wrote about this. Theplaybook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and nowthey’retalking about it in protecting children’s health. And,as Anna said,they’reusing words like mutilation. Puberty blockers are notmutilation. Pubertyblockers are a medication that delays the onset of puberty, and it is not irreversible.It’slike abrake. You take your foot off the brake,and puberty starts.There’ssome controversy about what age and how long, andthere’ssomepossible bonedamage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now—most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids,cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body.Soyou know, I think it’s really important to repeat…the point that Anna made, you know, 12-year-olds are not getting major surgery.Very few minors are, and when they are,it’scloser… theymay be under 18,it’srare. But ifyou’reunder 18,you’recloser to 18,it’slater inteens. Andit’snot like you walk into an operating room and say, you know,do this to me.There’syears of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania,in particular.This is something that peopledon’tunderstand and getvery upsetabout, and the inflammatorylanguage,it’snot creating understanding.

Rovner:We’llsee howthis one playsout. Finally, this week, things at the Department of Health and Human Servicescontinuesto be chaotic. In the latest round of“we’re cutting you off because you don’t agree with us,”the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to granteescancelingtheir fundingimmediately.It’snot entirely clear how many grants or how much money was involved, but itappeared to besomethingin the neighborhood of$2 billion—that’saround a fifth of SAMHSA’sentire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then,Wednesday night, after a furious backlash from Capitol Hill andjust about everymental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts.Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?

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

Rovner:Ididn’tcount, but I got dozens of emails yesterday.

Edney:Yeah.

Rovner:My entire email box was overflowing with peoplebasically freakingout about these cutsto SAMHSA. Joanne,you wantedto say something?

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

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

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

Kenen:Like, you know, the game we played when we were kids, remember,“RedLight-GreenLight,”you know, you’drun in one direction, you run back. And if you were8years old, it would end with someone crying. And that’ssort of thewaywe’rerunning the governmentthesedays[laughs].The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. Youcan’teven keep track. Youdon’teven know what email to use ifyou’retrying tokeepintouchwith themanymore. The churn,with what logic?It’s, as Alice said,justmore expensive, but it’s,it’salso just…likeyoucan’tget your job done.Even if you want a smaller government, which many of conservatives and Trump people do,you still want certain functions fulfilled.But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring.I mean, the American public is not against research, and the American public is not against keeping people alive.You know, the inconsistency is pretty mind-boggling.

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

Rovner:And all the institutional memorythat’swalking out the door. I mean,more people—and toAlice’s point about how thishasn’tsaved money—more people have taken early retirement than havebeen actually, youknow,RIF’dor fired or let go. I mean, they’ve just…a lot of peoplehave basically, includinga lot of leaders of many of these agencies, said,Wejustdon’twant to be here under these circumstances.Bye.Assuming at some point this government does want to use the Department of Health and Human Services to get things done,there might not be the personnel around to actually effectuate it.But we will continue to watch that space.

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

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor atKFFHealthNews and originator of our“Bill of the Month”series, which in itsnearly eightyears has analyzednearly $7 millionin dubious, infuriating,or inflated medical charges. Libby also wrote the latest“Bill of theMonth,”whichwe’lltalk about in a minute. Libby, welcome back to the podcast.

Elisabeth Rosenthal:Thanks for having me back.

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

Rosenthal:We wereworried itwouldn’tlast a year, and here we are, eight years later, still finding plenty to write about. I mean,we’vehad some wins.I think wehelped contribute to theNoSurprisesAct being passed.There arestates clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic,it’sthe same cost. Thecountry’sstarting to address drug prices.But,you know, weseem to bethe billingpolice, andthat’snot good.We’vegotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls,they’relike,Oh, that was a mistakeorYeah,we’regoing to write that off. AndI’mlike,You’renot writing that off;thatshouldn’thave been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional systemthathasleft,as we know, you know, 100 million adult Americans with medical debt.Sowe will keep going untilit’ssolved,I hope.

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

Rosenthal:Well, Maxwell[Kruzic]loves eating spicy foods, buthe’snever had a problem with it. And suddenly, one night, he had justexcruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right?Sothey were alllike,ready to go to the operating room. And then the scan came back, and it was like,whoops,his appendix is normal. And then,oh, could he have kidney stones?Andit’slike no sign of that either. And finally, he thought, or someone asked,Well, what did you eat last night?And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million[Scoville heat units], which is,like,through the roof, and it was a reaction to the chili peppers.I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff.

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

Rosenthal:Well, he was asked to pay a little over $2,000,which was his coinsurance for the emergency room visit. And as he said, you know, $8,000…now we go,well,that’snot bad.I mean, all they did,actually, was do a couple of scans and give him some IV fluids.Butin this day and age,you’relike, wow, he got away— you know, froma“Bill of aMonth”perspective, he got away cheap, right?

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

Rosenthal:That’sthe problem,like,and Maxwell—he’sa pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he keptthinking,I must owe something. And he checked and hecheckedand he checked and it kept saying zero. He actually called hisinsurer andto make sure that was right. And they said,No, no, no,it’sright. You owe zero. And then, you know, after like, six months, he thought,I guess Iowe zero. But then hedidn’tthink about it, and then almost two years later, this bill arrives in the mail, andhe’slike,What?!And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at“Bill of theMonth,”and in many cases, it’s legal, becauseofwhat was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like,Yeah, you know, someone was away on vacation, and someone left their job, and wecouldn’t…you know, the hospitalbilled themcorrectly. And the hospital said,No, wedidn’t.And they were justkind of doingthe usualback-end negotiations to figure out what a service is worth.And when they finally agreed two years laterwhat should be paid,that’swhen they sent Maxwell the bill. And the problemis,whetherit’slegal really depends on your insurance contracts, and whether they allow this kind of late billing.I do not know to this day if Maxwell’s did, because as soon as I called the insurerandthe hospital, they were like,Nevermind. Hedoesn’toweanything. And you know, as he said,he’sa geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said,Whoops, I forgot to bill for something, they would be like,Forgetit!youknow.SoI do think this is something that needs to be addressed at a policy level, as we so often discover on“Bill of theMonth.”

Rovner:Sowhat should you do if you get one of these ghost bills? I should sayI’mstill negotiating bills from a surgery that I had six months ago.SoI guess I shouldcountmyself lucky.

Rosenthal:Well, I think you should check with your insurer and check with the hospital. I think morewithyour insurer—if the contract says this is legal to bill.It’sunclearto me,in this case, whether it was.The hospital was very much like,Oh, we made a mistake;because it took so long,weactuallycouldn’tbill Maxwell.SoI think in his case, itprobably wasin the contract that this was too late tobill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude.Well,doesn’thurt to try, you know,maybethey’llpayit. And people are afraid of bills, right? Theypaythem.

Rovner:I know the feeling.

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

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

Rosenthal:He said he will never eatscorpion peppers again.

Rovner:Libby Rosenthal, thank you so much.

Rosenthal:Oh, sure.Thanksfor having me.

Rovner:OK,we’reback, and nowit’stime for ourextra-creditsegment.That’swhere we each recognize a story we read thisweekwe think you should read,too.Don’tworry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us off this week?

Edney:Sure.Somy extra credit is fromMedPageToday:“.”I appreciated this article because it answered some questions that I had,too,after the sweeping change to the childhood vaccine schedule. Therewasjust a lot of discussions I had about, you know, well, what does this really mean on the ground? And willparentsbe confused? Will pediatricians—how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMAPerspectivesthat lays out, essentially, toclinicians, you know, that they should not fear malpractice..issues ifthey’regoing to talk about the old schedule and not adhere to the newer schedule. Andsoit lays out some of those issues.And I thought that was really helpful.

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

Ollstein:Yeah, so I have a piece from ProPublica.It’scalled“.”Sothis is about howthere’sbeen this huge push on the right to end public water fluoridation that has succeeded in acoupleplaces and could spread more. And the proponents of doing that say thatit’sfine because there are all these other sources of fluoride. You can geta treatmentat thedentist,you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people whoarepushingfor ending fluoridated public drinking waterare also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plusall ofthe just rhetoric about fluoride, which is very misleading. It misrepresents studies about its allegedneurological impacts. But it also,that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, whatthat’sgoing to do to the nation’s teeth?

Rovner:Yeah,it’slike vaccines. The more youtalkitdown,the less people want to do it.Joanne.

Kenen:This isa piece byDhruv KhullarinThe New Yorker called“,”and it was really great, because there’s certain things I think that we who—like, I don’t know how all of you watch it—but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED[emergency department]have, you know, homelessness problems and can’t afford food and all that. ButDhruvtalkedabouthow itsortof brought that home to him, how our social safety net, the holes in it, end up in ourEDs.And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patientaday. But he talked about compassion and how that is rediscovered in this frenetic ED/ERscene.It’sjust a very thoughtful piece about why we all love that TV show. Andit’snot just because ofNoah Wyle.

Rovner:Although that helps. My extra credit this week is fromThe New York Times.It’scalled“,” by MaxineJoselow.And while it’s not about HHS, it most definitely is about health.It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the costtohuman health when setting clean air rules for ozone and fine particulate matter, quoting the story:“That would most likely lower costsfor companies while resulting in dirtier air.”This is just another reminder that the federal government ischarged with ensuring the help of Americans from a broad array of agencies, aside from HHS—or in this case, not so much.

OK, that’s this week’s show.As always, thanks to our editor, EmmarieHuetteman,and our producer-engineer, Francis Ying.We also hadhelpthis week from producer Taylor Cook.Areminder:What theHealth?is now available on WAMU platforms, the NPR app,and wherever you get your podcasts, as well as, of course, atkffhealthnews.org.Also, as always, you can email us your comments or questions.We’reatwhatthehealth@kff.org,or you can find me still on X, or on Bluesky.Where are you folks hanging these days?Alice.

Ollstein:MostlyonBlueskyand still onX.

Rovner:Joanne.

Kenen:I’mmostly onor on.

Rovner:Anna.

Edney:orX.

Rovner:We will be backin your feed next week. Until then, be healthy.

Credits

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]]> 2143097 Plan-Switching, Sign-Up Impersonations: Obamacare Enrollment Fraud Persists /news/article/obamacare-aca-fraud-gao-enrollment-marketplace-brokers/ Wed, 10 Dec 2025 10:00:00 +0000 /?post_type=article&p=2129781 Florida resident Keith Jones says his Affordable Care Act insurance plan was changed multiple times this year without his permission. Now the 52-year-old is struggling with his health problems while facing large premium bills he says he shouldn’t owe.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CMS Anti-Fraud Efforts Fall Short

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“That was beyond our scope,” he said.

Devilish Details

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

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

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

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

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

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

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

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]]> 2129781 What the Health? From ýҕl Health News: The State of the Affordable Care Act /news/podcast/what-the-health-421-affordable-care-act-enrollment-premiums-shutdown-congress-november-6-2025/ Thu, 06 Nov 2025 19:00:00 +0000 /?p=2110745&post_type=podcast&preview_id=2110745 The Host Julie Rovner ýҕl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ýҕl 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.

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

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

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

Guest

Cynthia Cox KFF click to open the transcript Transcript: The State of the Affordable Care Act

[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 ýҕl Health News and WAMU Public Radio in Washington, D.C.Welcome to“What the Health?”I’mJulie Rovner, chief Washington correspondent for ýҕl Health News.

Usually,I’mjoined by some of the best and smartest health reporters in Washington,but today we have a special episode.We’retaping this week on Monday, Nov.3,at 10a.m.As always, and especially this week, news happens fast,and thingsmight’vechanged by the time you hear this. So here we go.

Today,we’regoing to explore the state of the Affordable Care Act with one of my favorite experts, KFF’s Cynthia Cox,who’sa vice president and director of the program on the ACA. Open enrollment for 2026 health plans began on Saturday, Nov. 1, and there is so much confusion. I thought it would be helpful to see wherewe’vebeen and,possibly,wherewe’regoing.

Cynthia, thank you so much for joining us.

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

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

Cox:It has been quiteawhile, solet’s, I guess,rewind15 years or so.

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

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

And then still another issue with preexisting conditions was that insurersdidn’thave to cover your treatment for a condition,too. So,you might get a health insurance coverage for certain treatments but,say, it might exclude mental health treatment or even pregnancy care or prescription drugs or other things thatdidn’tneed to… There was nominimumstandard for what needed to be included in these health insurance plans that were sold to individuals.

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

Rovner:Or even a self-employed individual,whichwas…

Cox:Yes. Exactly.

Rovner:… growing in the early parts of this century.

Cox:Yeah.

Rovner:I think peopledon’tremember how much of a wildWestthe individual market really was at that point.The Congresshad regulatedthe employer market in 1996 with HIPAA[Health Insurance Portability and Accountability Act], which was about a lot more than confidentiality. Butthat’sfor another day. But the individual market was so crazy that you could get insurance—it wasn’t really insurance—or you could get charged more just for being a woman, right?

Cox:Exactly. You could even be charged based on what your job was. People who had risky professionsmight’vebeen excluded from health insurance,too. There were very few rules or standards in this market, it was…

One insurer might have insured you,and another insurerwouldn’thave. And there was no way to really know what was going to be available to you without having tomaybe applyto multiple companies and go through a lengthy underwriting process,too.

Rovner:How did the ACA change that?

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

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

And then itbasically prohibitsall those other things,like youcan’trescind coverage based on preexisting conditions or exclude coverage based on preexisting conditions, or… Itbasically issaying:If you have a preexisting health condition, that is not a reason for an insurance company to charge you more or denyyou coverage or carve out certain benefits.So now the health insurance that is sold to individuals—which now we’ve started callingthese theACA marketplaces or Obamacare markets or that sort of thing—so that coverage that’s sold there looks a lot more like the coverage that had been available to people with large employer coverage before the ACA.

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

Those premiums today are no more expensive than the premiums that employer plans have.They cover similar benefits. Itcosts aboutthe same, but when you get coverage through work, your work ispaying fora large part of that premium.And when you pay your premium,it’susually with some sort of tax benefit,too.SoI think a lot of us who have employer coverage justdon’trealize how expensive employer coverage is. And the ACA…

Rovner:We alsodon’trealize how muchwe’regetting subsidized by the government because that’s…

Cox:That,too. Yes.

Rovner:… one of the big fights.It’slike:Why are we giving these people subsidies?It’slike:You’regetting a subsidy,too,if you have employer coverage.

Cox:Yeah, exactly.Yeah,it’sa tax benefit.

And so basically, in the individual market or Obamacare markets, thepremiums—the raw total gross, whatever word you want to say, how much the insurance company is charging—isabout the same as in the employer market,anditcovers about the same services.It’sverysimilarcoverage,andthat’swhyit’sexpensive. Butthat’salso why there are tax credits that are available to help individuals afford coverage. Because ifyou’relow-income,there’sno wayyou’regoing to be able to afford full-price health insurance.

Rovner:And the tax credits have been a big boon to this market, right? Including…

Cox:That’sright.

Rovner:… the expanded tax credits from 2021.

Cox:Yeah. The ACA included premium tax credits to begin with. But the enhanced tax credits—which is what Congress is debating right now—thosewere passed in 2021,and thosebasically justboosted the amount of financialassistancethat people were getting.

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

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

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

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

Rovner:And we should talk about the mandate,because that was the big fight over the ACA…the idea wasif you were going to let all these sick people into the individual market, we needed to get more healthy people into the individualmarket. Andmaybethetax creditswouldn’tbe enough, sowe’regoing to require people to either pay a tax penalty or buy insurance. And that was so controversial thatit gotrepealed.

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

Andsothe concern was that if you wait untilyou’resick to get health insurance—if everyone waits untilthey’resick to get health insurance and only sicker people are buying health insurance—then basically that makes premiums astronomically high. No insurance company is going to want to evenparticipatein a market like that because it could lead towhat’scalled a death spiral—meaning the premiums just gethigher and higher and higher and higheruntil no one can afford topurchasethat coverage.

Andsothe individual mandate, sorry, was one way in which people were basically compelled to purchase insurance andnotwait until theyweresick.Basically, therewere carrots and sticks in the ACA.The sticks were the individual mandateand alsothis short open enrollment window.Soif youdidn’tsign up during open enrollment and you found out you had some serious illness after open enrollmentended, you would have to wait until the next open enrollmentto signup. And then the carrot was the tax credit,basically makingcoverage affordable.

Sowhen the individual mandate penalty was reduced to $0—effectively getting rid of the individual mandate—there was a lot of concern that that was going to lead to a death spiral or adverseselectionat least. Itdidn’treally play out that way, I think, because what really mattered was the carrots. The open enrollment window is still there as a stick, butI think peoplewant health insurance. It just needs to be affordable enough for them to get it. Andsothe tax credits arereally keythere to making the coverage affordable and attractive for someone to buy it even if they are not sick.

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

Cox:Yeah. Itbasically supersizedthe carrot.

That’swhenyou see when these enhanced tax credits rolledout,people started buying this coverage a lot more.The markets doubled in size. It went from about11 million peoplesigned up to over24 million peoplesigned up just within a few years of these enhanced tax credits being available.

Rovner:Sothere were also some things in the ACA that were supposed to help dampen, if you will, the acceleration of healthcare spending. The consensus is thosedidn’tworkquite aswell, but they were there, right?It’snotthat[the]law just ignored the cost of healthcare.

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

We have seen healthcare spending has slowed.It’snot growing as quickly as it was before the ACA in general.Idon’tknow if you can attribute all of that to the ACA,though, but we still are, as a nation, spending about 20% of our GDP[gross domestic product]onhealthcare. Whereas other countries that are large and wealthy, like the United States, spend closer to 10, 11, 12% of their GDP,andthat’sregardless of whetherthey’rea single-payer nation or not. Even countries that have multiple payers will still spend significantly less on healthcare than the United States does.

Rovner:But the Republican talking point that this is all,that healthcare spending has gotten out of controlbecauseof the ACAisn’ttrue.

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

When you look at the individual market, which is where so much of the emphasis has beeninchanging howpreexistingconditions are covered and that sort of thing, yes, premiums are higher today in the individual market than they were in the pre-ACA individual market. But individual market premiums today are reallysimilar toemployer premiums today, where the ACA,really,barely touched those plans.

I think the issueis that health insurance is justreally expensivein this country, andit’sreally expensivebecause we spend a lot on…we payhigh pricesfor doctor’s visits, hospital stays, prescription drugs.And the ACA did do some things to try to address those underlying reasons why healthcare is so expensive in the U.S.,but itwasn’treally themain focus. I think themain focusof the ACA was to subsidize coverage and make it affordable for individuals. But that still means thatit’sexpensive for society.

Rovner:Sowho are the individuals in the ACA individualmarket, ifyou will? There’s—what? —24 million of them?

Cox:Yeah.There’s24 million of them,and about half of them are either small-business employees,or owners,or self-employed people, andthat’sbecause a lot of us get coverage through work.

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

And so generally speaking—because youhave tohave an income of at least the poverty level to be getting a subsidy in this market—these are working individuals or working families. Also, a lot of farmers and ranchers rely on the ACA marketplace because, again,that’sa field where theydon’tnecessarily get health insurance through work. Sothat’sa big part of it.

The other thing that’spretty commonis pre-retireesor early retirees.So basically, peoplewho arenot quite oldenough to be on Medicare—since youhave tobe 65 to get on Medicare—you see a lot of 64-year-olds buying ACA marketplace coverage.

Rovner:I think the thing that confuses most people, at least the most people that I talk to, is that we keep hearing that ACA premiums are going up an average of 17% next year,or 30%,or more than 100%. Andall ofthose numbers areactually correctbecausethey’rereferring to different things.Sowhat’s the difference between premiums the insurerschargeand the premiums consumershave topay?

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

Basically, there’stwo ways to think about premiums in the individual market.There’show much the insurance company is charging for their premiums.That’sthe revenue that the insurance company is bringing in. But a lot of that is notpaidby individuals.The federal government is paying a large share of that in the form of a tax credit.

Sothen the other way that people think about premiums in this market is how much individuals are paying out of their own pockets for their premiums.And ifyou’rejust a regular person shopping on,that’swhat you see as your premium payment is how much youhave tocontribute as an individual.

The amount that the insurance companies arecharging,we have a couple of different numbers on that. We have what they requestedtostateregulators was an 18% increase on average. Four percentage points of that, they were saying, was this extra premium increase that theyweren’totherwise going to charge. But they were saying,we think that when these enhanced tax credits expire, that healthier people are going to drop their coverage, meaningwe’regoing to be left with a sicker group of enrollees, sowe’regoing to have to charge even higher premiums than we otherwise would have.Either way, even if the enhanced premium tax credits had been extended, insurers in this market stillwould’vebeen raising premiums by double digits.

That’sthe steepest increase thatwe’veseen in many years in this market. Butwe’realso, I think, looking at double-digit premium increases for employer plans,too.It’sjust an expensive year coming up.That’show much…

And then we have newer data that just looks at silver plans. This is super wonky.But basically, acertainplan thatis the benchmark against which subsidies are calculated. The insurers areactually charging26% more on average for that plan.SoI think that these requested rates might’ve understated how much insurers areactually charging. Andsothese arereally significantpremium increases. But…

Rovner:I would saya really importantpiece of this is that if the tax creditsweren’tchanging, peoplewouldn’tbe paying these increases.Right?They would be absorbed…

Cox:Exactly.

Rovner:… by the tax credit.

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

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

But even the people who continue to get a tax credit,they’lljust get a smaller tax credit next year.They’restill also going to see their premium payments go up, not because of what the insurance company is charging, butbecause ofCongress not extending the enhanced premium tax credits. So that means that theyhave topay a larger share of their income.Soa low-income person,instead of paying nothing each month,will have to start paying2%to 4% of their income. A middle-income person,instead of payingmaybe6%to 8% of their income,might pay8%to 10% of their income.

Again, for most people, this is not a function of what the insurance company is charging. It’sactually afunction of what Congress sets the law tobeand howmuch of atax credit they get.

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

Cox:Yeah. Our analysis shows that if people stay in the same plan, theywouldsee a premium increase of 114% on average. But for many people,it could bean optionto switch to a lower level of coverage. Somaybe insteadof buying a silver plan, theybuya bronze plan.

But the issue there is,a lot of the people who are buying ACA marketplace coverage right now are so low-income that they’re gettingreally generousfinancial help for their deductibles,too.It’snot just their premiums. So instead of a silver premium having a deductible of a few thousand dollars for that person, their deductible might be less than a hundred dollars now. Andsoif they were to switch from a silver plan to a bronze plan, they might still be able to keep azero premiumpayment,or near-zero premium payment, but their deductible would be $7,000 more than it is today. Either way,they’regoing to see their costs go up.It’sjust,do they see them go up when they go to the doctor,or have an emergency,or have a hospitalization,orfilla prescription drug?Or do they see their monthly costs go up for each month thatthey’repaying their premium?

Ifyou’reyoung and healthy, it might make sense to take the risk and get the bronze plan. But ifyou’repretty sureyou’regoing to use some healthcare next year, then it makes sense to just pay the higher premium so that you can keep that low deductible.

Rovner:Yeah. One of the main Republican talking points is all these people who have insurance butdon’tfile claims every year,which they say is evidence of widespread fraud. But isn’t it also possible that some of those peopledon’tuse their insurance because theyliterallycan’tafford these four-and five-figure deductibles?

Cox:Yeah.It’salso…There’sa lot of reasons why someone might not use their health insurance. We certainly know whetheryou’regetting your coverage through work or through the ACA marketplaces. If you have a high deductible, then that can be a significant cost barrier. Also,lower-income people face other non-cost-related access barriers, like getting timeoff ofwork,or just the ability to find an appointment.

Butalsothe market has gotten younger. And with enhanced premium tax credits attracting more people to buy coverage, this was part of the wholeidea wasthat you get younger, healthier people to sign up for coverage and not wait untilthey’resick. And so that also can make it look likethere’slessutilizationof care. But ifyou’rejust young and healthy, then you might not be going to the doctor either way.

And alsojust…

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

Cox:Right. A health spiral is what some peoplehave calledit.

But I thinkthere’salso just some issues with the data source that was used to do that. Iwon’tgo into all those details, but I think…there’ssomethingthere. There is fraud.There’sno question that there’s fraud in this market. Andit’sbeing committed mostly by agents and brokers who are signing people up either without their knowledge, or switching their plan, or switching the name of the broker so they can get the commission. But I think the scale of the fraud has been exaggerated.

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

Cox:I think thisisprobably oneof the biggest changes aside from theexpirationof the enhanced premium tax credit, and ithasn’tgotten a lot of attention.SoI’mworried that people who are buying their own coverage might not know about this.

Congress hasbasically repealedany limits on how much you would have to repay when you file your taxes the following year after you enroll in ACA marketplace coverage.The idea is that when you sign up for ACA coverage, youhave toproject what you think your income will be by the end of the next calendar year.That can bereally hardfor someone who, say, gets their income from driving Uber or working shiftsat a restaurant,or so on and so forth.Or even asmall-businessowner might havea hard timeprojecting exactly how much their income will be next year. And so,if you guess wrong—in other words, if you say,now I thinkI’mgoing to make $50,000 next year,but you end up making $60,000 next year—then you might have to repay a significant amount of the tax credit.

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

Rovner:Yeah,I think thisis a big deal. Andalsothere’s going to be less help available for people toactually signup for coverage, even though there’s all these big changes happening.

Cox:Yeah. When the ACA was first passed, there was this idea that it was goingto belikegoing online and booking your own hotel,or airplane,or whatever,andthat’sjust not how it has panned out. Most people need help signing up for health insurance. Itstill isa complicated process. Andsothey turned to agents, brokers, and what are called navigators,who are nonprofit organizations that have helpedpeople buy insurance.But the Trump administration has cut funding for the navigator programreally significantly,and sothere’sgoing to be fewer of those folks to help.

Also,I think thisis justgoing to beprobably oneof the busiest and most chaotic ACA open enrollment periodsever,probably,and so many…

Rovner:2013wasn’tgreat but…

Cox:Yeah. But thereweren’tso many buying it back then.

Rovner:… where the websitedidn’twork.

Cox:Yeah,yeah.

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

Rovner:True.

Cox:Idon’tknow if there are more agents or brokers thantherewere back then, but I suspect not. Butthere’sjust going to be busy people. Andsoif you need to make an appointment with an agent or broker, then go ahead and do that as soon as you can.

Rovner:Yeah. This is the trade-off here. On the one hand, people want to wait and see if Congressmaybe comesto some deal on these expanded subsidies.On the other hand, it’s going to bereally hardto sign up at the last minute.

Cox:Yeah,yeah.Soif it wereme—and I obviously would feel more comfortable signing up on my own without the help of someone—but I would personally prefer to wait and see what happens.I wouldn’t wait too long, but I might waittillThanksgiving or early December and wait tomake a decisionabout my plan until then.But youcan’tadvise everyone to do that because if you need an agent or broker to help you,maybe getthat appointment as soon as you can. Butmaybe alsojust keep an eye out on things and decide before Dec.15if you want to change your plan.

Rovner:Soit’snot just the expanded tax credits. There’s also[a]new restrictiononwho’seligible. There are a lot of people who are immigrants—who were here legally—who have been eligible for tax credits who no longer will be, right?

Cox:Yeah. There has been a lot of talk about undocumented immigrants getting this coverage.And just to be clear, the ACA marketplaces are not where undocumented people come to get health insurance. Youcan’teven buy this coverage without a subsidy ifyou’reundocumented.

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

Rovner:I know the Trump administration tried to make even more changes in its annual regulation governing the marketplace, although some of those have been blocked by the courts.What are some of those changes thataren’thappeningthisyearbut that people may have heard about and that may, depending on what the courts do,come into play next year?

Cox:I think one of the most important ones was this idea that they were going to change how auto re-enrollment works.Soa lot of people in the ACA marketplaces get azero premiumplan. And like all other healthinsurancesout there, whetherit’syour homeowner’s insurance or your car insurance, you just get automatically re-enrolled from one year to the next. Andthat’strue for these ACA marketplaces,too.

Sothe Trump administration had a rule that said:Well, if you were going to be auto-re-enrolled into a zero-premium plan, we want to make sure that you still want that plan. Because ifyou’renot paying anything each month, you might bejust gettingautomatically re-enrolled without your knowledge.Andsothe idea was that you would get charged $5 a month until you actively re-enroll. That was one of a few things that was…

There was a stay ina courtdecisionbasically saying:We need to hear more about this before the courtcouldmake a final decision.But long story short,that’snot going into effect this year. But there will be other changes to auto re-enrollment in the coming years,basically due tothe summer reconciliation package where auto re-enrollment would effectively end. And sothat’san even bigger deal,butthat’snot going into effect yet. That willbe inthe coming year.

Rovner:Yes.Somore people will have toactually goin and do something with their policy, but there are fewer people to help them. Do I have that right?

Cox:That’sright.Yeah.Sothere’sgoing to be a lot ofactivitythis year. This year and in coming years.Yeah.

Rovner:Sowhat’sthe bottom line here for people who now have Affordable Care Act coverage or who plan or hope to have it for next year?

Cox:I think,first of all, watch this closely anddon’tmake any decision about dropping your coverage or even dropping down to a lower level of coverage until probably early December is probably the right time to really make a final decision on this.You can still start makingall ofyour plans and getting all your paperwork together andtalkto an agent orbroker, butjust keep watching this until there’s some sort of clear resolution aboutwhat’sgoing to happen in Congress.Because if the enhanced premium tax credits do get extended,you’reprobably better offkeepingthe same level of coverage that you have now. Or for newer people,they’reprobably better off in a silver plan than a bronze plan in many cases.Soyoudon’twant to make asignificant changeto your coveragejust yetuntil you knowwhat’sgoing to happen next year.

But it’s a difficult situation for people to be in. Theyhave to, at a certain point, just make a judgment call.And I think that can lead to peoplepickinga planthat’snot necessarily the best one forthem, oreven going without insurance because they justdon’tfeel like they can afford it anymore.

Rovner:This is a conundrum.It’sobviously a conundrum for the Democrats becausethey’rekeeping the government closed—which they normallydon’twant to do—demanding that these tax credits be extended. Ironically, a lot of the people who will be helped if the tax credits do get extended are Republicans in Republican states.They’resmall-business people. There are people in a lot of these very red states where we saw enrollmentskyrocket. Why don’t the Republicans want to do that?It’stheir voters who would be helped.

Cox:Yeah.That’sright.

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

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

Rovner:Well, we will keep track ofwhat’shappening.Cynthia Cox, thank you so much.

Cox:Thank you.

Rovner:Thanksthis week to our fill-in editor,Stephanie Stapleton,and our fill-in producer-engineer,Taylor Cook.A reminder:“What the Health?”is now available onWAMU platforms, theNPR app, and wherever elseyou get your podcasts, as well as,of course,atkffhealthnews.org.As always, you can emailusyour comments or questions.We’reat whatthehealth@kff.org,or you can find me on Xor on Bluesky.Cynthia, are you hanging on social media these days?

Cox:Yes.@cynthiaccox on bothand.

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

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]]> 2110745 What the Health? From ýҕl Health News: Happy Open Enrollment Eve! /news/podcast/what-the-health-420-open-enrollment-obamacare-aca-shutdown-october-30-2025/ Thu, 30 Oct 2025 19:00:00 +0000 /?p=2105272&post_type=podcast&preview_id=2105272 The Host Julie Rovner ýҕl Health News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ýҕl 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.

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

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

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

Panelists

Paige Winfield Cunningham The Washington Post Read Paige's stories. Maya Goldman Axios Alice Miranda Ollstein Politico

Among the takeaways from this week’s episode:

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

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

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

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

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

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

Also mentioned in this week’s podcast:

Click to open the transcript Transcript: Happy Open Enrollment Eve!

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

Alice Miranda Ollstein: Hello.

Rovner: Maya Goldman of Axios News.

Maya Goldman: Good to be here.

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

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

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

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

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

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

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

Goldman: Exactly. Exactly.

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

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

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

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

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

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

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

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

Winfield Cunningham: Under the enhanced. OK.

Rovner: It’s going to go back to 10%.

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

Rovner: 400%.

Winfield Cunningham: Right. Yeah. Yeah.

Rovner: That’s right.

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

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

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

Winfield Cunningham: This is very true.

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

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

Rovner: Yeah. Although it is …

Goldman: Obviously, that’s a lot of what ifs, but …

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein: Definitely.

Rovner: Paige?

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

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

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

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

Rovner: Alice?

Ollstein: on Bluesky and on X.

Rovner: Paige?

Winfield Cunningham: I am still on X.

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

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]]> 2105272 KHN’s ‘What the Health?’: Health Care as Infrastructure /news/article/podcast-khn-what-the-health-191-health-care-as-infrastructure-april-8-2021/ Thu, 08 Apr 2021 17:15:00 +0000 https://khn.org/?p=1288290&post_type=article&preview_id=1288290 Can’t see the audio player?.

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

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

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

Among the takeaways from this week’s podcast:

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

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

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

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

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

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

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

To hear all our podcasts,click here.

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]]> 1288290 ‘An Arm and a Leg’: Shopping for Health Insurance? Here’s How One Family Tried to Pick a Plan /news/article/an-arm-and-a-leg-shopping-for-health-insurance-heres-how-one-family-tried-to-pick-a-plan/ Wed, 16 Dec 2020 10:01:00 +0000 https://khn.org/?p=1227316&post_type=article&preview_id=1227316 Can’t see the audio player?

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

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

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

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

And here are some other helpful big-picture takes:

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

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

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

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

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

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

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

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

To hear all Kaiser Health News podcasts,click here.

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

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]]> 1227316 KHN’s ‘What the Health?’: As Cases Spike, White House Declares Pandemic Over /news/podcast-khn-what-the-health-169-as-covid-cases-spike-white-house-declares-pandemic-over-october-29-2020/ Thu, 29 Oct 2020 19:00:47 +0000 https://khn.org/?p=1199669&preview=true&preview_id=1199669 Can’t see the audio player?. White House chief of staff Mark Meadows said this week that “we’re not going to control the pandemic,” effectively conceding that the administration has pivoted from prevention to treatment. But COVID-19 cases are rising rapidly in most of the nation, and the issue is playing large in the presidential campaign. President Donald Trump is complaining about the constant news reports about the virus, prompting former President Barack Obama to say Trump is “jealous of COVID’s media coverage.” Meanwhile, as the case challenging the constitutionality of the Affordable Care Act heads to the Supreme Court on Nov. 10, open enrollment for individual health insurance under the law begins Sunday. This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Anna Edney of Bloomberg News. Among the takeaways from this week’s podcast:
  • Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
  • Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
  • Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
  • Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
  • Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
  • Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
  • Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.
Also this week, Rovner interviews KHN’s Anna Almendrala, who reported the latest NPR-KHN “Bill of the Month” installment, about a patient who did everything right and got a big bill anyway. If you have an outrageous medical bill you would like to share with us, you can do that here. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too: Julie Rovner: The New York Times’ “,” by Abby Goodnough Joanne Kenen: The New Yorker’s “,” by Barack Obama Tami Luhby: KHN’s “Florida Fails to Attract Bidders for Canada Drug Importation Program,” by Phil Galewitz Anna Edney: The Wall Street Journal’s “,” by Julie Wernau, James V. Grimaldi and Stephanie Armour To hear all our podcasts,click here. And subscribe to What the Health? on,,,, or.

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

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]]> 1199669 Listen: The Hard-Knock Health Law Turns 10 Amid Pandemic /news/listen-the-hard-knock-health-law-turns-10-amid-pandemic/ Mon, 23 Mar 2020 21:55:00 +0000 https://khn.org/?p=1071570&preview=true&preview_id=1071570 On March 23, 2010, President Barack Obama signed the Affordable Care Act into law. Kaiser Health News chief Washington correspondent Julie Rovner talks to NPR’s Ari Shapiro about how the ACA has changed health care in America over the past decade and also how the coronavirus pandemic ultimately may change the still embattled law. Kaiser Family Foundation Executive Vice President Larry Levitt also , discussing with Noel King, on NPR’s “Morning Edition,” how the law led to 20 million Americans gaining health insurance.

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]]> 1071570 Feds Slow Down But Don’t Stop Georgia’s Contentious Effort To Ditch ACA Marketplace /news/feds-slow-down-but-dont-stop-georgias-contentious-effort-to-ditch-aca-marketplace/ Fri, 07 Feb 2020 10:00:33 +0000 https://khn.org/?p=1049609 The Trump administration announced Thursday it was putting on hold Georgia’s proposal to significantly alter how that state’s Affordable Care Act insurance marketplace operates but suggested it is eager to help the state get it done.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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]]> 1049609 Obamacare’s Star Ratings Offer A Glimmer Of Insight ― But Not For All /news/obamacare-star-ratings-offer-a-glimmer-of-insight-%e2%80%95-but-not-for-all/ Fri, 01 Nov 2019 09:00:35 +0000 https://khn.org/?p=1015199 ST. LOUIS — As millions of Americans start shopping Friday for individual health insurance for 2020, they will see federal ratings comparing the quality of health plans on the Affordable Care Act’s insurance marketplaces.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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