“La primera vez, el teléfono suena sin parar. La siguiente, te manda al buzón de voz y se corta la llamada”, dijo la mujer de 48 años, que vive en Delaware. “A veces te contesta alguien que dice que no es la persona indicada. Te transfieren y se corta. A veces contestan y no hay nadie en la línea”.

Pasó meses tratando de averiguar si su cobertura de Medicaid había sido renovada. Hasta finales de marzo, todavía no le había llegado la renovación anual para el programa estatal y federal que ofrece seguro de salud a personas con bajos ingresos y con discapacidades.

Crouch, quien sufrió un aneurisma cerebral debilitante hace una década, también tiene Medicare, que cubre a personas de 65 años o más, o a aquellas con discapacidades. Medicaid pagaba sus deducibles mensuales de Medicare de $200, pero en los últimos tres meses ha tenido que cubrirlos ella misma, lo que ha afectado el ingreso fijo de su familia, contó.

Los problemas de Crouch con el centro de llamadas de Medicaid en Delaware no son un caso aislado. Las agencias estatales de Medicaid pueden tener dificultades para mantener suficiente personal que ayude a las personas a inscribirse en los beneficios y atender llamadas de afiliados con preguntas.

La falta de estos trabajadores puede impedir que las personas usen plenamente sus beneficios, dijeron investigadores de políticas de salud.

Ahora, la ley One Big Beautiful Bill Act de los republicanos aprobada por el Congreso, que el presidente Donald Trump firmó el verano pasado, pronto exigirá más al personal de las agencias estatales en los lugares donde los legisladores ampliaron Medicaid a más adultos con bajos ingresos, que son casi todos los estados y el Distrito de Columbia.

Según la ley, que se espera reduzca el gasto de Medicaid en casi $1.000 millones en los próximos ocho años, estos trabajadores deberán no solo determinar si millones de afiliados cumplen con los nuevos requisitos laborales del programa, sino también verificar con mayor frecuencia que califican: cada seis meses en lugar de una vez al año.

�������ýҕ�l Health News contactó a agencias que deberán implementar estas reglas de trabajo, y muchas dijeron que necesitarán más personal.

Estas exigencias pondrán más presión sobre una fuerza laboral ya sobrecargada, lo que podría dificultar que afiliados como Crouch reciban servicios básicos de atención al cliente. Y muchos podrían perder acceso a beneficios a los que tienen derecho por ley, según afirmaron defensores del consumidor e investigadores de políticas de salud, algunos con experiencia directa trabajando en agencias estatales.

Los estados ya están “teniendo grandes dificultades”, dijo Jennifer Wagner, directora de elegibilidad e inscripción de Medicaid en el Center on Budget and Policy Priorities y ex subdirectora del Departamento de Servicios Humanos de Illinois. “Habrá desafíos adicionales importantes por culpa de estos cambios”.

Largos tiempos de espera para recibir ayuda

Los republicanos sostienen que los cambios en Medicaid, que entrarán en vigencia el 1 de enero de 2027 en la mayoría de los estados, incentivarán a los afiliados a conseguir empleo. Investigaciones sobre otros programas con requisitos laborales en Medicaid han encontrado poca evidencia de que aumenten el empleo.

La Oficina de Presupuesto del Congreso (CBO, por sus siglas en inglés) provocarán que más personas pierdan la cobertura de salud para 2034: indicó que más de 5 millones de personas podrían verse afectadas.

Muchos estados no tienen suficiente personal para procesar solicitudes o renovaciones de Medicaid con rapidez, dijeron defensores.

Los Centros de Servicios de Medicare y Medicaid (CMS, por siglas en inglés) supervisan si los estados pueden procesar el tipo más común de solicitud de beneficios dentro de un plazo de 45 días.

En diciembre, alrededor del 30% de todas las solicitudes de Medicaid y del Programa de Seguro de Salud Infantil (CHIP, por sus siglas en inglés) en Washington, D.C., y Georgia en procesarse. Más de una cuarta parte tardó ese tiempo en Wyoming. En Maine, una de cada 5 solicitudes no cumplió ese plazo.

Los CMS comenzaron a compartir públicamente datos de los centros de llamadas de Medicaid en 2023, lo que mostró un sistema bajo presión, según investigadores y defensores.

En Hawaii, las personas esperaron más de tres horas al teléfono en diciembre. En Oklahoma, casi una hora, y en Nevada, más de una hora.

En 2023, las agencias estatales de Medicaid comenzaron a verificar que todavía calificaban a los afiliados que habían sido protegidos para que no perdieran su cobertura durante la pandemia de covid. Ese proceso no funcionó bien en muchos estados, y más de .

Investigadores y defensores dicen que implementar las nuevas reglas será un reto mayor. Las reglas laborales requerirán cambios amplios en los sistemas informáticos y capacitación para los trabajadores que verifican la elegibilidad en un plazo ajustado.

“Es un nivel mucho mayor de complejidad administrativa”, señaló Sophia Tripoli, directora de políticas en Families USA, una organización de defensa de salud del consumidor.

Después de meses intentando hablar con alguien, Crouch dijo que finalmente obtuvo respuestas sobre sus beneficios de Medicaid luego de escribir a la oficina de la representante federal Sarah McBride (demócrata de Delaware). La oficina contactó a la agencia estatal de Medicaid, que finalmente la llamó con una actualización, dijo.

Crouch en realidad no calificaba para Medicaid. Dijo que eso nunca había surgido en dos años de interacciones con el estado.

“No tiene ningún sentido que el estado no se haya dado cuenta antes”, dijo.

La agencia de Medicaid de Delaware no respondió a solicitudes de comentarios sobre su caso.

Estados con poco personal para Medicaid

A fines de marzo, algunos estados dijeron a �������ýҕ�l Health News, que necesitarán más personal para implementar las reglas laborales de manera efectiva.

Idaho informó que tiene 40 vacantes para trabajadores de elegibilidad. Nueva York estimó que necesitará 80 nuevos empleados para manejar el trabajo administrativo adicional, con un costo de $6,2 millones. Pennsylvania tiene casi 400 puestos vacantes en oficinas de servicios humanos de los condados. La agencia de Medicaid de Indiana tiene 94 vacantes. Maine quiere contratar 90 trabajadores adicionales, y Massachusetts busca sumar 70 más. Montana llenó 39 de los 59 puestos que dice que necesitará.

La agencia de servicios sociales de Missouri ha reducido personal y tiene 1.000 trabajadores de primera línea menos que hace aproximadamente una década, esto con más del doble de afiliados en Medicaid y en el Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés), según comentarios de su directora, Jessica Bax,

“El departamento pensó que habría una mejora en la eficiencia gracias a las actualizaciones del sistema de elegibilidad”, dijo Bax. “Muchas de esas mejoras no se concretaron”.

Los estados podrían tener dificultades para encontrar personas interesadas en estos trabajos, que requieren meses de capacitación, pueden ser emocionalmente exigentes y generalmente ofrecen salarios bajos, afirmó Tricia Brooks, investigadora del Centro para Niños y Familias de la Universidad de Georgetown.

“Reciben muchos reclamos y gritos”, dijo Brooks, quien antes dirigió el programa de atención al cliente de Medicaid y CHIP en New Hampshire. “Las personas están frustradas. Lloran. Están preocupadas. Están perdiendo acceso a la atención médica, y no es un trabajo fácil cuando es difícil ayudar”.

Los estados están pagando millones de dólares a contratistas del gobierno para ayudar a cumplir con la nueva ley federal.

Maximus, un contratista de servicios gubernamentales, brinda apoyo en elegibilidad, como la gestión de centros de llamadas, en 17 estados que ampliaron Medicaid y atiende a casi 3 de cada 5 personas inscritas en el programa a nivel nacional, según la empresa.

Durante una llamada de resultados en febrero, la empresa dijo que puede cobrar según el número de gestiones que realiza para los afiliados, independientemente de cuántas personas estén inscritas en el programa en un estado.

Maximus no tiene “un enfoque único” para los servicios que ofrece ni para cómo cobra por ellos, dijo su vocera Marci Goldstein a �������ýҕ�l Health News.

La empresa, que reportó ingresos de $1.760 millones en 2025 en el área que incluye trabajo relacionado con Medicaid, espera que esos ingresos sigan creciendo, incluso si menos personas permanecen en el programa, “debido a las gestiones adicionales que serán necesarias”, señaló David Mutryn, director financiero y tesorero de Maximus.

Perder la cobertura de Medicaid no es solo una molestia, ya que muchas personas inscritas probablemente no ganan lo suficiente para pagar atención médica por su cuenta y pueden no calificar para ayuda financiera bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), dijo Elizabeth Edwards, abogada del National Health Law Program.

Las personas podrían no poder pagar medicamentos o recibir atención esencial, lo que podría tener impactos “devastadores” en la salud, dijo.

“Lo que está en juego son las vidas de las personas”, concluyó.

Los corresponsales de �������ýҕ�l Health News Katheryn Houghton y Samantha Liss contribuyeron con este artículo.

�������ýҕ�l 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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This story can be republished for free (details).

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

First, the basics of how the subsidies work.

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

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

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

Beware Surprise Tax Bills

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

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

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

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

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

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

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

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

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

Plan Ahead: The Rules Will Be Tougher Next Tax Season

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

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

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

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

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

And that could be a lot.

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

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

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

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

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

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

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

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

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

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

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This story can be republished for free (details).

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

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

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

Panelists

Among the takeaways from this week’s episode:

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

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

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

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

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

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

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

Also mentioned in this week’s podcast:

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

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

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

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

Alice Miranda��Ollstein:��Hello.��

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

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

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

Sandhya Raman:��Hello, everyone.��

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

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

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

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

Hellmann:��Yeah, exactly.��

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

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

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

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

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

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

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

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

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

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

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

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

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

Ollstein:��Power.��

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rovner:��One cent.��

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

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

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

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

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

Rovner:��OK, we��are back.��It’s��time for our��extra-credit��segment.��That’s��where we each recognize a story we read this��week��we think you should read,��too.��Don’t��worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Jessie, why don’t you go��first this week?��

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

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

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

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

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

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

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

Raman:��On����and on����.��

Rovner:��Alice.��

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

Rovner:��Jessie.��

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

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

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

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

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

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

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

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

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

Closing Consumer Windows

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

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

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

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

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

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

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

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

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

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

Targeting Fraud by Agents, Marketers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

��Next stop, emergency room.��

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

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

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

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

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

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

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

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

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

Some people faced horrifically stark new circumstances:��

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

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

Our partners at �������ýҕ�l Health News have been talking with lots of those people.��

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

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

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

Our pals at �������ýҕ�l Health News also introduced us to this man:

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

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

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

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

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

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

Dan:��Let’s go.��

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

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

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

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

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

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

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

Noah’s grandma closed up Skateboards Unlimited.��

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

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

Noah is as invested as anybody could possibly be.

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

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

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

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

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

Dan:��Noah’s a long-term kind of guy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan:��Yeah, yeah,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan:��Oh my God.

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

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

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

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

The expensive horses, the less-expensive home…

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

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

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

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

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

Dan:��Could they contemplate doing without insurance?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Not workable for almost anybody.��

[Music transition]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan:��Hmm.

Nicole Wipp:��I don’t know though.

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

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

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

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

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

Dan: Wow.��

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

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

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

Adam Raymonda is our audio wizard.

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

Claire Davenport is our engagement producer.

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

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

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

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

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

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

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

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

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

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

To hear all �������ýҕ�l Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

�������ýҕ�l 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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Still, 69% of those enrolled last year signed up again this year, often for less generous coverage. About 9% said they had to forgo insurance, according to the survey by KFF, a health information nonprofit that includes �������ýҕ�l Health News.

The KFF poll revisited the people who responded to of Affordable Care Act enrollees during open enrollment for ACA plans.

Steve Davis, a 64-year-old retired car salesman in Rogersville, Tennessee, who participated in both polls, said he was looking at an annual premium of about $14,000 to renew his ACA coverage this year. He didn’t qualify for enough of a tax credit to defray the cost, he said, after Congress gridlocked on an extension of more-generous subsidies put in place under President Joe Biden.

But things worked out for Davis. He landed a job at a convenience store that came with insurance, with his share costing about $100 more a month than the $300 he paid for an ACA plan last year, before the enhanced tax credits expired.

“As it happened, the Lord provided and my insurance kicked in through my employer,” he told �������ýҕ�l Health News.

In the November survey, many respondents were not sure what they would do for their health insurance in the coming year.

Some were waiting to see whether Congress would extend the enhanced premium subsidies, which had helped many people get lower-cost — or even zero-cost — health premiums.

Congress’ inaction left some consumers in a bind.

Now, the new poll found, affordability issues are hitting home as the midterm election approaches. And that might play a role in competitive districts, creating headwinds for Republicans.

Midterm Signals

Across all respondents who were registered to vote, the poll found more than half place “a lot” of blame for rising costs on Republicans in Congress (54%), with a similar share putting the same level of blame on President Donald Trump (53%). A smaller group placed a lot of the blame on congressional Democrats (34%). Among independents, a group expected to be a key factor in many districts, the percentages putting a lot of the blame on the GOP (56%) and Trump (58%) were higher.

Among Republicans, 60% placed a lot of the blame on Democrats in Congress.

“Those who have marketplace coverage, who remained on it, they’re really struggling with health care costs,” said Lunna Lopes, senior survey manager for KFF.

While more than half (55%) of returning ACA enrollees said they will have to pare back on other household expenses to cover health care costs, about 17% said they might not be able to continue paying insurance premiums throughout the year.

Overall, 80% of those who reenrolled for 2026 said their premiums, deductibles, or other costs are higher this year than last, with 51% saying they are “a lot higher.”

About three-quarters of ACA enrollees in the survey who were registered voters said the cost of health care will have an impact on their decision to vote — and on which party’s candidate they support.

Democrats were more than twice as likely as Republicans to say those costs will have a major impact on their decision.

“Democrats seem particularly more energized by health care costs than their Republican counterparts,” Lopes said.

Enrollment Tally Down

Data released Jan. 28 by federal officials showed that about 23 million people enrolled in Obamacare plans across the federal healthcare.gov marketplace and those run by states, about 1.2 million fewer than in 2025.

But it isn’t yet known how many are paying their monthly premiums on time, and many analysts expect overall enrollment numbers to fall as that data becomes available in the coming months.

For most people, having to pay more for premiums this year was mainly due to the expiration of the enhanced tax cuts, pollsters noted. Because the subsidies that remain are less generous, households have to pay more of their income toward coverage. Congressional inaction also meant the restoration of an income cap for subsidies at four times the poverty level, or $62,600 for an individual, sticking people like Davis with higher bills.

Not everyone saw increases.

Matthew Rutledge, a 32-year-old substitute teacher in Apple Valley, California, who participated in both KFF polls, said he qualified as low-income and his subsidies fully offset his monthly premium payment, just as they did last year. He does have copayments when he sees a doctor or accesses other medical care, but he told �������ýҕ�l Health News that “as long as the premium doesn’t go up, I’m fine with it.”

Rising premiums are fueled by a variety of factors, including hospital costs, doctors’ services, and the prices of drugs.

To lower premiums, insurers offer plans with higher deductibles or copayments. In the ACA, plans with lower premiums but higher deductibles are called “catastrophic” or “bronze” plans. “Silver” plans generally balance premiums and out-of-pocket spending, while the highest-premium plans with lower deductibles are “gold” or “platinum.”

About 28% of those who stayed in the ACA marketplaces switched plans, the pollsters noted.

One 56-year-old Texas man told pollsters that his family’s income exceeded the cap for subsidies, so they switched down from a gold plan to a bronze. “Even doing that, our premiums are three times what they were in 2025, with lower plan features and a higher deductible,” he said, according to a KFF poll news release.

For some, reenrolling was not a viable option.

In addition to the 9% who said they are now uninsured, about 5% said they switched to some type of non-ACA coverage.

Some people, like Davis, landed job-based coverage, while others found they qualified for Medicaid, the joint state-federal program for low-income residents.

Such churn in and out of ACA coverage is not unusual, Lopes noted. “People get a job. They get married. They age into Medicare,” the program for older or disabled people, she said.

The poll highlighted that many people dropping coverage were younger, between 18 and 29. About 14% of people in that range now say they are uninsured.��

That’s not surprising, given that younger people tend to use health coverage less. ACA insurers said one reason they raised premiums this year was because they expected more young or healthy people to drop out, leaving them with a higher share of older, more costly enrollees. Among those 50 or older, the poll found that only 7% are now uninsured.

GOP critics of the now-expired enhanced subsidies say they were always meant to be temporary. Extending them would have cost about $350 billion from 2026 to 2035, .

But not extending them means more people will become uninsured. The CBO said the extension would have meant 3.8 million more people having insurance coverage in 2035.

KFF pollsters, in February and early March, surveyed 1,117 U.S. adults, more than 80% of the ACA enrollees originally polled in November, online and by telephone. The margin of error is plus or minus four percentage points for the full sample.

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

�������ýҕ�l 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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This story can be republished for free (details).

Congress appears ready to approve a spending bill for the Department of Health and Human Services for the first time in years — minus the dramatic cuts proposed by the Trump administration. Lawmakers are also nearing passage of a health measure, including new rules for prescription drug middlemen known as pharmacy benefit managers, that has been delayed for more than a year after complaints from Elon Musk, who at the time was preparing to join the incoming Trump administration.

However, Congress seems less enthusiastic about the health policy outline released by President Donald Trump last week, which includes a handful of proposals that lawmakers have rejected in the past.

This week’s panelists are Julie Rovner of �������ýҕ�l Health News, Sandhya Raman of CQ Roll Call, Sheryl Gay Stolberg of The New York Times, and Paige Winfield Cunningham of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• Congress is on track to pass a new appropriations bill for HHS, with the current, short-term funding set to expire next week. The bill includes a slight bump for some agencies and, notably, does not include deep cuts requested by Trump. But with the administration’s demonstrated willingness to ignore congressionally mandated spending, the question stands: Will Trump follow Congress’ instructions about how to spend the money?
• A health package with bipartisan support is set to hitch a ride with the spending bill, after falling by the wayside in late 2024 under pressure from then-Trump adviser Musk. However, the president’s newly released list of health priorities largely isn’t reflected in the package. The GOP faces headwinds in the midterms after allowing expanded Affordable Care Act premium tax credits to expire, a change that’s expected to cost many Americans their health insurance.
• One year into the second Trump administration, its policies are particularly evident in the political takeover of the nation’s public health infrastructure, the growing number of uninsured Americans, and creeping brain drain in U.S.-based scientific research.
• And Health and Human Services Secretary Robert F. Kennedy Jr. has fired members of a panel overseeing the federal government’s vaccine injury compensation program. Kennedy is expected to remake the panel in an effort to expand the list of injuries for which the government will compensate Americans. The current list does not include autism.

Also this week, Rovner interviews oncologist and bioethicist Ezekiel Emanuel to discuss his new book, Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life.

And �������ýҕ�l Health News’ annual Health Policy Valentines contest is now open. You can enter the contest here.

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

Julie Rovner: CIDRAP’s “,” by Liz Szabo.

Sheryl Gay Stolberg: Rolling Stone’s “,” by Katherine Eban.

Paige Winfield Cunningham: Politico’s “,” by Amanda Chu.

Sandhya Raman: Popular Information’s “,” by Judd Legum.

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

Julie Rovner:��Hello from��KFF��Health��News and WAMU��public radio��in Washington, D.C. Welcome to��What��the��Health?��I’m��Julie Rovner,��chief Washington correspondent for��KFF��Health��News, and��I’m��joined by��some of��the best and smartest health reporters in Washington.��We’re��taping this week on Thursday, Jan.��22,��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 videoconference by��Sandhya Raman��of CQ��Roll��Call.��

Sandhya Raman:��Good morning,��everyone.��

Rovner:��Sheryl Gay Stolberg��of The New York Times.��

Sheryl Gay Stolberg:��Hello,��Julie. Glad to be here.��

Rovner:��And Paige Winfield Cunningham��of��The Washington Post.��

Paige Winfield Cunningham:��Hey,��Julie.��

Rovner:��Later in this episode,��we’ll��have my interview with Dr.��Ezekiel Emanuel, whose new book,��Eat��Your��Ice��Cream,��is both a takedown of the wellness industrial complex and a kinder, gentler way to live a more pleasant and meaningful life. But first, this week’s news.��

So, and I��don’t��want to jinx��this,��it looks like Congress might pass a spending bill for the Department of Health and Human Services that will become law��—��meaning not a continuing resolution��—��for the first time in years. And attached to that spending bill,��scheduled for a vote in the House today,��is��a compromise health extenders��deal that��was dropped��from the final spending bill in 2024 and which��we’ll��talk about in a minute. But first,��the HHS appropriations bill. Sandhya, what are��some of��the highlights?��

Raman:��So��I think overall we��just see��a little bit of a slight increase for HHS compared to last year.��Some��agencies get a little bit of a bump:��NIH��[the National Institutes of Health],��SAMHSA��[the Substance Abuse and��Mental Health Services Administration], HRSA��[the Health Resources and Services Administration],��Administration for��Community��Living. CDC��[the Centers for Disease Control and Prevention]��is��kind of��the��same as last year. But then we do see��some��cuts in��some��places. Something that was��getting watched��a little bit was refugee and entrant��assistance, given��some of��the��different national news related to refugees and immigrants, and so��that’s��getting cut��by about a billion. And��some of��the back-and-forth there is,��some��conservatives wanted more than that,��some��Democrats��didn’t��want that to��be cut. I think the��big thing��in health��care that we were waiting on��on��this was��whether or not��they would prohibit NIH forward funding, which is something the administration has been pushing for,��just giving out a lump sum for grants through NIH rather than over a multiyear period. And the concern the Democrats had on that was that if��you’re��doing the lump sum all at first, fewer groups would get money for research. And��so��there is a prohibition on that, on doing the forward funding.��

Rovner:��But just to be clear,��the��president, the administration, had asked for deep, deep cuts��to��the Department of Health and Human Services, and Congress is��basically saying:��Yep. Nope.��

Raman:��Yeah. I think even if you look at what the��House had proposed last year, they had��cut��a lot of��programs, or proposed to cut��a lot of,��and that was not there. I think a lot of times, what we’ve seen is that��even in Trump��1, there’d be a lot more proposed cuts in their proposal, when the White House puts out their blueprint, and then��Congress comes to more of a medium point, kind of similar to previous years.��So��I think that��was something that��a lot of��the health groups had celebrated, that they weren’t going to get the steep cuts that they thought could be��part of the process.��

Rovner:��Of course, the big question here is:��Does the administration��actually spend��this money?��We saw in 2025 them refusing to spend money, cutting grants, cutting��off entire universities. And this is money that Congress had��appropriated��and that the administration is supposed to spend. Are they going to do it this time, is Congress? Have they put anything in this bill to ensure that the administration is going to do it this time?��

Raman:��There’s��a little bit here and there on��some of��that. I��don’t��think��there’s��quite the sweeping things that��some��Democrats would have wanted to prevent��some of��that.��Just last week, we had the back-and-forth with SAMHSA grants��getting pulled��and then unpulled. And��so��there’s��a little language related to��that in��there, just because that was such a big 24-hour issue. And then education funding��is coupled��with HHS,��and��there��there��is specific language saying you��can’t��transfer the money that would be for education into another department to dismantle it.��So—��

Rovner:��And,��I would say,��and basically, you��can’t��cut the Department of Education unless Congress says you can.��

Raman:��Yeah.��So��there’s��some��things in there that are like that, but to get appropriations done, it��has to��be a bipartisan thing to get that to the finish line.��So��no one is going to get everything they wanted, not even President��[Donald]��Trump.��

Rovner:��Yes, and I will point out that they are not there yet.��The��House��has to��pass this.��The Senate��has to��pass this��when they come back next week.��We’ve��got, apparently, a��gigantic snowstorm coming towards Washington, D.C.��So��it’s��moving in the right direction, but��it’s��not there yet. All right. Now onto the health package��that’s��catching a ride on��this spending bill.��What’s��in it?��And how close is it to the package that��got stripped��from the 2024 bill after Elon Musk tweeted that the bill was too many pages long?��

Raman:��I think it’s��fairly similar.��We have a lot of the same PBM��[pharmacy benefit manager]��language that we had when that got dismantled, and a lot of these same kind of extenders that we see from time to time��whenever we get an appropriations deal, extending things that are pretty bipartisan but just never have a place to ride elsewhere��—��National Health Service��Corps,��Special Diabetes Program, things like that. I think that��since this time we haven’t had that pushback, we don’t have Elon Musk weighing in and kind of pulling the strings in the way that we did before,��these have been very bipartisan provisions that��both chambers have been��saying that they want to get this done, they want to get this done as soon as possible, even in the beginning of last year.��So��I��don’t��sense that��something’s��really going to derail��language targeting��PBMs��and stuff like that.��

Rovner:��I would say the big piece of this is the deal that Congress came up with in 2024��to require more transparency on the part of these pharmacy benefit managers that everybody on both sides is accusing of��pocketing some of the savings that they’re getting from drug companies and therefore making drug prices more expensive for employers and consumers.��

Raman:��So��I think that this has been such a priority that this is their shot to get it done. And it seems like as long as nothing derails appropriations in the next day and a half, then this is their chance to do that.��

Rovner:��So��what’s��not in either of these packages are��most of��the pieces of the legislation that President Trump called for last week in his self-titled��Great��Healthcare��Plan, with the PBM provisions being a major exception. What else��is in��Trump’s plan?��And what are the prospects for passing it in��pretty much any��form this year?��

Winfield Cunningham:��I would��say��not great.��Yeah.��A��couple of things that struck me about this plan, which I would note was one page long:��This is very Trumpy. Trump obviously��loves,��he’s��a lot��more into hauling pharmaceutical CEOs into the White House to make deals than he is crafting detailed policy.��Because if you’re��actually trying��to do health care reform, this is not the way that you would do it.��What you would do is��actually spend��a lot of��time on the Hill seeing what Republicans can sign onto, and��working��with staff to��craft detailed policies��and��etc.,��etc.��But,��yeah, so��most of��this stuff��—��yet I guess another��big thing��that struck me was��a lot of��this��actually goes��after insurers. There are��some��things in here that drugmakers��don’t��like, but��Trump goes��so far as��to propose��bypassing insurers entirely and sending money to people. And of course he��doesn’t��detail��how that would work.��And then��there’s��a lot of��stuff in��here about transparency by insurers.��I would��note��the Affordable Care Act had��some��insurer transparency provisions already.��

So I think what this plan, if we want to call it a plan, reflects is just Trump’s desire to have something that he can call a��“great”��health care plan that he’s promised for a long time��and��which he’s going to��talk��a lot��about. But��yeah, I��don’t��think��we’re��going to see Republicans in Congress do��much��on this.��Yeah,��with the exception of��the PBMs, which is��pretty notable, and I think��actually��represents��a��really big��win for the pharmaceutical industry, which has obviously felt under fire in this administration and��has struck these deals with the White House, which they really��don’t��like. But they had��been threatened��that the administration would go further in trying to do this��“most favored nation”��price caps. And��so��it’s��interesting because��insurers are��kind of Trump’s��new target.��That’s��what I��kind of read��in this.��And��of course��I would mention today that major insurers are testifying on the Hill because��they’re��under fire for raising insurance premiums.��

Rovner:��Although, as��we’ve��noted��many��times,��they’re��raising insurance premiums because the cost of health care is going up. Yes,��Sheryl.��

Stolberg:��Julie, I think the political context of the��Great��Healthcare��Plan, the so-called��Great��Healthcare��Plan, is important.��First of all, Republicans have had trouble for decades��coming up with��some kind of health plan,��even before��the Affordable Care Act��was passed��and signed into law in 2010.��They��weren’t able to��do it��then.��President Trump famously��said��“nobody knew”��that health care was��“so complicated.”��He’s��in a situation now where Republicans have stripped��many��Americans of their health insurance by letting the extended Obamacare credits expire, and��we’re��going into a midterm election season in which his party and he have promised repeatedly that they were going to��come up with��a plan.��He said he had a concept of a plan. I think this plan, so to speak, is��not even a concept of a plan, and its primary provision��actually��lifts��from��what Sen.��[Bill]��Cassidy was��promoting, which was to steer money away from insurance companies and toward consumers. Trump��kind of latched��onto that. He��doesn’t��say that explicitly in this 325-word proposal, but it seems clear to me that that is his idea, and that is just not a workable idea.��

He wants, they want,��to move money into health savings accounts. I cracked up my elbow earlier this year. I had surgery to repair it. I saw the bill. The bill was $122,000.��I am very blessed to have good health insurance through my company. There is no way that the government is going to steer that kind of money into a health savings account for an uninsured person.��These are accounts that are meant to be��sort of supplemental��to spend on��relatively small��expenditures.��And if you are an uninsured person, there is really no way that you can cover yourself.��And��that’s��basically what��this��so-called��“great”��American health��care plan is proposing, which I suspect, if most Americans really looked at it, they would say, is not so great.��

Rovner:��Yeah. I��also, I��broke my wrist this summer. I also had surgery, although I had outpatient surgery,��and it cost $30,000.��So��it’s,��yeah, health��care is��really expensive, which, as I said, is why insurance premiums are going up.��So,��this week marks a year since the start of Trump 2.0,��and it would take us the rest of the year to detail all that has changed in health policy. But I did want to hit��a few��themes,��some of��which��you’ve��started to talk about,��Sheryl.��One is the administration’s effort to��basically end��the��federal��public��health structure as we know it. The Centers for Disease Control and Prevention in Atlanta has��basically been��taken over by political appointees,��most of��them without health experience or��expertise.��Sheryl,��you’re��our public health expert here. What does it mean for public health to be��basically ceded��back to the��states?��

Stolberg:��Well,��I think this��is��kind of a��novel experiment here.��The core of the CDC is its infectious disease programs. Now, over the decades, since the 1970s,��the CDC has��greatly expanded��its remit to cover things like chronic disease and gun violence prevention and auto safety,��etc.��But its core is infectious disease. And we know that infectious��disease knows��no borders.��So��what we risk having here is a patchwork of state-by-state vaccine recommendations, where��some��states will follow the CDC’s��recommendations,��presumably those��that are red states. This was never political before. And��we’re��seeing��some��states,��like blue states like New York and Massachusetts and other New England states,��kind of coming��together to put forth their own vaccine recommendations.��I think this��has implications for what vaccines will��be covered��and what vaccines will��be offered��by the Vaccines for Children��Program, which��was created��by��[President]��Bill Clinton to cover poor kids and make sure they get vaccinated. I��don’t��think we know how��that’s��going to play out.��

I saw��[Health and Human Services]��Secretary��[Robert F.]��Kennedy��[Jr.]��yesterday in Harrisburg, Pennsylvania, and he insisted that��he’s��not taking any vaccines away from anyone.��If you want your vaccines, you can get them.��But the truth is that for��decades, the American public and the medical establishment have relied on��the CDC to provide guidance. The CDC��doesn’t��mandate anything, but it��provides��really important��guidance to the country, and the agency��is crippled��now. Its guidance is not going to��be followed. And I think��we’re��in uncharted territory here.��We’re��already seeing��measles is��on the rise. The country’s about to lose its measles elimination status, which we��acquired��in 2000.��Whooping��cough is on the rise.��

Rovner:��Basically��things��we know we can prevent with vaccines.��

Stolberg:��Exactly, exactly.��

Winfield Cunningham:��One of the things I keep thinking about is, Kennedy says��over and over again��that if you’re a mom, you should do your own research.��And it seems like��a lot of��the effects here��is��stepping away from this��broad recommendation to now this patchwork of recommendations.��So��when you go to your pediatrician, you might hear guidance based on AAP’s��[the��American Academy of Pediatrics’]��guidance, for example. States are doing��different things. And as a parent, when you go to your pediatrician, it��all of a sudden, I think, becomes��a lot��more confusing, especially if��you’re��someone who��maybe already��has a little bit of hesitancy about vaccines.��

I��was in��with��our pediatrician last week and asked her what��they’re��seeing, and people��are��coming in with��a lot��more questions. And interestingly, they��actually are��changing their policy for mandatory vaccines. They��actually had��required every patient to be up to date by age��2��with the CDC-recommended vaccines. Now those vaccines that are under shared clinical decision-making,��they’re��no longer going to require those. And��it’s��not, and��they’re��going to continue to recommend them, but I think��they’re��concerned that patients are going to come��in��and��they’re��saying:��Hey, the CDC��doesn’t��necessarily recommend these now.��I’m��worried about them.��So��it’s put��pediatricians in a difficult place.��But,��yeah, it’s, as a parent,��you’re��having to make a million decisions about your children, and this just kind of makes that more complicated and confusing, potentially,��for parents.��

Rovner:��And takes time away from doctors who would like to counsel about other things,��too.��

Stolberg:��I just want to add one thing about that.��Kennedy��says��do your own research. And if you read the package inserts on a vaccine,��you’re��going to see that vaccines have side effects, just like any drug.��But that information needs context around it, and the parents who are weighing those side effects need also to��be told��about the risk of the diseases that those vaccines��are intended��to prevent. And my kids��are grown.��I’m��wondering how pediatricians are having that conversation, or if��they’re��having that conversation,��in talking to parents about:��These are the risks of the vaccine. But should your child get measles, these are the risks.��Before vaccination was widespread for measles,��450 kids died��on average every year.��Many��more��were hospitalized.��So��I think��those conversations��need to��be had.��

Winfield Cunningham:��And I think��it’s��hard for pediatricians sometimes to��illustrate that, because��we’re��so far removed from people having examples or knowing anyone who had these.��

Rovner:��Not anymore.��

Winfield Cunningham:��Not anymore.��But largely, right? I have��a lot of��parent friends, and I��don’t��know a child��who’s��had measles. Our pediatrician was telling me that when she was in medical school, it was still common for pediatric hospitals to��be filled��with babies with rotavirus. She said you could smell it down the hallway. And now, actually,��the��people in medical school,��they’re��not experiencing that,��because of widespread vaccination.��

Rovner:��All right.��Well, the second��big thing��I want to hit on is, as��Sheryl already mentioned, people��losing��their health insurance. Last summer’s big budget bill would cut��nearly a��trillion dollars from the Medicaid program and make it more difficult for people to��maintain��their coverage through the Affordable Care Act.��Republicans refusing to extend the expanded Affordable Care Act subsidies from the Biden era is already prompting people to drop coverage that they can no longer afford. What does it mean to the health care system��as a whole that��the number of Americans without health insurance is going to begin to rise again?��

Raman:��I think��it’s��a multipronged thing.��There are some aspects of these things that might not be felt immediately, that might be later this year��or��early next year as different provisions of the��[One] Big��Beautiful Bill kind of come into play��—��work requirements, things like that that might affect��how many people have insurance. But also, I think it��kind of goes��back to��some of��the things that��Sheryl and Paige were��saying about, just, if fewer people��are vaccinated, it��increases the risks for everyone. And if fewer people have health insurance, regardless of what they have, it also makes it more difficult.��If people are not��getting treated��for things,��they��get��exacerbated��into more serious conditions.��So��I think there��are��a lot of��issues at play.��Some of��them have��just,��we’re��kind of waiting��to see how the effects are.����

You know, people that may have skipped out on ACA insurance this��year,��maybe they��haven’t��needed to go to the doctor yet.��We’re��in the first month. People might not go��every month. But that��doesn’t��mean��they’re��not going to��be hit��with something big, even tomorrow, next month,��month��after that. And��so��I think��all of��these��things��kind of compound together to make it��a lot��more difficult of a situation, and just��a lot of��the complexities, I think��it’s��kind of in��both of them��where��you’re��not sure.��Oh, is this renewed? Is this not renewed?��It’s, I think,��a lot��more difficult for the average person to follow this national conversation as��much��as��people that��are really plugged��in, so that by the time that it��trickles down to��them, it’s like:��Can I sign up for health insurance��still?��Are the costs high? Am I still eligible?��It gets��more and more��confusing. And then people who might be eligible might��kind of be scared away with��some of��that chilling effect.��

Stolberg:��I should say, I think emergency rooms will also��bear the brunt of��the reduction in insurance, because without,��people who��don’t��have health insurance will forgo going to the doctor��until��their [conditions are]��unable to��be ignored. And then they will��wind up in the emergency room.��

Rovner:��And then those, I was going to say,��and then those emergency rooms will end up passing the bills that they��can’t��pay—��

Stolberg:��Exactly.��

Rovner:��—onto��others who can,��or in—��

Stolberg:��Exactly.��It will drive up��costs—��

Rovner:��Paige, started—��

Stolberg:��—in the end.��

Winfield Cunningham:��I think��a lot of��this is going to become clearer over the next couple of months. We still��don’t��really know the effects of those extra subsidies expiring.��I was��actually surprised��to see that the ACA marketplace enrollment figures they released, I believe last week,��were not actually that much lower than last year.��But people��aren’t��kicked��off their plan until they��haven’t��paid their premium for three months.��So��I think we��need to wait until April or so to see how��many��people were, say, auto-enrolled in a plan which they can no longer afford, and now��they’re��kicked off. And��maybe it’s��fewer people than we think.��Maybe��it’s��more��people than we think. But I think we just��don’t��know that yet, and��we’re��going to��have to��wait for��a��couple��months��to��see.��

Rovner:��Yeah, I think��you’re exactly��right. I had the same reaction to seeing those numbers. Like,��Wow, those are��pretty high.��And then��it’s��like,��yeah, but those��aren’t��necessarily people��who’ve��had to pay their bills yet. Those are just the people who I think may have signed up hoping that Congress was going to do something. So,��yeah, we will have to see how��many��people, I��think��it’s��called��“effectuated enrollment,”��and we��won’t��get those numbers for a little while.��

Well, finally, dismantling the federal research enterprise. As I said,��we’ve��talked about this��a lot, but I��didn’t��want to let it��sort of go��unstated. This administration appears to like to keep people guessing by cutting and then restoring research grants, refusing to spend congressionally appropriated funding until��they’re��ordered to do it by the court,��and firing or laying off workers only to call them back weeks or months later. All that makes it difficult or impossible for researchers and universities to plan their projects and personnel needs. Combined with new limits on federal student loans for��a lot of��graduate students, are we at risk of losing the next generation of researchers?��We’re��already talking about seeing people moving to Europe to continue their research.��

Stolberg:��Yes. I think the answer to that is��an unequivocal��yes.��I am hearing from scientists who are having trouble filling their postdoctoral slots.��Or young scientists.��It’s��really the next generation, right? People who are here already and who have families are trying as best they can to��sort of stick��it out, or��maybe��they’ll��go into industry if they��have to��leave academia because��they’ve��lost their grant funding, or if��they’ve��left NIH.��But it really is the next generation of researchers. I hate to draw this comparison, but we did see during World War��II, the United States absorbed��a lot of��European researchers. This is how we got Albert Einstein, right?��So��I��don’t��know that��we’ll��see necessarily��a reversal of that, of scientists fleeing, but we might see more young people choosing not to go into academic biomedicine.��

Rovner:��And��we’re��already��seeing,��it’s��not just Europe.��It’s��China and India—��

Stolberg:��Yeah.��Right.��

Rovner:��—offering packages.��

Stolberg:��And��they’re��recruiting.��Those countries��are recruiting.��Yeah,��they’re��recruiting young scientists, especially China.����

Rovner:��Yeah.��

Stolberg:��And��that’s��a good point. David Kessler, the former FDA��[Food and Drug Administration]��commissioner, has argued that this is really a national security threat for the country.��China is a main adversary of the United States, certainly of President Trump. And if��we’re��at risk of losing highly qualified biomedical researchers to China, then we are giving them an advantage.��

Rovner:��Yeah, something else we will keep an eye on, I think, for the rest of the year. OK,��we’re��going to take a quick break. We will be right back.��

Meanwhile, back to this week’s news. The American Academy of Pediatrics is leading a coalition of public health groups that are suing to reverse the changes to the childhood vaccine schedule made by the CDC earlier this month. The suit claims that the administration violated portions of the law that oversees federal advisory��committees that require membership on those panels to be,��quote,��“fairly balanced,”��and not,��quote,��“inappropriately influenced.”��Among other things, the lawsuit asked the court to ban the CDC’s��Advisory Committee on Immunization Practices from further meetings.��That would��basically stop��any further changes to the vaccine schedule,��I assume?��

Raman:��At the end of the day, what ACIP does is just a recommendation to CDC, and they can choose��whether or not��to go with that recommendation.��So��I’m not��really sure��what would happen next, but it is��kind of a��whack-a-mole situation where just because you stop this does not mean that changes above that aren’t going to happen.��

Stolberg:��Yeah.��The Advisory Committee on Immunization Practices is just that.��It’s��an advisory committee.��So��this lawsuit takes issue with appointments to that committee��and��also��complains that the committee��was not consulted��before the decision��was made��public to change the vaccine recommendations.��I’m��not exactly sure what��the legal��authority is for that.��There’s��apparently a��federal law requiring federal advisory committees to be,��quote,��“fairly balanced”��and not��“inappropriately influenced.”��But this isn’t��—��it’s��an executive action��—��right?��—��to appoint committee members. It comes out of the executive branch.��So��I don’t know of any situation in the past where the judiciary has weighed in and said,��You��can appoint these people��or��not these people, or��You��have to��redo a committee.��So��it’s��hard to predict what the courts will say about this.��

Rovner:��Meanwhile,��it’s��not just the ACIP that HHS Secretary RFK Jr.��is taking aim at. Following his remaking of that advisory committee,��he’s��now fired��some of��the members of a separate panel, the Advisory Commission on��Childhood��Vaccines, which oversees the federal Vaccine Injury Compensation Program, which Kennedy has said he also wants to revamp.��That’s��the program that compensates patients who can��demonstrate��injury from side effects of vaccines. How big a deal could this be if��he’s��going to go after the vaccine compensation program?����

Stolberg:��Julie, this��is a big deal, and��I’ll��tell you why. That committee sets what is known as the table of vaccines. Which injuries does the federal government compensate for? And the federal government does not compensate for autism as a vaccine injury. And I have no evidence of this, but if I were betting,��that is where Kennedy wants to go. He does not like the 1986 law that created the National Vaccine Injury Compensation Program because it offered liability protection to pharmaceutical companies. He wants to strip away the��liability��protection, but as I understand it, he does not want to do away with the law. He does not want to do away with the compensation program.��So��he may be trying to lay the foundation for the compensation program to be more expansive and cover injuries or allow claims for injuries that��are not currently considered��vaccine injuries,��like autism.��

Rovner:��Which of course would collapse the program because��it’s��paid for by an excise tax on vaccines. That was the original deal back in 1986. The vaccine manufacturers��said:��We’ll��pay you this tax, from which you, the federal government, will��determine��who gets compensated. And in exchange,��you’ll��relieve us of this liability, because��we’re��getting sued��to death. And if you��don’t��do this,��we’re��going to stop making vaccines entirely.��That was the origin of this back in 1986. And I was there.��I covered it.��

Stolberg:��Yeah, exactly.��I have read��a lot of��this history, and��the CDC was really��over a barrel.��The companies were writing to CDC, saying,��We’re��going to pull the plug on our vaccines.��And the CDC was worried that American kids were going to go without lifesaving vaccines because companies were going to quit making them.��So��they pushed this bill.��[President Ronald]��Reagan��didn’t��like it. He signed it into law anyway.��And it’s created this program, which is��actually imperfect.��A��lot of��people who��actually legitimately��have vaccine-injured children have trouble��getting compensated��through this program., and I think��many��people on all sides of this issue would say that it does need to��be overhauled. But it will be interesting to see who Kennedy��picks for��those committee slots.��

Rovner:��Yeah, I think��we’re��going to learn��a lot��more about it.��We’re��going to learn��a lot��more about it this year. Well, finally, in vaccine land��this week, Texas��attorney��general and U.S.��Senate candidate Ken Paxton on Wednesday announced what his office is calling a,��quote,��“wide sweeping investigation into unlawful financial incentives related to childhood vaccine recommendations.”��His statement says that there is a,��quote,��“multi-level, multi-industry scheme that has illegally incentivized medical providers to recommend childhood vaccines that are not proven to be safe or necessary.”��Actually, one��of the reasons that Congress created the Vaccines for Children��Program back in the 1990s,��Sheryl, as you mentioned earlier, is because most pediatricians lost money on giving vaccines. And today,��many��people��can’t��even get vaccines from their doctors,��because��it’s��too expensive for the doctors to stock them. What does Paxton think he might find here?��

Stolberg:��This is like��stump��the��panelists.��No one knows.��

Rovner:��I see��a lot of��people’s—��

Raman:��I’m not sure what he thinks he might find, but I do think that he is one of the attorneys general that is��generally on��the forefront of��trying things,��to throw spaghetti at the wall and see if it sticks on a variety��of issues.��So��it might be the sort of thing where if he��finds something, then it could be��kind of a��jumping point for other��conservative��attorneys��general. And��of course��just that��he’s��primarying��Sen.��John Cornyn for Senate, so if it��raises his profile for more folks. But��I’m��not sure if��there’s��a specific thing that��he’s��looking��for.��

Rovner:��So��he’s��trying to curry favor with the anti-vaxxers in Texas, of which we know there are��a lot.��

Raman:��That would be my best read.��

Stolberg:��Austin is,��actually,��the��state��capital in Austin is a hot spot for anti-vaccine activism. Andrew Wakefield, who wrote the 1998 Lancet article��that’s��been retracted, is in Austin. Del Bigtree, who runs the��Informed��Consent Action Network, is in Austin.��There’s��a group that I have����called Texans for��Vaccine��Choice that is one of the early parent-driven groups seeking to roll back vaccine mandates, is��based in Austin.��So��there’s��a lot of��sentiment there that Ken Paxton might be trying to appeal to.��

Rovner:��See?��You’ve��answered my question.��Thank you. All right, that is this week’s news. Before we get to my interview with Dr.��Zeke Emanuel, a couple of corrections from last week. First, I misspoke when I said House Republicans were becoming a minority in name only. Of course, I meant they were becoming a majority in name only. I also incorrectly said the lawsuit that helped get the��Title��X��family planning money flowing back to clinics��was filed��by Planned Parenthood. It was��actually filed��by the ACLU��[American Civil Liberties Union]��on behalf of the National��Family��Planning and��Reproductive��Health��Association. Apologies to all.��OK, now we will play my interview with Dr.��Zeke Emanuel about his new��wellness book, and then��we’ll��come back and do our extra credits.��

I am so pleased to welcome back to the podcast Dr.��Ezekiel Emanuel.��Zeke is an oncologist and bioethicist by training��and currently serves as��vice��provost for global initiatives and��professor of��medical��ethics and��health��policy at the University of Pennsylvania. He formerly worked at the National Institutes of Health before he helped write and implement the Affordable Care Act while his brother Rahm��was serving as President��[Barack]��Obama’s White House��chief of��staff. Zeke’s latest book,��Eat��Your��Ice��Cream:��Six Simple Rules for a Long and Healthy Life,��is out now. Zeke, welcome back to��What the��Health?��

Ezekiel Emanuel:��Oh,��it’s��my great honor and pleasure.��

Rovner:��So��I feel like the subtitle of this book could be��How to��Keep��Yourself��Healthy��Without��Making��Yourself Crazy or Broke��and that��it’s��a not so thinly veiled attack on what��many��of us refer to as the��“wellness industrial complex.”��What’s��gone wrong with the wellness movement? Isn’t it good for us to pursue wellness?��

Emanuel:��It is good for us to pursue wellness.��I think that there��are��probably three��things that are seriously wrong with the movement. The first one is that they make wellness an obsession that you��have to��focus all your energy on, which is��totally wrong.��Wellness should be a habit that sort of works in the background while you focus on the��really important��things of life.��I think the second thing��is they tend to overcomplicate things. Part of that is��they’ve��got to send out an email every day or every other day.��They’ve��got to do a video, a podcast, what have��you.��And��so��they make it complicated so that they have something to report on. And the third thing is they make it oversimple.��They’re��reductionist.��They talk about diet and exercise and sleep, and leave out other��very, very important��parts of wellness,��maybe the��most important part of wellness, which is your social interactions.��And��almost all��these experts ignore it.��

And the last thing I would say��—��I guess I��have four points��—��the last thing I would say is they have huge conflicts of interest. The��wellness industrial complex is between��$1-��and��$2 trillion��a year, depending��on��what you want to include in that bucket, which means that��there’s��lots of��people chasing��lots of��money trying to sell you��lots of��crazy items.��So��there’s money to��be had��and��Them��thar��hills��and people make all sorts of exaggerations. I want to emphasize for your listeners,��I’m��selling nothing, absolutely nothing.��

Rovner:��I will say,��I went to your book party.��I’ve��been to��a lot of��book parties over the years.��Yours is the first one where I��actually was��not expected to buy the book.��You��actually gave��the book��away.��

Emanuel:��Yeah,��I��can’t��stand that. Oh, I hate that.��

Rovner:��I would say, I assume you were making a point with that. I also ate��the ice��cream, which was��very good.��

Emanuel:��Yes.��

Rovner:��I feel like your underlying message here is that��it’s��not enough to make yourself biologically healthy��—��you��have to��do things that make you happy,��too. Is that a fair interpretation?��

Emanuel:��Yes,��that’s��a very fair interpretation. Look, if��you’re��going to do wellness��right,��you’re��going to be doing it for years and decades of your life. You��cannot will��yourself to do something for decades. You��can will��yourself to do��something��for��a few��weeks and��a few��months, but then, unless it becomes a habit that you��actually enjoy,��you’re simply not going to continue to do it. And��so��if you want to eat��well, you want to exercise, you want to have social interactions, you��actually have��to make them something��that’s��pleasurable for your life, something��that you find meaningful, even.��That’s, again, I��think��something��that’s��seriously missing from��a lot of��these wellness influencers, because they make��a lot of��wellness about self-denial, about:��You should deprive yourself.��You should fast.��Maybe you��should��fast.��That’s��OK��if you can do it and you can work it into your schedule.��Actually��today��is one of my fast days, so I am working it into my schedule. But��that’s��not for everyone, and��it’s��not essential to wellness and living a long and happy life.��

Rovner:��So��what are your six simple rules,��in two minutes or less?��

Emanuel:��The first one is:��Don’t��be a��schmuck.��Don’t��take unreasonable risks.��Don’t��climb Mount Everest.��Don’t��go BASE jumping.��Don’t��smoke.��Don’t��do��a lot of��other stupid things. The second is: Engage people. A rich social life is the most important thing for a long, healthy,��and happy life, and having close friends who you get together with regularly,��talk to every week, have dinners��with,��acquaintances,��very, very important. And then casually talking to people who you happen to interact with, either when you get your coffee, you go to the grocery store, you go to the restaurant, you hop in an Uber or a cab. Those are��very important��social interactions that we tend to ignore and tend to downplay. The third rule is: Keep your mind mentally sharp. And there are important aspects of that.��Don’t��retire. Take on new cognitive challenges.��

The fourth is:��Eat well,��and make sure you get rid of the unhealthy eating part and eat important, non-processed items. The fifth is:��Exercise. Do the three kinds of exercise:��aerobic exercise, strength training,��and balance and flexibility with yoga. And the last one��is:��Sleep��well.��It’s��the one you��cannot will��yourself to begin doing. You can only��sort of prep��the bedroom and then hope it happens.��

Rovner:��So��this whole thing��didn’t��really need to be book length, but you spent��a lot of��time reviewing the literature on various aspects of health and wellness, like,��you know, a scientist would. Are you trying to make a point here about the current state of science and how the public views it?��

Emanuel:��I am.��I am a data-driven guy. I like data. I think when you have more than��3 million people��that have��been surveyed��and followed in terms of social interactions and their impact on your wellness and your physical health,��that’s��worth noting, and��it’s��worth noting what those studies come to. And they all come to the same basic thing, which is you can reduce your risk of death and mortality in the��subsequent��six,��10, 12 years, depending upon the study, by about 20%��to 30% by greater social interaction, more robust friendships.��That’s��a��pretty impressive number, if you ask me.��So��I’m��trying to emphasize the data and get people to understand and��be motivated��by the data.��And I think I’m��pretty clear��about moments when I,��say, interpret the data differently than��a lot of��other people do, because I think that’s part of science.��

So,��for example, the PSA��[prostate-specific antigen]��test.��Most guidelines say you should��get��a PSA test.��I’m��against the PSA test because, yes, it will reduce your risk of dying from prostate cancer, but it does not reduce your overall mortality. I think I��don’t��much��care��what’s��written on my death certificate. I care about the length and wellness of my life, and the PSA��isn’t��going to affect that. But others disagree,��and then��I’m��very frank about��those kind of disagreements.��

Rovner:��So��in 2014 you��rather famously��wrote��an Atlantic article called��“.”��Has��writing��this book changed your mind about this? And I will say,��I’m��only a year younger than you, so I have a stake in this,��too.��

Emanuel:��No,��writing��this book��didn’t��change my mind.��It did change��some��things that I��do.��I will say,��what really changed my mind,��to the extent that anything changed my mind, was covid and the idea of getting vaccines after 75,��I think, is a good thing, especially if��whatever’s��going around is targeting older people.��It seems easy to protect yourself, whether from the flu or something like covid, with a vaccine.��So��that,��I have changed my mind. Researching this book made me put a little more emphasis on, for example, strength training, which I had not done a whole lot of, directly.��I’d��done it because I��ride��a bicycle and I��strengthen��my lower half,��my quads and my hamstrings and my gluteal muscles, but I��hadn’t��really focused on the upper body.��

Rovner:��You should do Pilates.��It’s��great.��

Emanuel:��Noted.��

Rovner:��Zeke��Emanuel. It is always fun to chat with you. And congratulations on the book.��

Emanuel:��Thank you, Julie. This has been wonderful and very rapid-fire, more rapid-fire than anyone, because you get right to the heart of things.��

Rovner:��Well, we have��a lot��more��that��we’re��going to talk about this week. Thank you,��Zeke.��

Emanuel:��Take care,��Julie.��Bye-bye.��

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

Raman:��My extra credit is called��“,”and��it’s��by Judd��Legum for��Popular��Information,��his newsletter. And I thought this was really interesting, because,��I think,��for me, I look very much at HHS and major health agencies, but his piece kind of looks at how��ICE [Immigration and Customs Enforcement]��has not been paying third-party providers for medical care for detainees since October and that��ICE,��last week, the agency kind of quietly announced that it would not be processing any of the claims for medical care until April of 2026. And��so��doctors��are instructed��to��kind of hold��on that. And that’s��kind of a��downward spiral of providers denying services to detainees because they know��they’re��not going to��get paid��for a while. And��so��I thought this was��a really interesting��piece looking��at that.��

Rovner:��Yes,��indeed. And��kind of scary. Paige.��

Winfield Cunningham:��Yeah, mine is a piece in Politico called��“,”��and��it’s��by Amanda Chu. And this really caught my eye because��it was a look at how RFK’s demonization of food and��pharma is motivating��trial��lawyers representing consumers who are saying they’ve been harmed by these products��— one example, of course, is the lawsuit against the maker of Tylenol��—��and how this really kind of goes against where Republicans have usually been,��against��trial��lawyers representing consumers who say they’ve been harmed by big, bad companies.��And so,��yeah, it was��a��really interesting��look at that and just at how RFK’s��kind of populist, pro-consumer streak has fueled all of this.��

Rovner:��The��world indeed��turned upside down.��Sheryl.��

Stolberg:��So��my extra credit is from Rolling Stone. The headline is��“,”��and��it’s��by��Katherine Eban.��She’s��a terrific journalist. And this is about the study in Guinea-Bissau. When CDC pulled back its recommendation for children to��be vaccinated��at birth against��hepatitis B, HHS gave this grant to these Danish researchers to conduct this study in Guinea-Bissau, which would compare vaccinated infants to unvaccinated infants. And there was a huge howl of protest.��This study��would��never��be done��in this country. The idea of withholding a vaccine from an��infant that has��been proven��to be safe and effective��is highly unethical. It evokes memories of the Tuskegee study,��in which government doctors withheld treatment for syphilis.��So��there was this huge uproar, and it turns out that the researchers who got the grant are these Danish statisticians who have a��really questionable��research history.��And the story documents, through emails, how they got��basically this��no-bid grant by coordinating with��some of��Kennedy’s allies from��his movement, from his vaccine��advocacy��days. And it was��kind of an��inside��deal, basically.��So��I just think that this study has generated��a lot��a��lot of��complaints. I should say that the researchers have amended the protocol, and now I think��they’re��going to give shots to one group at age��6��weeks. But still,��it’s��a very problematic study, and the story exposes how it came to be.��

Rovner:��Yeah, it is quite the story. Well, I also have an immigration story.��It’s��from my former colleague Liz Szabo at the University of Minnesota’s Center for Infectious Disease Research and Policy, and��it’s��called��“.”��And��it’s��not just undocumented people avoiding medical care, as Liz details.��U.S.��citizens with serious health needs are also scared of��getting caught��up in the��ICE��dragnet��that’s��now all around the city. And��ICE��officials have even been entering hospitals and other health facilities��—��which in previous years they had not��been allowed��to do.��In the dead of winter in Minneapolis,��with a particularly severe flu year, this is threatening to become a health crisis as well as an immigration crisis.��

OK, that’s this week’s show. Before we go,��it’s��almost February. That means our annual��KFF��Health��News��Health��Policy Valentine contest is open. Please send us your clever, heartfelt,��or hilarious tributes to the policies that shape health��care. I will post a link to��the formal announcement��in the show notes. As always, thanks to our editor,��Emmarie Huetteman,��and our producer-engineer, Francis Ying.��A��reminder:��What the��Health?��is now available on WAMU platforms, the NPR app,��and wherever you get your podcast, as well as, of course,��kffhealthnews.org.��Also��as always you can email us your comments or questions.��We’re��at��whatthehealth@kff.org.��Or you can find me still on X,��, or on Bluesky,��. Where are you folks hanging these days?��Sandhya.��

Raman:����and��, @SandhyaWrites.��

Rovner:��Sheryl��

Stolberg:��I’m����and��,��@SherylNYT.��

Rovner:��Paige.��

Winfield Cunningham:��I’m��on��X,��,��and��Bluesky,��.��

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

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Y ahora, los subsidios mejorados de la Ley de Cuidado de Salud a Bajo Precio (ACA, por sus siglas en inglés), en los que muchos estadounidenses —incluidos los agricultores— confiaban para comprar cobertura, desaparecieron luego de .

James Davis, de 55 años, cultiva algodón, soya y maíz en el norte de Louisiana. Dijo que no sabía cómo él y su esposa podrían pagar el seguro. Su parte de la prima mensual se cuadruplicó para 2026, alcanzando unos $2.700.

“No se puede pagar”, dijo Davis. “Así de simple. No hay nada que discutir. Sin los subsidios, no se puede pagar”.

Más de una cuarta parte de la fuerza laboral agrícola compra su seguro médico en el mercado individual, según .

Ese 27% es mucho más alto que el de la población general: solo el tiene cobertura fuera de los seguros de empleadores o programas públicos.

Los agricultores están acostumbrados a enfrentar desafíos como el clima impredecible y los precios variables de los productos. Pero la pérdida de los subsidios mejorados, sumada a las difíciles condiciones económicas, hará que para muchos resulte imposible pagar por cobertura médica.

Sin una intervención importante de Washington, los agricultores dicen que tendrán que elegir entre quedarse sin seguro o dejar el trabajo en el campo para conseguir un empleo que ofrezca cobertura de salud.

Un trabajo de alto riesgo

La agricultura es una actividad peligrosa. Los trabajadores del campo pasan gran parte del tiempo al aire libre. Muchas de sus tareas pueden causar lesiones o enfermedades. Operan maquinaria pesada, trabajan con químicos tóxicos y manipulan animales grandes.

La tasa de muertes relacionadas con el trabajo agrícola es que el promedio nacional.

El costo financiero de las lesiones no fatales también es significativo. del Centro Médico de la Universidad de Nebraska encontró que el costo promedio de una lesión agrícola es de $10.878 en atención médica y $4.735 en salarios perdidos.

Es fundamental que los agricultores puedan acceder a un seguro integral, dijo , socióloga rural y profesora asociada de salud y seguridad agrícola en la Universidad Estatal de Pennsylvania, donde estudia las necesidades sociales y económicas de los hogares agrícolas.

En un , Becot halló que más del 20% de los hogares agrícolas en Estados Unidos tenían deudas médicas mayores a $1.000 y que más de la mitad no confiaban en poder afrontar los costos de una enfermedad o lesión grave.

“Eso muestra el nivel de vulnerabilidad y preocupación que enfrentan los agricultores”, dijo.

La salud mental también es un motivo de alarma. Los agricultores tienen el de morir por suicidio que la población general. Las líneas de ayuda para la salud mental que atienden a comunidades rurales han visto un .

Estas preocupaciones por el de los agricultores, sumadas al , evocan recuerdos de la crisis agrícola de los años 80, dijo , vicepresidente del grupo de la industria . En esa década hubo una ola de ejecuciones hipotecarias y .

“Realmente tememos lo que pueda pasar”, dijo Klein.

Estar sin seguro no es una opción

Los agricultores pueden mostrarse renuentes a admitir que dependen de un seguro subsidiado por el gobierno, dijo Meghan Palmer, de 43 años, quien maneja una granja lechera en el noreste de Iowa junto con su esposo John, de 45.

“No somos de los que piden ayuda”, dijo Palmer.

Más del 40% de los productores lecheros no tiene seguro médico, uno de los entre todos los sectores agrícolas.

Pero quedarse sin seguro no es una opción para los Palmer.

Contaron que, en su primer año de casados, no tenían seguro y tuvieron que pagar de su bolsillo dos crisis de salud inesperadas: a Meghan le hicieron una apendicectomía y su esposo necesitó puntos después de que una vaca lo pateara en la cara.

“Fue una tontería de nuestra parte”, dijo Palmer sobre la decisión de no contratar cobertura médica.

Pero este año, el gasto mensual combinado de su bolsillo aumentará más del 90%, hasta $368.18. Su deducible total en 2026 será de $7.200.

La Granja Prairie Star ha estado en la familia de Palmer por tres generaciones. Ella espera que alguno de sus hijos quiera continuar con la operación, pero cada vez es más difícil que una granja sea rentable.

Palmer es enfermera registrada y trabaja turnos cuando la necesitan, lo que le da la flexibilidad de priorizar su trabajo en la granja. Ahora está buscando un empleo que le ofrezca seguro médico. Pero le preocupa que un trabajo que no le permita ocuparse de las labores del campo termine generándole más carga a su esposo.

“John trabaja agotado casi todo el tiempo”, dijo. “Y así es como se cometen errores y terminas en la sala de emergencias”.

Consecuencias políticas

Aunque los subsidios mejorados expiraron a finales de 2025, los Palmer calculan que su ingreso seguirá siendo lo suficientemente bajo como para que califiquen para algunos créditos fiscales que les permitan pagar la cobertura.

Sin embargo, bajo la ley propuesta por los republicanos, llamada One Big Beautiful Bill Act, . Así que si en 2026 su granja es inesperadamente rentable, tendrían que devolver parte —o incluso la totalidad— de esos subsidios al momento de hacer sus impuestos.

El ingreso de un agricultor puede variar drásticamente de un año a otro, explicó Becot, en parte porque los precios de los productos pueden fluctuar rápido.

Algunos agricultores podrían optar por no expandir su negocio deliberadamente, porque ganar demasiado podría significar perder el acceso a los subsidios de salud.

Los agricultores cubiertos por Medicaid tienen preocupaciones similares, agregó Becot. Pero priorizar la asequibilidad del seguro médico limitando el crecimiento de la operación puede tener consecuencias negativas a largo plazo para el éxito de la granja.

Palmer, en Iowa, y Davis, en Louisiana, están frustrados porque sienten que los legisladores no son suficientemente sensibles ante las exigencias económicas de la agricultura y cómo estas coinciden con el aumento en los costos de atención médica.

El presidente Donald Trump prometió recientemente $12.000 millones en únicos para productores de cultivos extensivos, pero eso no detendrá el aumento de los costos del seguro médico.

Los republicanos saben que la asequibilidad de la atención de salud es un problema y han presentado propuestas, dijo , politóloga de la Universidad del Norte de Iowa. Pero la mayoría no apoya la extensión de los subsidios mejorados de ACA porque no los considera una solución adecuada al problema del aumento en los costos.

Este artículo es parte de una alianza que incluye a��,�� y���������ýҕ�l Health News.

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“Si no tuviéramos problemas de salud, volvería a lo que hacía cuando tenía 40 años y no tendría seguro médico”, dijo. “Pero ahora no estamos en esa situación”.

Freeman y su esposo, , son trabajadores independientes que se dedican a la narración de historias y a la producción de podcasts.

En octubre, Lawrence, de 52 años, se enfermó gravemente y de forma repentina.

“Sabía que estaba en problemas”, contó. “Entré a la sala de emergencias, me acerqué al mostrador y dije: ‘Hola, subí 25 libras en cinco días, me cuesta respirar y me duele el pecho’. Y se quedaron mirándome sin parpadear”.

Los doctores le diagnosticaron una enfermedad renal y estuvo internado por cuatro días.

Ahora debe tomar un medicamento que, sin seguro, cuesta $760 al mes.

En enero, la prima de su plan actual del nivel Plata subió casi un 75%, a $801.

Para conseguir dinero extra, Freeman empezó a trabajar a medio tiempo como barman.

con planes de salud de ACA enfrentan aumentos drásticos en las primas en 2026, al no contar con el respaldo de los subsidios mejorados que el Congreso no ha renovado. Algunas personas evalúan cambios drásticos en sus vidas para poder enfrentar los nuevos precios que entraron en vigencia el 1 de enero.

Con frecuencia, recae en las mujeres la tarea de resolver el rompecabezas del seguro médico familiar.

Las mujeres suelen utilizar que los hombres, en parte por la necesidad de servicios de salud reproductiva, según , profesora de la Escuela de Salud Pública de la Universidad Brown.

También suelen ser quienes toman , especialmente en lo relacionado con los hijos.

“Hay un papel que desempeñan las mujeres, de manera desproporcionada, dentro de las familias respecto a lo que llamamos la carga mental”, explicó Tobin-Tyler, lo que incluye “tomar decisiones relacionadas con el seguro médico”.

Antes de las fiestas de fin de año, algunas formas de aliviar los aumentos en las primas, pero no se concretó ninguna medida, y ya vencieron fechas límite importantes.

¿Quedarse sin seguro?

A medida que se acercaba el final de 2025, B. se angustió tratando de decidir qué hacer con el seguro médico de su familia. Estaba buscando un trabajo de tiempo completo con beneficios, porque los precios que veía para los planes de ACA en 2026 eran alarmantes.

Mientras tanto, decidió que ella y su esposo dejarían de estar cubiertos y mantendrían solo el seguro para sus hijos. Pero sabía que era arriesgado.

“Mi esposo trabaja con herramientas pesadas todo el día”, dijo, “así que se siente como si estuviéramos jugando a la ruleta”.

NPR y �������ýҕ�l Health News la identifican solo por la inicial de su segundo nombre porque teme que sus necesidades médicas afecten su búsqueda de trabajo con beneficios de salud.

La familia vive en Providence, Rhode Island. Su esposo es carpintero independiente, y ella trabajaba como gerente de una organización sin fines de lucro hasta que perdió su empleo la primavera pasada.

Después de quedarse sin trabajo, recurrió al mercado de seguros de ACA. El de la familia les costaba casi $2.000 al mes en primas.

Era demasiado dinero, así que usaron parte de sus ahorros para la jubilación para cubrir ese gasto, mientras B. seguía buscando empleo.

Como el Congreso no extendió los subsidios mejorados para los planes de ACA —pese a las batallas políticas y al prolongado cierre del gobierno por este tema—, el plan familiar de B. habría costado aún más en 2026: casi $3.000 al mes.

“No tengo $900 adicionales por ahí para incluir en el presupuesto familiar”, dijo.

B. ya había retirado $12.000 de sus ahorros de jubilación para pagar las primas de 2025.

A no ser que encuentre un nuevo trabajo pronto, los ingresos proyectados de su familia para 2026 serán . Eso significa que los niños califican para cobertura gratuita a través de Medicaid.

Así que B. decidió comprar un plan en el mercado de ACA solo para ella y su esposo, con una prima de $1.200 al mes.

“La conclusión es que nada de esto es accesible o económico, así que vamos a tener que seguir usando nuestros ahorros para pagar”, se lamentó.

Postergar una boda

La posibilidad de primas más altas también obligó a Nicole Benisch a poner en pausa sus planes de boda.

Benisch, de 45 años, tiene un negocio de bienestar holístico en Providence. Pagaba $108 al mes por un plan Plata ��sin deducible a través del mercado de seguros de Rhode Island.

Pero el costo en 2026 es más que el doble, llegando a $220 al mes.

Ella y su prometido planeaban casarse el 19 de diciembre, el día del cumpleaños de su madre fallecida. “Y luego”, dijo, “nos dimos cuenta de cuánto iba a cambiar el costo de mi prima”.

Como pareja casada, sus ingresos combinados superarían el 400% del nivel federal de pobreza, y eso haría que Benisch dejara de ser elegible para ayuda financiera. Las primas mensuales de su plan actual se triplicarían, superando los $700 al mes.

Benisch consideró un plan Bronce, más barato, pero ese plan no cubre la terapia vocal que necesita para tratar una , una afección que puede hacer que su voz se esfuerce o se le apague.

Si se casan, hay otra opción: cambiar al plan de salud de su prometido, que vive en Massachusetts. Pero eso significaría perder a todos sus doctores en Rhode Island, ya que quedarían fuera de la red.

“Tenemos decisiones difíciles que tomar. Y ninguna de las opciones es realmente buena para nosotros”, expresó.

Este artículo forma parte de una alianza con .

�������ýҕ�l 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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“If we didn’t have health issues, I’d just go back to where I was in my 40s and not have health insurance,” she said, “but we’re not in that position now.”

Freeman and her husband, , are freelancers who work in storytelling and podcasting.

In October, Lawrence, 52, got very sick, very fast.

“I knew I was in trouble,” he said. “I went into the emergency room, and I walked over to the desk, and I said, ‘Hi, I’ve gained 25 pounds in five days and I’m having trouble breathing and my chest hurts.’ And they stopped blinking.”

Doctors diagnosed him with kidney disease, and he was hospitalized for four days.

Now Lawrence has to take medication with an without insurance of $760 a month.

In January, the cost of the couple’s current “silver” plan rose nearly 75%, to $801 a month.

To bring in extra cash, Freeman has picked up a part-time bartending gig.

Millions of who have ACA health plans are facing soaring premium payments in 2026, without help from the enhanced subsidies that Congress failed to renew. Some are contemplating big life changes to deal with new rates that kicked in on Jan. 1.

It often falls to women to figure out a family’s insurance puzzle.

Women generally than men, in part because of their need for reproductive services, according to , a professor at Brown University’s School of Public Health.

Women also tend to be the for the family, she said, especially for the children.

“There’s a disproportionate role that women play in families around what we think of as the mental load,” said Tobin-Tyler, and that includes “making decisions around health insurance.”

Before the holidays, a few forms of relief for the premium hikes, but nothing has materialized, and significant deadlines have already passed.

Going Uninsured?

As the clock ticked down on 2025, B. agonized over her family’s insurance options. She was looking for a full-time job with benefits, because the premium prices she was seeing for 2026 ACA plans were alarming.

In the meantime, she decided, she and her husband would drop coverage and insure only the kids. But it would be risky.

“My husband works with major tools all day,” she said, “so it feels like rolling the dice.”

NPR and �������ýҕ�l Health News are identifying B. by her middle initial because she believes her insurance needs could affect her ongoing search for a job with health benefits.

The family lives in Providence, Rhode Island. Her husband is a self-employed woodworker, and she worked full-time as a nonprofit manager before she lost her job last spring.

After she lost her job, she turned to the ACA marketplace. The family’s cost them nearly $2,000 a month in premiums.

It was a lot, and they dug into retirement savings to pay for it while B. kept looking for a new position.

Because Congress failed to extend enhanced subsidies for ACA plans, despite ongoing political battles and a lengthy government shutdown over the issue, B.’s family plan would have cost even more in 2026 — almost $3,000 a month.

“I don’t have an additional $900 lying around in my family budget to pay for this,” she said.

B. had already pulled $12,000 out of retirement funds to pay her family’s 2025 rates.

Unless she finds a new job soon, the family’s projected income for 2026 will be less than . That means the children qualify for free coverage through Medicaid.

So B. decided to buy a plan on the ACA marketplace for herself and her husband, paying premiums of $1,200 a month.

“The bottom line is none of this is affordable,” she said, “so we’re going to be dipping into savings to pay for this.”

Postponing a Wedding

The prospect of soaring insurance premiums put a pause on Nicole Benisch’s plans to get married.

Benisch, 45, owns a holistic wellness business in Providence. She paid $108 a month for a zero-deductible “silver” plan on Rhode Island’s insurance exchange.

But the cost in 2026 more than doubled, to $220 a month.

She and her fiance had planned to marry on Dec. 19, her late mother’s birthday. “And then,” she said, “we realized how drastically that was going to change the cost of my premium.”

As a married couple, their combined income would exceed 400% of the federal poverty level and make Benisch ineligible for financial help. Her current plan’s monthly premium payments would triple, costing her more than $700 a month.

Benisch considered a less expensive “bronze” plan, but it wouldn’t cover vocal therapy, which she needs to treat , a condition that can make her voice strain or give out.

If they get married, there’s another option: Switch to her fiance’s health plan in Massachusetts. But that would mean losing all her Rhode Island doctors, who would be out-of-network.

“We have some tough decisions to make,” she said, “and none of the options are really great for us.”

This article is from a partnership with .

�������ýҕ�l 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 .

USE OUR CONTENT

This story can be republished for free (details).