HHS is reinstating the Task Force on Safer Childhood Vaccines.

The Host Julie Rovner KFF Health News @jrovner @julierovner.bsky.social Read Julie's stories. Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

A new executive order from President Donald Trump has potentially broad implications for the future of the federal research enterprise by transferring direct funding decisions away from career professionals to political appointees.

And a gunman, reportedly disgruntled over covid vaccines, attacked the headquarters of the Centers for Disease Control and Prevention in Atlanta, highlighting how increasingly inflammatory rhetoric from health critics endangers the public health workforce.

This week’s panelists are Julie Rovner of KFF Health News, Sarah Karlin-Smith of the Pink Sheet, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin @sarahkarlin-smith.bsky.social Read Sarah's stories. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories.

Among the takeaways from this week’s episode:

• Trump’s executive order highlights the tension between how Congress has directed federal science funding and what the administration can do to alter that course. Congress has traditionally set the parameters and experts have made the judgments for moving forward. The National Institutes of Health, considered an American crown jewel, specifically has remained apolitical. But this step opens the door to concerns about grant cancellation and adds to growing uncertainty in scientific research. Even investors are starting to hold back. The ripple effects could be much bigger than the Trump administration anticipates.
• Many CDC staffers blame Health and Human Services Secretary Robert F. Kennedy Jr. and other agency leaders for stoking the negative climate that led to last week’s attack. Kennedy appears to have doubled down on his language, however, announcing decisions and policies that continue to fuel vaccine opposition and hesitation.
• This week, Kennedy also made the unprecedented move of calling on the Annals of Internal Medicine, a medical journal, to retract a study that found that the aluminum adjuvant in many childhood vaccines did not cause harm. The journal refused to retract the study based on Kennedy’s scientifically unsubstantiated claims that the additive was damaging.
• More fallout is emerging about the GOP-backed sweeping budget law enacted this summer. Republicans have argued that its cuts to Medicaid — most of which will not kick in until after the midterm elections — would touch only waste, fraud, abuse, and people who weren’t entitled to the coverage. In reality, the sprawling nature of Medicaid is already becoming clear as institutions — ranging from hospitals to community health centers — prepare for cuts that could limit their ability to provide services.
• The CDC reported this week that Americans are eating less ultra-processed food but that it is still a big part of the American diet. The Trump administration has talked a big game about addressing this public health issue yet has seemed loath to require the food industry to do anything. Much of the administration’s efforts have focused on “voluntary” changes. Former FDA chief David Kessler this week highlighted a regulatory, legal way the administration could compel more action.

Also this week, Rovner interviews Aaron Carroll, president and CEO of the health services research group AcademyHealth, about how to restore the public’s trust in public health.

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

Julie Rovner: ProPublica’s “Veterans’ Care at Risk Under Trump as Hundreds of Doctors and Nurses Reject Working at VA Hospitals,” by David Armstrong, Eric Umansky, and Vernal Coleman.

Alice Miranda Ollstein: The New York Times-KFF Health News’ “Why Young Americans Dread Turning 26: Health Insurance Chaos,” by Elisabeth Rosenthal and Hannah Norman.

Sarah Karlin-Smith: The New York Times’ “This Ohio Farm Community Is a Mecca for the ‘MAHA Mom,’” by Caroline Kitchener.

Shefali Luthra: Stat’s “Inside the American Medical Association’s Sudden Strategy Shift in Washington,” by Theresa Gaffney.

Also mentioned in this week’s podcast:

• The Washington Post’s “This Phrase Was Meant To Increase Trust in Science. It Backfired,” by Aaron E. Carroll.
• Stat’s “Former Surgeon General: The CDC Shooting Must Be a Wakeup Call,” by Jerome Adams.
• PBS NewsHour’s “Federal mRNA Funding Cut Is ‘Most Dangerous Public Health Decision’ Ever, Expert Says,” by Geoff Bennett and Karina Cuevas.
• The Washington Post’s “How Schools Could Be Hit by Medicaid Cuts,” by Terell Wright.

Credits Francis Ying Audio producer Stephanie Stapleton Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF 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 KFF.

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Jacob Sweidan has seen his patients through the federal immigration raids of the 1990s, a sitting governor’s call to abolish birthright citizenship, and the highly publicized workplace crackdowns and family separation policies of President Donald Trump’s first term.

But in his 40 years as a pediatrician in Southern California serving those too poor to afford care, including many immigrant families, Sweidan said he’s never seen a drop-off in patient visits like this.

“They are scared to come to the offices. They’re getting sicker and sicker,” said Sweidan, who specializes in neonatology and runs five clinics in Los Angeles and Orange counties. “And when they are near collapsing, they go to the ER because they have no choice.”

In the last two months, he has sent young children to the emergency room because their parents worked up the courage to call his office only after several days of high fever. He said he attended to a 14-year-old boy in the ER who was on the verge of a diabetic coma because he’d run out of insulin, his parents too frightened to venture out for a refill.

Sweidan had stopped offering telehealth visits after the covid-19 pandemic, but he and other health care providers have brought them back as ramped-up immigration enforcement drives patients without legal status — and even their U.S. citizen children — deeper into the shadows.

Patients in need of care are increasingly scared to seek it after Trump rescinded a Biden-era policy that barred immigration officials from conducting operations in “sensitive” areas such as schools, hospitals, and churches. Clinics and health plans have taken a page out of their covid playbooks, revamping tested strategies to care for patients scared to leave the house.

Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said she’s heard from clinic administrators and industry colleagues who have experienced a substantial drop in in-person visits among immigrant patients.

“I don’t think there’s a community health center in the country that is not feeling this,” Rosenbaum said.

At St. John’s Community Health clinics in the Los Angeles area, which serve an estimated 30,000 patients without legal status annually, virtual visits have skyrocketed from roughly 8% of appointments to about 25%, said Jim Mangia, president and chief executive officer. The organization is also registering some patients for in-home health visits, a service funded by private donors, and has trained employees how to read a warrant.

“People are not picking up their medicine,” Mangia said. “They’re not seeing the doctor.”

Mangia said that, in the past eight weeks, federal agents have attempted to gain access to patients at a St. John’s mobile clinic in Downey and pointed a gun at an employee during a raid at MacArthur Park. Last month, Immigration and Customs Enforcement contractors sat in a Southern California hospital waiting for a patient and federal prosecutors charged two health center workers they say interfered with immigration officers’ attempts to arrest someone at an Ontario facility.

C.S., an immigrant from Huntington Park without legal status, said she signed up for St. John’s home visit services in July because she fears going outside. The 71-year-old woman, who asked to be identified only by her initials for fear of deportation, said she has missed blood work and other lab tests this year. Too afraid to take the bus, she skipped a recent appointment with a specialist for her arthritic hands. She is also prediabetic and struggles with leg pain after a car hit her a few years ago.

“I feel so worried because if I don’t get the care I need, it can get much worse,” she said in Spanish, speaking about her health issues through an interpreter. A doctor at the clinic gave her a number to call in case she wants to schedule an appointment by phone.

Officials at the federal Department of Health and Human Services did not respond to questions from KFF Health News seeking comment about the impact of the raids on patients.

There’s no indication the Trump administration intends to shift its strategy. Federal officials have sought to pause a judge’s order temporarily restricting how they conduct raids in Southern California after immigrant advocates filed a lawsuit accusing ICE of deploying unconstitutional tactics. The 9th U.S. Circuit Court of Appeals on Aug. 1 denied the request, leaving the restraining order in place.

In July, Los Angeles County supervisors directed county agencies to explore expanding virtual appointment options after the county’s director of health services noted a “huge increase” in phone and video visits. Meanwhile, state lawmakers in California are considering legislation that would restrict immigration agents’ access to places such as schools and health care facilities — Colorado’s governor, Democrat Jared Polis, signed a similar bill into law in May.

Immigrants and their families will likely end up using more costly care in emergency rooms as a last resort. And recently passed cuts to Medicaid are expected to further stress ERs and hospitals, said Nicole Lamoureux, president of the National Association of Free & Charitable Clinics.

“Not only are clinics trying to reach people who are retreating from care before they end up with more severe conditions, but the health care safety net is going to be strained due to an influx in patient demand,” Lamoureux said.

Mitesh Popat, CEO of Venice Family Clinic, nearly 90% of whose patients are at or below the federal poverty line, said staff call patients before appointments to ask if they plan to come in person and to offer telehealth as an option if they are nervous. They also call if a patient doesn’t show five minutes into their appointment and offer immediate telehealth service as an alternative. The clinic has seen a roughly 5% rise in telehealth visits over the past month, Popat said.

In the Salinas Valley, an area with a large concentration of Spanish-speaking farmworkers, Clinica de Salud del Valle de Salinas began promoting telehealth services with Spanish radio ads in January. The clinics also trained people how to use Zoom and other digital platforms at health fairs and community meetings.

CalOptima Health, which covers nearly 1 in 3 residents of Orange County and is the biggest Medi-Cal benefits administrator in the area, sent more than a quarter-million text messages to patients in July encouraging them to use telehealth rather than forgo care, said Chief Executive Officer Michael Hunn. The insurer has also set up a webpage of resources for patients seeking care by phone or home delivery of medication.

“The Latino community is facing a fear pandemic. They’re quarantining just the way we all had to during the covid-19 pandemic,” said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, an advocacy group that promotes health access for immigrants and Latinos.

But substituting telehealth isn’t a long-term solution, said Isabel Becerra, chief executive officer of the Coalition of Orange County Community Health Centers, whose members reported increases in telehealth visits as high as 40% in the past month.

“As a stopgap, it’s very effective,” said Becerra, whose group represents 20 clinics in Southern California. “Telehealth can only take you so far. What about when you need lab work? You can’t look at a cavity through a screen.”

Telehealth also brings a host of other challenges, including technical hiccups with translation services and limited computer proficiency or internet access among patients, she said.

And it’s not just immigrants living in the country unlawfully who are scared to seek out care. In southeast Los Angeles County, V.M., a 59-year-old naturalized citizen, relies on her roommate to pick up her groceries and prescriptions. She asked that only her initials be used to share her story and those of her family and friends out of fear they could be targeted.

When she does venture out — to church or for her monthly appointment at a rheumatology clinic — she carries her passport and looks askance at any cars with tinted windows.

“I feel paranoid,” said V.M., who came to the U.S. more than 40 years ago and is a patient of Venice Family Clinic. “Sometimes I feel scared. Sometimes I feel angry. Sometimes I feel sad.”

She now sees her therapist virtually for her depression, which began 10 years ago when rheumatoid arthritis forced her to stop working. She worries about her older brother, who has high blood pressure and has stopped going to the doctor, and about a friend from the rheumatology clinic, who ices swollen hands and feet because she’s missed four months of appointments in a row.

“Somebody has to wake up or people are going to start falling apart outside on the streets and they’re going to die,” she said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF 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 KFF.

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Jacob Sweidan ha visto a sus pacientes superar las redadas federales de inmigración de la década de 1990, el pedido de un gobernador para abolir la ciudadanía por nacimiento y las muy publicitadas medidas represivas en el lugar de trabajo y las políticas de separación familiar del primer mandato del presidente Donald Trump.

Pero en sus 40 años como pediatra en el sur de California, atendiendo a personas demasiado pobres para costear la atención médica, incluyendo a muchas familias inmigrantes, Sweidan dijo que nunca había visto semejante baja en las visitas de pacientes como ahora.

“Tienen miedo de venir a las consultas. Cada vez están más enfermos”, dijo Sweidan, quien se especializa en neonatología y dirige cinco clínicas en los condados de Los Ángeles y Orange. “Y cuando están al borde del colapso, van a emergencias porque no tienen otra opción”.

En los últimos dos meses, ha enviado a niños pequeños a salas de emergencias porque sus padres solo se animaron a llamar a su consultorio después de varios días de fiebre alta. Dijo que atendió en una emergencia a un chico de 14 años que estaba al borde de un coma diabético  porque se había quedado sin insulina, y sus padres estaban demasiado asustados como para salir a buscar la reposición.

Sweidan había dejado de ofrecer consultas de telemedicina luego de la pandemia de covid-19, pero él y otros profesionales de salud las han restablecido a medida que el aumento de las medidas migratorias empuja a los pacientes sin papeles, e incluso a sus hijos ciudadanos, a una situación aún más sombría.

Los pacientes que necesitan atención médica tienen cada vez más miedo de buscarla después que Trump derogara una política de la era Biden que prohibía a los funcionarios de inmigración realizar operaciones en zonas “sensibles” como escuelas, iglesias y hospitales. Las clínicas y los planes de salud han adoptado medidas similares a las de sus manuales de covid, renovando estrategias probadas para atender a los pacientes que temen salir de casa.

Sara Rosenbaum, profesora emérita de derecho y políticas sanitarias en la Universidad George Washington, comentó que ha escuchado a administradores de clínicas y colegas del sector decir que están experimentando una disminución sustancial en las consultas en persona entre pacientes inmigrantes. “No creo que haya ningún centro de salud comunitario en el país que no esté sintiendo esto”, agregó.

En las clínicas de St. John’s Community Health, en el área de Los Ángeles, que atienden a aproximadamente 30.000 pacientes sin papeles anualmente, las visitas virtuales se han disparado del 8% del total de citas a cerca del 25%, dijo Jim Mangia, su presidente y director ejecutivo.

La organización también está registrando a algunos pacientes para visitas médicas a domicilio, un servicio financiado por donantes privados, y ha capacitado a sus empleados en la lectura de órdenes judiciales.

“La gente no recoge sus medicamentos”, dijo Mangia. “No están viendo al médico”.

Agregó que, en las últimas ocho semanas, agentes federales intentaron acceder a pacientes en una clínica móvil de St. John’s en Downey y apuntaron con un arma a un empleado durante una redada en el Parque MacArthur.

En julio, contratistas del Servicio de Inmigración y Control de Aduanas (ICE) esperaron a un paciente en un hospital del sur de California, y la fiscalía federal acusó a dos trabajadores del centro de salud que, según afirman, interfirieron con los intentos de los agentes de inmigración de arrestar a una persona en un centro de Ontario.

C.S., una inmigrante de Huntington Park sin papeles, dijo que se inscribió en los servicios de visitas domiciliarias de St. John’s en julio porque teme salir.

La mujer de 71 años, que pidió ser identificada solo por sus iniciales por temor a ser deportada, comentó que este año ha salteado análisis de sangre y otras pruebas de laboratorio. Demasiado asustada para tomar el autobús, faltó a una cita reciente con un especialista para revisar la artritis en sus manos. También es prediabética y sufre de dolor en las piernas después que un auto la atropellara hace unos años.

“Estoy muy preocupada porque si no recibo la atención que necesito, puede empeorar mucho”, dijo. Un médico de la clínica le dio un número para llamar si desea programar una cita por teléfono. Funcionarios del Departamento de Salud y Servicios Humanos federal no respondieron a las preguntas de KFF Health News en busca de comentarios sobre el impacto de las redadas en los pacientes.

No hay indicios de que la administración Trump tenga la intención de cambiar su estrategia.

Funcionarios federales han buscado frenar temporalmente la orden de un juez que restringe la forma en que realizan las redadas en el sur de California después que defensores de inmigrantes presentaran una demanda acusando a ICE de emplear tácticas inconstitucionales. El 1 de agosto, el Tribunal de Apelaciones del Noveno Circuito de Estados Unidos denegó la solicitud, dejando la orden de restricción vigente.

En julio, supervisores del condado de Los Ángeles ordenaron a las agencias del condado que exploraran la posibilidad de ampliar las opciones de citas virtuales después que el director de servicios de salud del condado observara un “enorme aumento” en las visitas telefónicas y por video.

Mientras tanto, los legisladores estatales de California están considerando una legislación que restringiría el acceso de los agentes de inmigración a lugares como escuelas y centros de salud; el gobernador de Colorado, el demócrata Jared Polis, promulgó una ley similar en mayo.

Es probable que los inmigrantes y sus familias terminen utilizando atención médica más costosa en emergencias. Y se espera que los recientes recortes aprobados para Medicaid presionen aún más las salas de emergencia y los hospitales, afirmó Nicole Lamoureux, presidenta de la National Association of Free & Charitable Clinics.

“Las clínicas no solo intentan llegar a las personas que se están alejando de la atención médica antes de que sufran afecciones más graves, sino que la red de seguridad sanitaria se verá afectada debido al aumento de la demanda de pacientes”, dijo Lamoureux.

Mitesh Popat, director ejecutivo de Venice Family Clinic, donde casi el 90% de los pacientes se encuentran en el umbral de pobreza federal o por debajo de él, explicó que el personal llama a los pacientes antes de las citas para preguntarles si planean ir en persona y para ofrecerles la telemedicina como opción, si están nerviosos.

También llaman si un paciente no se presenta cinco minutos después de su cita y ofrecen el servicio de telemedicina de inmediato como alternativa.

La clínica ha experimentado un aumento de aproximadamente el 5% en las visitas de telemedicina durante el último mes, afirmó Popat.

En el Valle de Salinas, una zona con una gran concentración de trabajadores agrícolas hispanohablantes, la Clínica de Salud del Valle de Salinas comenzó a promocionar sus servicios de telemedicina con anuncios de radio en español en enero. Las clínicas también capacitaron a las personas en el uso de Zoom y otras plataformas digitales en ferias de salud y reuniones comunitarias.

CalOptima Health, que cubre a casi uno de cada tres residentes del condado de Orange y es el mayor administrador de beneficios de Medi-Cal en la zona, envió en julio más de 250.000 mensajes de texto a pacientes, animándolos a usar la telemedicina en lugar de renunciar a la atención médica, según informó el director ejecutivo Michael Hunn.

La aseguradora también ha creado una página web con recursos para pacientes que buscan atención por teléfono o entrega de medicamentos a domicilio.

“La comunidad latina se enfrenta a una pandemia de miedo. Están en cuarentena, tal como todos tuvimos que hacerlo durante la pandemia de covid-19”, dijo Seciah Aquino, directora ejecutiva de la Latino Coalition for a Healthy California, un grupo de defensa que promueve el acceso a la salud para inmigrantes y latinos.

Pero sustituir la telemedicina no es una solución a largo plazo, afirmó Isabel Becerra, directora ejecutiva de la Coalición de Centros de Salud Comunitarios del condado de Orange, cuyos miembros reportaron aumentos de hasta un 40% en las consultas de telemedicina durante el último mes.

“Como medida provisional, es muy eficaz”, afirmó Becerra, cuyo grupo representa a 20 clínicas en el sur de California. “La telemedicina tiene sus límites. ¿Qué ocurre cuando se necesitan análisis de laboratorio? No se puede ver una caries a través de una pantalla”.

Esta estrategia también conlleva otros desafíos, como problemas técnicos con los servicios de traducción y pacientes con un dominio limitado de las computadoras o pobre acceso a internet, explicó.

Y no solo los inmigrantes que viven en el país sin papeles tienen miedo de buscar atención médica. En el sureste del condado de Los Ángeles, V.M., una ciudadana naturalizada de 59 años, depende de su compañera de piso para que recoja sus compras y recetas. Pidió que solo se usaran sus iniciales para compartir su historia y la de su familia y amigos por temor a ser blanco de ataques.

Cuando se aventura a salir, ya sea a la iglesia o a su cita mensual en una clínica de reumatología, lleva su pasaporte y mira con recelo cualquier auto con vidrios polarizados.

“Me siento paranoica”, dijo V.M., quien llegó a Estados Unidos hace más de 40 años. “A veces tengo miedo. A veces me siento enojada. A veces me siento triste”.

Ahora hace terapia virtual por su depresión, que comenzó hace 10 años cuando la artritis reumatoide la obligó a dejar de trabajar. Le preocupa su hermano mayor, que tiene hipertensión y ha dejado de ir al médico, y una amiga de la clínica de reumatología, que le pone hielo en las manos y los pies hinchados porque ha faltado a sus citas durante cuatro meses seguidos.

“Alguien tiene que reaccionar o la gente empezará a desmoronarse en las calles y morirá”, dijo.

KFF 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 KFF.

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HHS Secretary Kennedy, Jr. traveled to Alaska last week to highlight the vital role of rural hospitals and affirm his deep commitment to Tribal communities.

In southern Colorado’s San Luis Valley, clouds billow above the towering mountains of the Sangre de Cristo range. A chorus of blackbirds whistle as they flit among the reeds of a wildlife refuge. Big, circular fields of crops, interspersed with native shrubs, give it a feel of bucolic quiet.

But amid the stark beauty in one of the state’s most productive agricultural regions, there was a sense of unease among the community’s leaders as Congress debated a budget bill that could radically reshape Medicaid, the government health program for low-income people.

“I’m trying to be worried and optimistic,” said Konnie Martin, CEO of San Luis Valley Health in Alamosa, Colorado, the hub for health care services for 50,000 people in six rural counties.

Martin said Medicaid is vital to rural health care.

“I think in Colorado right now, nearly 70% of rural hospitals are operating in a negative margin,” in the red, Martin said.

The health system’s annual budget is $140 million, and Medicaid revenue makes up nearly a third of that, according to Shane Mortensen, chief financial officer for SLV Health.

The operating margin is razor-thin, so federal cuts to Medicaid could force difficult cuts at SLV. “It will be devastating to us,” Mortensen said.

The region is one of the state’s poorest. In Alamosa County, 2 in 5 residents are enrolled in Health First Colorado, the state’s Medicaid program.

It’s a lifeline, especially for people who wouldn’t otherwise have easy access to health care. That includes low-income seniors who need supplemental coverage in addition to Medicare, and people of all ages with disabilities.

Envisioning a future with deep Medicaid cutbacks leaves many patients on edge.

“I looked into our insurance and, oh my goodness, it’s just going to take half my check to pay insurance,” said Julianna Mascarenas, a mother of six. She said Medicaid has helped her cover her family for years. Mascarenas works as a counselor treating people with substance use disorders. Her ex-husband farms — potatoes and cattle — for employers that don’t offer health insurance.

Across the state, Medicaid covers 1 in 5 Coloradans, more than a million people.

That includes children in foster care.

“We’ve had 13 kids in and out of our home, six of which have been born here at this hospital with drugs in their system,” foster parent Chance Padilla said, referring to SLV’s flagship hospital in Alamosa.

“Medicaid has played a huge part in just being able to give them the normal life that they deserve,” he said. “These kids require a lot of medical intervention.”

Chris Padilla, Chance’s husband, said: “At one point, we had a preteen that needed to be seen three times a week by a mental health professional. There’s no way that we could have done that without Medicaid.”

Staff and administrators at SLV Health wonder whether federal cuts will make it hard for the system to keep its cancer center running.

“It could be pretty dramatically affected,” said Carmelo Hernandez, SLV’s chief medical officer.

The hospital in Alamosa has its own labor and delivery unit, the type of service that other rural hospitals across the U.S. have struggled to keep open. About 85% of the hospital’s labor and delivery patients are covered by Medicaid, Hernandez said.

“If we don’t have obstetric services here, then where are they going to go?” said Hernandez, whose specialty is obstetrics and gynecology. “They’re going to travel an hour and 20 minutes north to Salida to get health care. Or they can travel to Pueblo, another two-hour drive over a mountain pass.”

Tiffany Martinez, 34, was recently forced to think about that possibility after giving birth to her fourth child.

Her pregnancy was high-risk, requiring twice-a-week ultrasounds and stress tests at the hospital. She’s enrolled in Medicaid.

“Everything down here is low-pay,” Martinez said. “It’s not like we have money to just be able to pay for the doctor. It’s not like we have money to travel often to go to the doctor. So it’s definitely beneficial.”

Providing Health Care — And Jobs

With 750 workers, the health system is the valley’s largest employer. Clint Sowards, a primary care physician, said having less Medicaid funds will make it harder to attract the next generation of doctors, nurses, and other health care workers.

Certain medical specialties might no longer be available, Sowards said. “People will have to leave. They will have to leave the San Luis Valley.”

Kristina Steinberg is a family medicine physician with Valley-Wide Health Systems, a network of small clinics serving thousands in the region. She said Medicaid covers most nursing home residents in the area. “If seniors lost access to Medicaid for long-term care, we would lose some nursing homes,” she said. “They would consolidate.”

Audrey Reich Loy, a licensed social worker and SLV Health’s director of programs, said the system utilizes Medicaid “as sort of the backbone of our infrastructure.”

“It doesn’t just support those that are recipients of Medicaid,” she said. “But as a result of what it brings to our community, it allows us to ensure that we have sort of a safety net of services that we can then expand upon and provide for the entire community.”

Seeking More Efficiency

Republicans in Congress who pushed for the big spending and tax law, which estimates suggest will result in large cuts to Medicaid, say they want to save money and make the government more efficient.

Many in the Alamosa County region voted for Donald Trump. “He’s potentially affecting his voter base pretty dramatically,” Hernandez said.

He said Medicaid cuts could give President Trump’s supporters second thoughts, but he noted that politics is a sensitive topic that he mostly doesn’t discuss with patients.

Sowards said he understands that some people believe the Medicaid system is ailing and costly. But he said he has grave doubts about the proposed cure.

“Losing Medicaid would have drastic repercussions that we can’t foresee,” Sowards said.

Cuts Would Create Ripple Effect

SLV Health’s regional economic impact is more than $100 million a year, with Medicaid accounting for a major part of that, Martin said.

Any Medicaid cuts would hit the health system hard, but they would also affect small businesses and their employees. The region is feeling economic stress from other changes, like recent cuts the Trump administration made to the federal workforce.

The San Luis Valley is home to the Monte Vista National Wildlife Refuge, Great Sand Dunes National Park, and other federally managed lands.

Joe Martinez, president of San Luis Valley Federal Bank, said that recently laid-off federal workers are already coming to banks saying: “‘Can I find a way to get my next two months’ mortgage payments forgiven? Or can we do an extension?’ Or: ‘I lost my job. What can we do to make sure that I don’t lose my vehicle?’”

Ty Coleman, Alamosa’s mayor, traveled to Washington, D.C., in April to talk to Colorado’s congressional delegation. He said his message about Medicaid cuts was straightforward: “It can have a devastating economic impact.” Coleman put together a long list of possible troubles: More chronic disease and higher mortality rates. Longer wait times for care. Medical debt and financial strain on families.

“It’s not just our rural community but the communities, rural communities, across Colorado as well, and the United States,” Coleman said. “And I don’t think people are getting it.”

This article is from a partnership that includes CPR News, NPR and KFF Health News.

KFF 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 KFF.

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When a New York couple purchased a health insurance plan from a telemarketer, they thought it covered everything they wanted: doctor visits, tests, and medicine. But then came the unexpected bills for thousands of dollars, forcing them to skip crucial medical care. 

In their series “Health Care Hustlers,” Bloomberg reporters Zachary Mider and Zeke Faux revealed how this couple and thousands of other people signed up for health plans by unknowingly agreeing to work fake “jobs.”  

Mider and Faux join “An Arm and a Leg” host Dan Weissmann to peel back the surprising layers of this story, from a TV-sitcom-writer-turned-investor who masterminded the idea to the legal gray area that allows these plans to proliferate.

Dan Weissmann @danweissmann Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting. Credits Emily Pisacreta Producer Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: A Wild Health Insurance Hustle

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—

This story’s outline may sound familiar, but what’s underneath — what we unravel here: It’s a new kind of thing. And it’s weird. 

And it could become huge.

So: A couple from New York, Sarah and Joe Strohmenger started new businesses, so they needed to buy their own health insurance for the first time..

And Sarah says the New York state marketplace, with Obamacare plans, seemed a little risky: If they got a subsidy, and then their new businesses did well, they might have to pay that subsidy back.

Sarah Strohmenger: As new business owners, we had not a clue of how much we were gonna make in the year.

So we were nervous about. How much we were gonna have to back pay. 

Dan: Looking elsewhere seemed like a cautious thing to do. Google led them to a site that offered quotes for insurance policies — just enter your phone number. They started getting calls from telemarketers, a lot of them, and eventually they picked a plan one of them offered. 

Sarah and Joe thought they were being reasonably careful. After all, Insurance is a regulated business. 

Sarah Strohmenger: We’re thinking it’s monitored. We had no clue that this was kind of like a free for all.

Dan: So as you’ve probably already guessed: Pretty quickly, and very painfully, Sarah and Joe figured out that they’d been hustled. 

But it took a pair of reporters from Bloomberg News to uncover the nature of that hustle. 

Zach Mider: There’s this kind of new breed of people offering health plans to the public that are not, um, not insurance companies at all, 

Dan: That’s one of those Bloomberg reporters, Zach Mider. As Zach and his reporting partner Zeke Faux revealed, this telemarketer had — on paper — made Joe an employee of a company he’d never heard of until those reporters told him about it.

And according to the legal theory underneath all of this, making Joe a certain kind of employee allowed the salesman to sell Joe an insurance plan so skimpy that— as Zach and Zeke’s story says — it would “normally be illegal.”

Zach Mider says these kinds of plans currently operate in a legal grey area, with nobody regulating it — not states, not the feds. 

Zach Mider: So it really is just kind of this weird legal vacuum where, you know, market actors are free to kind of jump in and start trying to do this.

Dan: Which, Zach says, they seem to be doing, more and more. 

Zach Mider: It looks like the numbers are shooting up

Dan: In their Bloomberg story, Zach and Zeke cite hundreds of complaints to the FTC from people who were sold these kinds of health plans.

They also write about meeting the guy who seems to have invented these plans — a former TV sitcom writer who they say actually believes he’s solving an important problem.

Their reporting — in a series called “Health Care Hustlers” — shows something else too: 

How each hustle gets created by a chain of legally-distinct operators — some of them truly operating completely independently of each other — and how, by being just one link in a chain, each operator can say:

“I was just doing a totally legit thing. It’s not my fault if some other guy is shady.”

Basically: These stories are showing us, more clearly than I’ve ever seen, what we’re up against when we take a call from somebody who says they’ve got a great insurance plan for us.

And it’s a totally wild ride. Here we 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 on one of the most enraging, terrifying, depressing parts of American life — and bring you something entertaining, empowering and useful.

To start, here’s how bad things got for Sarah and Joe Strohmenger.

As they knew: They needed good health insurance. They’ve got pre-existing conditions.

For instance, Joe takes medicine that Sarah says costs 1500 dollars a month. And he’s got a benign brain tumor and has a doctor monitoring it. 

Sarah Strohmenger: That doctor was the most important doctor because it’s a doctor you can’t afford without health insurance.

Dan: Sarah says the monitoring includes periodic bloodwork and MRIs.

So she says when they were picking this plan, they asked about the doctor, about the tests, about the medicine, all their providers.

She says the sales rep for this plan told them, Yes. That is all covered.

Sarah Strohmenger: You know, it sounded great, covered everything that we needed.

Dan: Joe and Sarah paid about 87 hundred dollars upfront— a discount for a full year’s coverage. 

But Sarah says once they tried actually using the plan, things went south. She says their pharmacist told her Joe’s medicine wasn’t covered, and Joe’s doctor said his visits weren’t covered either.

And she says bills arrived that she did not expect.

Sarah Strohmenger: We were getting blood work bills back in the mail, for like $4,000 at a pop at a time, 3000.

Dan: According to the Bloomberg story, Joe called the company they’d bought the policy from— and reached a guy who said upgrading their plan would fix everything. They ultimately paid 20 thousand dollars for insurance that still didn’t cover what they needed.

Sarah says she thinks they also ended up on the hook for 10 to 15 thousand dollars in medical bills. 

Sarah Strohmenger: Within like six months, we stopped going to doctors.

Dan: They couldn’t afford to.

Sarah Strohmenger: We just were like, if we end up in the hospital, we’re basically screwed, you know? So Joe stopped going to all of his doctor’s appointments, he stopped taking his medication, and it was bad.

Dan: Meanwhile, Sarah says they also complained to state regulators about the company that sold them this policy.

The regulators wrote back, saying: We’ve never licensed or approved this entity. So… sorry. Sarah was like, Wait, WHAT? 

Sarah Strohmenger: I lived in a paradox that I didn’t know existed for a year. My mind was blown. 

Dan: I’m telling you — it’s REALLY weird. I’ve seen the letter, that’s what it says. And no: It’s not like there’s some other state office Sarah was supposed to write to. I checked.

Sarah says she and Joe took legal action against the marketing company, but they haven’t recovered any money. She says they paid off all the bills. And she says they signed up for a plan on New York’s Obamacare marketplace, which has been covering what they need. 

But she never understood what the heck had happened — the nature of the hustle — until she sent her story as a tip to Bloomberg News, and Zach Mider got in touch.

As it happened, he’d been digging into exactly this kind of hustle. 

Which has, I have to say, just an amazing number of layers and twists. Starting here:

When Zach looked at Sarah and Joe’s insurance cards, he noticed something that they had missed.

The name of a GROUP at the top — like as if this was a group plan, like you’d get from your job. 

And that was a key to the whole arrangement. That group — Outreach Data Partners Limited Partnership — is not an insurance company.

As Zach puts it, their legal stance is: They haven’t sold insurance to Sarah and Joe — or anybody else. That’s not the relationship.

Zach Mider: They’re claiming they have an employer-employee relationship with the people who buy health plans from them, and therefore, all of the state insurance laws don’t apply. 

Dan: Now, first: It’s actually true that for most people who get health benefits from their employer — like two-thirds — state insurance laws don’t apply. Lots of employers operate plans regulated by the federal Department of Labor.

Which Zach says is how Outreach Data Partners set up the plan Sarah and Joe bought.

All of which was news to Sarah and Joe.

Zach Mider: They just thought they were buying health insurance. 

Dan: And if they’re workers here, what was the JOB supposed to be?

Zach Mider: Yeah, that’s a great question. So, there is some work that is supposed to be done.

Dan: OK, strap in: Zach says to start with, in theory, the company gives you a special browser to use on your phone.

Zach Mider: The idea is if you want to go do something on the internet, you use this special browser and they’re collecting data about people’s browsing habits which then they can turn around and sell that information to advertisers.

Dan: So that’s the “job”: By using this browser, you’re producing value for the company— you’re working for them. Joe and Sarah told Zach they never got any special browser. And of course there’s another thing they might have expected to get from a job, ANY job: A paycheck.

And here’s how Zach says that absence gets explained.

Zach Mider: These data companies have been described to me as sort of, they’re startups, right?

Dan: And here’s where the full name of this company comes into play: ?Outreach Data Partners Limited Partnership. On paper, Joe and Sarah aren’t mere employees, they’re … limited partners— part owners. But in a company that hasn’t started making money yet. 

Zach Mider: Maybe they have a millionth share of the company. And so if the company starts making a lot of money, they will get a check. 

Dan: I don’t think Joe and Sarah are holding their breath for a check from Outreach Data Partners.

According to the Bloomberg story the company doesn’t have a public-facing website, and LinkedIn doesn’t list any employees. But the story also says that in a government filing the company claims 4,800 workers.

Zach and Zeke checked out the company’s headquarters: Box 371 at a UPS store in an Atlanta strip mall — between a dry cleaner and a Vietnamese restaurant. 

They found more than a dozen other companies using the same mailbox as their address — companies with names like Consumer Data Partners. All told, their story says these companies claim more than 30,000 employees.

And when Zach and Zeke started calling people connected to those companies, they ended up talking with the guy who seems to have invented what they call this fake-jobs healthcare setup.

A guy named Bill Bryan.

Zach Mider: Bill Bryan, was a pretty successful sitcom writer in the eighties and nineties. He wrote for Night Court

Judge from Night Court: What’s up Mac?

Mack from Night Court: A little case of disturbing the piece at a Star Trek convention, sir.

Zach Mider: And Coach

Craig Nelson: I didn’t lose the game. The team lost the game. I didn’t.

Zach Mider: And he wrote for a bunch of others. And then he does some real estate deals. He gets involved in some other investments. He ends up being a fairly wealthy guy and looking for new things to invest in, and comes across the idea of doing something with health plans.

Dan: ?Zach says, the idea was this: Obamacare had imposed standards on a lot of health insurance. Minimum stuff that had to be covered. Hospitalization. Mental health services. Prescription drugs. But covering all that stuff is expensive. It means premiums can be high, even with subsidies. And deductibles can be super-high: Thousands of dollars.

So Bill Bryan thought… 

Zach Mider: maybe if there was a way of designing a product that was legal. That covered less stuff than Obamacare, but still gave people what they wanted. You know? Um, it’s a free country. Maybe people should be able to decide what kind of healthcare they wanna buy and not have to meet all these minimum standards that maybe they’re not interested in.

Dan: So the plan that Sarah and Joe got sold, Zach says it does not meet those minimum standards. He says it covers like three doctor visits a year, a couple of lab services, and not a lot else.

Zach Mider: No coverage for hospitalization, no cover for emergency room visits. There is a prescription or there is a pharmacy benefit, but it only covers generics. 

Dan: Zach says Bill Bryan really thinks: that’s a product somebody might prefer to an Obamacare plan with a high deductible. Under the Affordable Care Act, you can’t sell that product as insurance. Actually, if you have a lot of employees, you can’t offer it to them either. 

But as a health-insurance law expert at Georgetown told me: You could maybe offer it to OWNERS of your company.

So by making people like Joe and Sarah LIMITED PARTNERS, maybe you could offer them this kind of super-stripped-down health plan legally.

Zach says: Bill Bryan thinks of this as a way to fix a problem he sees with Obamacare: Full coverage is too expensive for some people. 

Zach Mider: He’s a very smart guy, and so over the years he’s had to fight a lot for this, and I think that’s only kind of strengthened his conviction that it would be a corrective to the Obamacare system to have something that’s more affordable and more accessible for people to get.

Dan:Of course, that’s not what Joe and Sarah wanted – price wasn’t their top concern. They needed insurance that covered their providers, their treatments, their tests, their meds. That’s what they thought they were paying for.

I asked Zach and Zeke, what does Bill Bryan say about the kind of thing that happened to Joe and Sarah? 

Zach Mider: So it, it’s really important to point out here that like Bill Bryan didn’t sell the plan to Joe and Sarah. You know, he doesn’t do the call centers, right? These salespeople are all kind of independent operators who are essentially just selling this stuff for a commission. And so, he certainly doesn’t defend anybody misleading a customer.

Dan: According to Bloomberg’s story, Bryan said he had cut ties with the agency that sold Joe and Sarah their plan — years ago. 

And when he was told that the agency had sold the couple one of his plans much more recently, Bryan said, “That is absolutely news to me. I just don’t have anything more to say about any of these motherfuckers.” 

Zeke Faux: When we were talking with Bryan, though…

Dan: That’s Zach’s reporting partner, Zeke Faux.

Zeke Faux: …he and his colleagues were pretty evasive about exactly how these plans are sold.

Dan: Zeke says the way the plans are sold — specifically, the big commission rates for salespeople — was one of the reasons he and Zach got interested in this story in the first place.

Zeke Faux: Basically, the percentage of whatever the customer’s paying that is going to the salesman and the various middlemen involved is so high that it’s kind of hard to imagine that the customer could be getting a good deal. 

Dan: Even if the plan was cheap. Zach had pulled some data, crunched some numbers. The Bloomberg story says— at least in some cases— all those commissions and fees added up to 74 percent of what people like Joe and Sarah paid for these plans.

Zach Mider: If a person’s paying a dollar almost 74 cents is gonna go to commission to other various middlemen and whatever and only 26 cents is left for actually going into the pool from which medical care is paid out of. 

Dan: 26 cents for medical care. So, just to compare. Obamacare requires insurance plans to spend at least 80 cents of every dollar on medical care.

Everything else — your sales operation, all your admin costs — including the people who deny claims— and your CEO’s pay, and your profits — has to come out of that remaining 20 cents. 

With Bill Bryan’s plans, Zach’s numbers show that ratio can get almost flipped: 26 cents for medical care. 74 cents for commissions, fees, everything else

Zeke says: They brought these issues up to Bill Bryan. 

Zeke Faux: And when we tried to ask about that, Bryan and his colleagues pleaded ignorance, as if it was not really their business how the salesmen got paid.

Dan: And this is a big, big theme in this story: There’s no SINGLE entity doing all of this. It’s a chain of different players, and each one can blame the others.

Bill Bryan blamed the sales outfit for what happened to Joe and Sarah. 

And that company? Their CEO told Zach and Zeke that Outreach Data Partners screwed up, denying claims for the Strohmengers that should’ve been paid. And as the Bloomberg story reports: Bill Bryan dismissed that notion.

But there are more links in this chain than that. For instance, Outreach Data Partners — the company that theoretically made Joe and Sarah limited partners?

Bill Bryan does not run it. He doesn’t run ANY of the companies that employ 30,000 people from a mailbox in an Atlanta strip mall.

Which isn’t to say that he has nothing to do with them. That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues.

So, Bill Bryan seems to be the mastermind behind what Bloomberg calls these 30,000 fake-jobs, and the health plans they offer.

But no, he doesn’t run the data companies behind those jobs. That would be illegal. 

Zach Mider: The data companies themselves wouldn’t be allowed under federal labor law to turn a profit on these health plans.

Dan: I mean, that sounds like a good law: Your boss isn’t supposed to make money by selling you a health plan. 

Zach Mider: So it’s all very segregated. They’re very careful to say these data companies are separate from us. The data companies are employing these people and they are sponsoring these health plans. And Bill Bryan’s role is he runs a series of vendors which provides services to the data companies.

Dan: Services like … running a health plan! Which, for a normal company, is a normal arrangement.

Remember how we said: Lots of employer health plans — ones tied to normal jobs— are exempt from state insurance laws?

The way those plans are set up, the employer normally hires a vendor — typically a big insurance company, like Blue Cross or Aetna — to run their health plan.

These data companies, instead of hiring Aetna to administer a health plan — for their 30 thousand “limited partners” — they’re hiring a company that Bill Bryan happens to run.

Zach Mider: I think he’s done a pretty good job of keeping these things formally separate, right? So he’s not formally in control. He doesn’t own the data companies, doesn’t formally direct their activities.

Dan: But Zach says: Bill Bryan seems to have had a hand in getting them set up. So they could offer health plans. That he could run.

Zach Mider: I think it’s fair to say that this was his and his partner’s idea, this whole kind of construct. But he’s tried pretty hard to, as a formal matter, make it compliant with federal labor law.

Zeke Faux: I feel like we should call the data companies and be like, hey, I can see that you have a lot of complaints about your health plan. It might be hurting recruiting. You know, would you like to switch to Aetna? Then we could find out if, uh — how independent they are.

Dan: That’s Zeke again, and yeah: He and Zach wrote in their story that they found HUNDREDS of complaints to the Federal Trade Commission, and the Better Business Bureau, and Apple’s App store about health plans tied to fake jobs.

A graphic that goes with their story shows dozens of quotes, like: This whole thing feels like a big scam that I fell for.

And: I can’t imagine I am the only person who has been lied to and basically stolen from.

And: Stay away at all costs.

Which raises a big question: Is any of this really legal? Isn’t there someone regulating it?

Zach says Bill Bryan wants answers to those questions too. 

Seven years ago, a data company the Bloomberg story describes as “allied with Bryan” went to the Labor Department for clarification— and validation. Basically, they said:

Zach Mider: We want you to sign off on this and confirm to everyone in the marketplace that this is legit. That these are real employees, these limited partner employees who are downloading the web browser are real employees, and that therefore we can sell ’em, these health plans without any problem. And the Department of Labor when push came to shove said, no, these aren’t employees. You’re just trying to sell insurance.

Dan: Bryan’s allies went to court to fight back. 

Zach Mider: And they’re still fighting over it all these many years later. That was 2018 when they were first trying to get this opinion. And um, now it’s 2025 and it’s still unresolved. 

Dan: ?Here’s what’s happened so far: A district judge ruled against the Labor Department, calling its opinion “arbitrary and capricious.” An appeals court later agreed with that conclusion, but sent the case back to the district court to reconsider other details, including: what should happen next.

Zach Mider: So the way it stands, it’s really in a kind of strange limbo, where the Department of Labor really doesn’t get to say, these are legit, or these are not while we wait for the litigation to play out. But it does open the door for other people like Bill Bryan to come into the marketplace and start selling this kind of stuff. 

Dan: And it looks like they have. The Bloomberg story has a chart, showing the number of households enrolled in “fake jobs” plans. After the appeals court ruled against the labor department, the numbers more than doubled.

And meanwhile, NOBODY is regulating these plans. They’re not traditional insurance plans, so state insurance departments don’t have jurisdiction. So with the federal case on hold, people like Sarah and Joe have no one to turn to.

In a letter to the editor that Bloomberg published, Bill Bryan blames what happened to people like Sarah and Joe on the Labor Department, for not validating his model.

“If the department stepped up and played its proper role,” he wrote, “the fraud reported in your story could have very well been prevented.”

He added: “At a minimum, it would give victims someplace to seek recourse.”

So: everybody’s got somebody else to blame. 

Which is one of the themes that connects Bill Bryan’s story with a totally WILD tale that Zeke traced to Florida. One that doesn’t start out sounding like it has anything to do with health insurance.

In 2024, he writes, “if you were poor and online, certain ads were everywhere you looked.”

These ads featured celebrity deepfakes — promising 6 thousand four hundred dollars, if you call a certain phone number. 

Zeke Faux: I mean, it looks like it’s Taylor Swift, and she’s saying…

Fake Taylor Swift: Remember those stimulus checks? Well, there’s a new thing going viral. 

Zeke Faux: Or it’s Dr. Phil and he’s saying..

Fake Dr. Phil: They’re giving out $6,400 to anyone who makes the call 

Zeke Faux: Or Andrew Tate saying…

Fake Andrew Tate: If you don’t act now, you’re basically throwing away $6,400. That’s just stupid.

Zeke Faux: And these ads didn’t even, they might briefly mention health insurance or maybe they don’t say health insurance at all.

Dan: But if you called that number, you’d end up talking with someone ready to sign you up for health insurance. 

Sign you up so quickly that… you might not have any idea that’s what had just happened. 

Or, for that matter, that no, you would not be getting 64 hundred bucks to spend.

This story goes in some WILD directions, but here’s how Zeke describes the connection with the fake-jobs saga. 

Zeke Faux: in reporting both of these stories, I think what we learned is that there is kind of a subculture of call center operators who have turned what seems like a pretty boring business selling health insurance into a get rich quick kind of operation.

Dan: The call centers, the telemarketers. That’s the connection— Bloomberg paired these stories under the heading “Health Care Hustlers.”And those hustlers are always looking for a new angle. 

Which is to say: Zeke and Zach’s stories reinforce a big Arm and a Leg rule: 

If the internet leads you to a phone call with someone who says they’ve got a GREAT health insurance deal for you… be very, very suspicious.

And a lot of people will be looking for deals on health insurance. 

During the Biden Administration, Congress added more-generous subsidies to Obamacare plans, which made them more affordable. 

Unless Congress re-ups them soon— which seems unlikely— those extra subsidies will expire this year. 

People will look for alternatives, and these call centers will offer them.

In a way, it’s back to the future: 

The first Trump Administration loosened certain rules, making it easier to sell short-term plans that didn’t meet Obamacare standards. Zeke says he reported on the results back then.

Zeke Faux: I spoke with people who had bought these plans and then had medical emergencies and been stuck with 50 or a hundred thousand dollar bills, so we’ll be — we’re kinda watching to see what new products emerge or what these call centers start selling. 

Dan: And meanwhile, just — look:  Don’t buy insurance over the phone from somebody you’ve never met. Don’t bother with google. Healthcare dot gov. That’s basically it. 

What you’ll find there, I’m not saying you’ll love it. It’s probably gonna cost more than you want to pay, and deductibles will likely be high. 

But even though subsidies for Obamacare plans aren’t AS generous this year, they still exist. And these policies are regulated. Anything else… like Sarah Strohmenger said, it’s a free-for-all. And there are some hustlers out there. 

Meanwhile: the Trump Administration and Congress have both set up changes to the ACA marketplaces — administrative hassles that will make it harder to get, and keep, your coverage.

The time to start planning for it is now. And we’re gonna have some help for you, starting with next week’s First Aid Kit newsletter. 

My colleague Claire Davenport has been digging into those changes, what they mean for all of us, and how we can start preparing. 

You can sign up on our website at armandalegshow dot com, slash, first aid kit.

By the way: We just launched a new version of our website — with a brand new feature: Starter Packs. 

Here’s where we bring together our best reporting on questions you need answers to, like: How do I shop for health insurance? 

We’ll have a link wherever you’re listening, 

and we’ll be back with a new episode in a few weeks.

Until then, take care of yourself.

This episode of An Arm and a Leg was produced by Emily Pisacreta and me, Dan Weissmann — with help from Lauren Gould—

And edited by Ellen Weiss.

Claire Davenport is our engagement producer. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.

Bea Bosco is our consulting director of operations.

Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF 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 KFF Health News. He’s the editorial liaison to this show.

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR 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.

Thanks! And thanks for listening.

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

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

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF 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 KFF.

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EKALAKA, Mont. — There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.

There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

He pointed to Vermont, where a report recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.

The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told KFF Health News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

KFF 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 KFF.

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People thinking about starting a business or retiring early — before they’re old enough for Medicare — may want to wait until November, when they can see just how much their Affordable Care Act health insurance will cost next year. Sharp increases are expected.

Premiums for ACA health plans, also known as Obamacare, which many early retirees and small-business owners rely on for coverage, are going up, partly due to policy changes advanced by the Trump administration and Congress. At the same time, more generous tax subsidies that have helped most policyholders pay for coverage are set to expire at the end of December.

After that, subsidies would return to what they were before the covid-19 pandemic. Also being reinstated would be an income cap barring people who earn more than four times the federal poverty level from getting any tax credits to help them purchase coverage. Although Congress potentially could act to extend the credits, people weighing optional life changes should factor in the potential cost if lawmakers fail to do so.

“I would hate for people to make a big decision now and then, in a few months, realize, ‘I’m not even going to qualify for a tax credit next year,’” said Lauren Jenkins, an insurance agent whose brokerage helps people sign up for coverage in Oklahoma. “Coupled with the rate increases, that could be significant, especially for someone at or near retirement, when it could easily cost over $1,000 a month.”

Still, how things play out in the real world will vary.

The key factor is income, as the subsidy amount people receive is primarily based on household income and local insurance costs.

People experiencing the biggest dollar increase in out-of-pocket premiums next year will be those who lose subsidies altogether because they earn more than 400% of the federal poverty level. This year, that’s $62,600 for a single person and $84,600 for a couple.

This “subsidy cliff” was removed in the legislation first enacted during the covid pandemic to create enhanced subsidies, but it will be back next year if they expire. About 1.6 million people who earn more than 400% of the poverty threshold bought ACA plans this year, many of them getting some tax credits to help with the premiums, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

“A lot of small-biz owners fall around that level of income,” said David Chase, vice president of policy and advocacy for the Small Business Majority, a Washington, D.C.-based advocacy group, which is urging Congress to extend the credits.

And a good chunk of ACA enrollment consists of small-business owners or their employees because, unlike larger firms, most small businesses don’t offer group health plans.

In the Washington metropolitan area, “seven out of 10 people who qualify for lower premiums [because of the tax credits] are small-business owners,” said Mila Kofman, executive director of the DC Health Benefit Exchange Authority.

Congress must decide by the end of December whether to extend the subsidies a second time. Permanently doing so could cost taxpayers $335 billion over the next decade, but not acting could cause financial pain for policyholders and pose political repercussions for lawmakers.

Because new premiums and smaller subsidies would take effect in January, the potential fallout has some Republican lawmakers worried about the midterm elections, according to news reports.

Republican pollsters Tony Fabrizio and Bob Ward warned the GOP in a memo that extending the enhanced credits could mean the difference between success and failure in some midterm races, because support for the premium help “comes from more than two-thirds of Trump voters and three-quarters of Swing voters.”

While supporters credit the enhanced subsidies for a record 24 million sign-ups for this year’s ACA plans, critics have blamed them for instances in which sales brokers or consumers engaged in improper enrollment.

“The expanded subsidies were a temporary covid pandemic policy enacted by congressional Democrats on a party-line vote and scheduled to end after 2025,” said Brian Blase, president of the Paragon Health Institute, a conservative think tank. “They have led to tremendous fraud and waste, they reduce employer coverage, and they should be permitted to expire.”

Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, acknowledged that people earning more than 400% of the poverty level would not be happy with losing access to subsidies, but he expects most to stay enrolled because they want to avoid huge medical bills that could threaten their businesses or savings.

“They are middle-class or upper-income people who are self-employed, or early retirees with significant income, which means they have a lot of assets behind that income,” he said. “These are people who view insurance as financial protection.”

He thinks lawmakers would win political support from voters in this category by addressing two of their other major ACA concerns: that annual deductibles are too high and insurers’ networks of doctors and hospitals are too small.

“If you just give these people money by extending subsidies, it’s only addressing one of their problems, and it’s the one they are least upset about,” Haislmaier said. “That is the political dynamics of this.”

Here’s how the expiration of subsidies could play out for some hypothetical consumers.

People in households earning less than four times the poverty rate would still get subsidies — just not as generous as the current ones.

For example, those whose earnings are at the lower end of the income scale — say, just over 150% of the poverty threshold, or about $23,000 — will go from paying a national average of about $2 a month, or $24 toward coverage for the year, to $72 a month, or $864 a year, according to a KFF online calculator.

On the other end of the income spectrum, a 55-year-old Portland, Oregon, couple with a household income of $85,000 would also take a big hit on the cost of their benchmark plan. They currently pay about $600 a month in premiums — about 8.5% of their household income — with subsidies kicking in about $1,000 to cover the remainder.

Next year, if the tax credits expire, the same couple would not get any federal help because they earn over four times the poverty limit. They would pay the full monthly premium, with no subsidies, which would be about $1,800, based on initial 2026 premium rates filed with state regulators, said Jared Ortaliza, a policy analyst at KFF.

People should begin to see insurance rates late this fall, and certainly by Nov. 1, when the ACA’s open enrollment season begins, said Jenkins, the Oklahoma insurance agent. That gives them time to mull over whether they want to make changes in their plan — or in their lives, such as quitting a job that has health insurance or retiring early. This year, open enrollment extends to Jan. 15. Under new legislation, that open period will shorten by about a month, starting with the 2027 sign-up period.

Those who do enroll for 2026, especially the self-employed and people retiring early, should closely track their incomes during the year, she said.

It would be easy to bust through that income cap, she said.

If they do, they’ll have to pay back any tax credits they initially qualified for. Their income might rise unexpectedly during the year, for example, pushing them over the limit. An income bump could come from drawing down more money from retirement accounts than planned, landing a new customer account, or even from winning big at the casino.

“Maybe they win $5,000 at the casino, but that puts them $500 over the limit for the year,” Jenkins said. “They might have to pay back $12,000 in tax credits for winning a few thousand at the casino.”

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Se suponía que iba a ser más fácil.

Cuando la Ley de Cuidado de Salud a Bajo Precio (ACA) se aprobó en marzo de 2010, el objetivo era ayudar a que más personas en el país obtuvieran seguro médico. Y, de hecho, la creación de mercados en línea y la ampliación de los criterios de elegibilidad para Medicaid lograron ese propósito.

Sin embargo,15 años después, el sistema dista mucho de ser fácil de usar.

A los jóvenes que buscan seguro médico pueden ayudarlos los navegadores que trabajan para los mercados en línea. Pero si prefieres hacerlo por tu cuenta, aquí tienes algunos consejos para buscar un plan, en base a laexperiencia de expertos.

Abróchate el cinturón.

Comienza aquí

Inicia tu búsqueda por lo menos dos meses antes de tu cumpleaños 26 (la edad en la que los jóvenes adultos deben salir del plan de salud de sus padres). En algunos casos, puedes inscribirte en un plan con anticipación para que entre en vigencia el día de tu cumpleaños.

Primero, averigua si tu plan familiar termina el día de tu cumpleaños o al final de ese mes. Algunos estados permiten que los jóvenes permanezcan en el plan familiar hasta los 29 años, bajo ciertas condiciones y, por lo general, con costos más altos.

Un navegador podrá darte más detalles.

Podrías mantener el seguro familiar a través de COBRA, un plan federal que permite extender el tiempo bajo este plan. Pero es imporante saber que puede ser muy costoso porque se debe pagar el total de la prima.

Quienes declaran una discapacidad generalmente pueden permanecer en el plan familiar después de los 26, dependiendo del tipo de seguro que tenga la familia.

Si estás en tratamiento médico y no puedes cambiar de hospital o de doctor, pagar esta prima podría ser tu mejor opción. No tendrás esta alternativa si tu familia tiene seguro a través de un plan de ACA.

Antes de empezar a buscar, haz una lista de los medicamentos y doctores de los que dependes, y destaca aquellos que son imprescindibles para ti. Incluso puedes jerarquizarlos.

Es muy probable que tengas menos opciones en el mercado que las que tenías en el plan de tus padres. Prepárate para hacer cambios y concesiones.

Encuentra tu mercado

Treinta y dos estados adoptaron el mercado federal como el lugar al que sus residentes pueden comparar y comprar cobertura. El resto administra sus propios mercados en línea. Puedes averiguar aquí dónde comprar seguro de slaud en tu estado.

Asegúrate de entrar a un sitio oficial de ACA. Hay muchas páginas que parecen oficiales pero que en realidad las operan corredores privados. El mercado federal está en cuidadodesalud.gov y en ningún otro lugar.

Ten en cuenta que los mercados estatales oficiales a veces tienen nombres poco comunes. Ejemplos son New York State of Health, Kynect (Kentucky), Covered California y CoverMe (Maine).

En los estados que usan el mercado federal, puedes encontrar ayuda aquí. En los mercados estatales, suele haber un botón o pestaña de “find local help” (buscar ayuda local) que te dirige a alguien que puede ayudarte a encontrar un buen plan.

Generalmente, te pedirán elegir entre un corredor, que recibe comisión si te inscribes, o un “asistente” que ofrece el servicio sin costo. Los asistentes han recibido capacitación especial en el mercado donde trabajan y, al no recibir comisión, no tienen incentivos para dirigirte hacia un plan que les genere ingresos.

Los asistentes suelen ser navegadores contratados por el mercado, pero a veces trabajan para hospitales, planes de salud u organizaciones sin fines de lucro. Tendrás que preguntar.

Aunque los navegadores suelen ser una fuente confiable de asesoría, podrían ser más difíciles de encontrar ahora que la administración recortó su financiamiento en los estados que dependen del mercado federal (los estados con mercado propio no han sido afectados).

Muchas organizaciones sin fines de lucro y estados ofrecen excelentes programas de asistencia gratuita. Estos expertos te guiarán paso a paso y sabrán qué opciones seleccionar para asegurarte la mejor cobertura posible al mejor precio disponible.

Inscríbete

Una vez en un sitio oficial que ofrezca planes de ACA, te pedirán ingresar tu información personal y una estimación de tus ingresos.

Cuarenta estados y el Distrito de Columbia ofrecen Medicaid a jóvenes solteros sin hijos si sus ingresos son lo suficientemente bajos para calificar. Si cumples con los requisitos, elsitio te redirige a la plataforma de Medicaid para iniciar el proceso de inscripción, o podrías inscribirte directamente desde el mercado.

Sin embargo, debes saber que la nueva ley aprobada por los republicanos ha aumentado los requisitos y la cantidad de trámites necesarios para obtener y mantener la cobertura de Medicaid.

Medicaid, un programa conjunto federal y estatal que ofrece seguro médico a personas con bajos ingresos, no cobra prima y cubre medicamentos a bajo costo o gratis. El inconveniente es que quienes están inscritos tienen menos doctores y hospitales dentro de la red para elegir.

Si tus ingresos superan el límite para Medicaid, tendrás que buscar una póliza en el mercado.

En la mayoría de los sitios, hay una herramienta para verificar si tu doctor u hospital están dentro de la red de un plan. Pero cuidado: estos directorios suelen tener errores, pese a las leyes federales que exigen su exactitud.

Por eso, antes de seleccionar un plan, llama al doctor o hospital para confirmar que aceptan el seguro que estás considerando.

Haz números

Para los cálculos, es mejor usar una computadora que un teléfono. Generalmente, puedes comparar los costos y la cobertura de solo tres planes a la vez.

Debes considerar:

• La prima (teniendo en cuenta cualquier subsidio que recibas según tus ingresos) y otros gastos que deberás pagar, llamados “gastos compartidos”.
• Deducible: lo que debes pagar de tu bolsillo antes de que el seguro comience a cubrir los gastos. (Algunos planes incluyen ciertas visitas al médico de atención primaria sin que cuenten para el deducible).
• Copagos: cantidad fija que pagas por una visita al médico o a la sala de emergencias.
• Coseguro: porcentaje de la factura total, comúnmente entre 10% y 30%, que puede ser muy alto. Por ejemplo, con el esquema común 80-20, tú pagas el 20%. Una estancia hospitalaria puede costar decenas o cientos de miles de dólares, y el 20% de eso es mucho dinero.
• Límite de gastos de bolsillo: lo máximo que pagarás en un año, siempre que uses proveedores de la red y cumplas con el deducible.

Hacer números implica evaluar de manera integral lo que puedes pagar en primas frente a lo que puedes cubrir de los gastos mencionados antes. Si el deducible supera los $3.000 y el máximo anual de gastos es de $9.200, ¿tienes ese dinero?

En general, cuanto más baja es la prima mensual, mayor es la parte de los costos que deberás pagar si necesitas atención médica. Una misma aseguradora puede ofrecer planes muy distintos en el mismo mercado, con diferentes políticas de pago y redes.

Las personas con ingresos de hasta 2,5 veces el nivel de pobreza pueden obtener alivio en los gastos compartidos, pero solo si se inscriben en planes “Plata”. Los planes suelen clasificarse como Bronce, Plata, Oro y Platino; cada nivel refleja el porcentaje de gastos médicos que cubre el plan. Los planes de Bronce ofrecen la cobertura más baja.

Elige con sabiduría

Cuando reduzcas la lista de opciones a unos pocos planes, examínalos a fondo.

Un plan con deducible bajo podría requerir un copago diario de $1.000 o un coseguro del 50% en hospitalizaciones. Un plan que enumere tu sistema hospitalario como parte de la red podría solo incluir algunas de sus sedes, y no necesariamente las más cercanas o las que ofrecen el tipo de atención que necesitas.

Revisa el “resumen de beneficios y cobertura” para ejemplos concretos de lo que cubre el plan. Pon atención a los servicios que requieren autorización previa y, por ejemplo, cuántas visitas de fisioterapia cubren al año. La autorización previa puede ser un proceso largo y complicado.

En general, las primas más bajas implican más requisitos de autorización previa y menos cobertura. También revisa el listado de medicamentos cubiertos (llamado formulario) y confirma si tus doctores están en la red del plan.

Los planes del mercado suelen ofrecer menos opciones que los que ofrecen los empleadores: no hay tantos doctores u hospitales para elegir.

Verifica si la póliza cubre algo fuera de la red. Algunos planes pagan, por ejemplo, el 60% o 70% de los cargos aprobados, algo útil si necesitas ver un especialista fuera de la red o si la espera para una cita es muy larga.

Un estudio comprobó que las personas con planes del mercado tienen acceso, en promedio, a solo el 40% de los doctores cercanos, y en algunas zonas el acceso baja al 25%. Es probable que la cifra sea aún menor para especialistas en salud mental.

Recurso adicional

Si intentas elegir un plan y aún tienes dudas, busca uno de “precios fáciles” o estándar. Estos cumplen con ciertos requisitos básicos establecidos por los Centros de Servicios de Medicare y Medicaid (CMS), que supervisan los mercados federales. Estos planes incluyen algunas citas de atención primaria antes de que tengas que pagar el deducible.

El gobierno indica que en el mercado federal deben aparecer con la etiqueta “easy pricing”, aunque en los mercados estatales pueden identificarse de otra manera. En Nueva York, por ejemplo, se marcan simplemente con las letras ST (por estándar).

Por ahora, el financiamiento para subsidios a las primas está garantizado al menos este año, y sigue habiendo asistencia experta gratuita, así que no lo dejes pasar. Hay buenas ofertas disponibles, siempre y cuando te tomes el trabajo de encontrarlas.

Que tengas suerte.

KFF 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 KFF.

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HHS Secretary Kennedy, Jr. visited the CDC headquarters in Atlanta today in response to Friday’s tragic gunfire attack.

Centers for Disease Control and Prevention workers whose jobs have been reinstated after dizzying Trump administration disruptions say they remain stuck in a budgetary, political, and professional limbo.

Their work includes major agency priorities such as HIV testing and monitoring, as well as work at the nation’s leading sexually transmitted infections lab. And while employees are back, many projects have been canceled or stalled, as funding disappears or is delayed.

“For a while, work was staring at a blank screen,” an HIV scientist said. “I had a couple of projects before this. I’m trying to get them restarted.”

“We don’t know what’s happening or what to do,” said an HIV prevention researcher who was fired then rehired.

These employees voiced deep concern over the future of the agency and its work on HIV and other threats. The unprecedented downsizing could lead to loss of life and higher spending on medical care, they say. Their uncertain employment status has sunk morale. Many worry about the future of public health.

On Aug. 8, a gunman identified by Georgia authorities as Patrick Joseph White fired shots at CDC buildings in Atlanta. A first responder on the scene, DeKalb County police officer David Rose, was killed. White, who was found dead, was possibly motivated by his views on vaccines, according to news reports.

The attack added another level of anxiety for agency workers.

“We feel threatened from inside, and, obviously, now from outside,” a lab scientist said Aug. 10. “The trauma runs so differently in all of us. And is this the last straw for some of us? The overall morale — would you go back in the building and you could be shot at?”

Healthbeat interviewed 11 CDC workers, who offered a rare glimpse into conditions at the agency. All but one had been fired then offered their jobs back. Most have worked on HIV-related projects for at least several years. All spoke on the condition of anonymity, citing a fear of retaliation.

They fear their employment, in the HIV scientist’s terms, “is on shaky ground.”

“I’m concerned there is chaos and that we lost ground on HIV prevention” from reductions in data collection and layoffs of local public health workers, an HIV epidemiologist said. “I feel like a pawn on a chessboard.”

HHS spokesperson Emily Hilliard responded to a query with this statement:

“Under Secretary Kennedy’s leadership, the nation’s critical public health functions remain intact and effective. The Trump administration is committed to protecting essential services — whether it’s supporting coal miners and firefighters through NIOSH, safeguarding public health through lead prevention, or researching and tracking the most prevalent communicable diseases. HHS is streamlining operations without compromising mission-critical work. Enhancing the health and well-being of all Americans remains our top priority.”

The workers received some positive news July 31, when a Senate committee voted to keep CDC funding at more than $9 billion, near its current level. “It is very encouraging, but that’s only one step in the appropriations process,” the HIV researcher said.

Still, under the Trump administration’s budget request, the CDC’s programs on HIV face uncertainty. John Brooks, who retired as chief medical officer of the CDC’s Division of HIV Prevention last year, expressed concern over the Ending the HIV Epidemic initiative. Launched in President Donald Trump’s first term, it “breathed new life into HIV prevention,” Brooks said.

The successes of the Ending the HIV Epidemic initiative are jeopardized by the administration plan to scale back HIV prevention efforts, Brooks said. That would include the potential elimination of the CDC Division of HIV Prevention, which provides funds to state health departments and other groups for testing and prevention, conducts HIV monitoring and surveillance, researches HIV prevention and care, and assists medical professionals with training and education.

“There is no way to achieve the goals of EHE without maintaining the national prevention infrastructure it depends on,” Brooks said. “There is every reason to worry that in fact new HIV infections will rise again.”

Under Secretary Robert F. Kennedy Jr., the Department of Health and Human Services carried out widespread layoffs at the CDC and other health agencies beginning in early April. Lawsuits over those mass firings are playing out in federal courts.

The administration’s budget blueprint would move CDC HIV work — with many fewer employees, according to people Healthbeat interviewed — to the Administration for a Healthy America, a new HHS division Kennedy has championed.

The Medical Monitoring Project, which tracks outcomes, quality, and gaps in HIV treatment, is set to be a casualty under the Trump restructuring plan, an HIV prevention physician said.

HHS officials have not communicated with the rank and file about the restructuring, several CDC workers said.

“It’s been crickets,” the HIV scientist said.

The White House’s proposed CDC budget for the next fiscal year contains a cut of more than 50%, plummeting from $9.2 billion in fiscal year 2025 to about $4.2 billion, according to administration documents and public health advocacy groups, with some agency functions transferred to the proposed AHA. The Senate committee, by an overwhelming vote, injected billions back into the agency budget and declined to fund the AHA.

U.S. Sen. Jon Ossoff, a Georgia Democrat, thanked the committee for “rejecting the unacceptable effort to defund most of the CDC.”

“The budget request from the White House included a 56% cut to the world’s preeminent epidemiological agency,” Ossoff said. He also criticized a “systematic destruction of morale at the CDC, the disbandment of entire agencies focused on maternal health and neonatal health and disease prevention at the CDC.”

If the White House prevails and the prevention program is eliminated, “we would see most states have no funding for HIV prevention,” said Emily Schreiber, senior director of policy and legislative affairs for the National Alliance of State and Territorial AIDS Directors. “That means most states would not be able to conduct any HIV testing, any referral to care, and/or referral to preventive services like PrEP,” or pre-exposure prophylaxis, a drug that can prevent HIV infections.

“It means that states would not be able to help people get access to medications,” she said, “and that means that we would see new cases and an increased spread of HIV across the United States.”

“We would definitely see layoffs at the CDC, and I think we’d probably see them at state health departments and community-based organizations as well,” she added.

The Los Angeles County Department of Public Health has recently laid off or reassigned dozens of HIV workers due to funding problems, according to a statement emailed to Healthbeat.

“I fear all HIV prevention work will go away permanently,” the HIV prevention researcher said. “I don’t think this administration wants HIV prevention work to be done by the federal government.”

Georgia leads U.S. states in the rate of new HIV infections, according to the latest data from AIDSVu. CDC workers also said they’re concerned that vulnerable communities of color and LGBTQ+ communities would be deeply harmed by funding cuts.

In Georgia and other states, information provided by the Medical Monitoring Project about access to care will disappear, the HIV physician said. Information on prevention and treatment will dwindle for people who are disadvantaged, he said, including those with substance abuse problems or mental illness, transgender people, and those living in poverty.

“There is a lot of anger and sadness among people over the termination of the project,” the physician said. “A lot of the enthusiasm is gone.”

An effective home testing program for HIV plans to shutter this fall, said Patrick Sullivan, the Together TakeMeHome project’s lead scientist and a professor at Emory University’s Rollins School of Public Health. In its notice canceling funding for the project, the CDC said it no longer had the staff to oversee it. Based at Emory, the project delivered more than 900,000 free home testing kits to people across the country through an easy-to-use website and integration with dating apps.

More than 100 HIV workers were among the more than 450 CDC staffers brought back, said employees interviewed by Healthbeat. Some cited media coverage, support in Congress, and advocacy by patient groups and pharmaceutical companies for their reinstatement. “Members of Congress are going to bat for HIV,” the epidemiologist said.

Several are closely watching a lawsuit brought by 20 Democratic attorneys general, seeking to halt an agency restructuring plan Kennedy announced in March. They are also paying attention to a lawsuit filed in California that challenges the firings.

A few people whose jobs were restored have retired or moved on to other work. “Some people aren’t trusting we will remain, so they’re leaving,” the HIV prevention researcher said.

At the CDC’s sexually transmitted infections lab in Atlanta, work has also slowed due to a shrinking staff and new spending constraints on supplies, the lab scientist said.

Restored lab workers are focusing on high-priority areas such as syphilis and gonorrhea while other diseases have been back-burnered, the scientist said, adding “a lot of what we were doing was staying ahead of the next pathogen, and we feel like our time and effort to do that now is limited.”

“We’re all public health because we know what the mission is,” the scientist said. “We just want to get our job done and protect the American public.”

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for its national newsletter here.

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Amid the challenges of adulthood, one rite of passage is unique to the United States: the need to find your own health insurance by the time you turn 26.

That is the age at which the Affordable Care Act declares that young adults generally must get off their family’s plan and figure out their coverage themselves.

When the ACA was voted into law in 2010, what’s known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.

But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA’s online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.

The erosion of the law has now created an “insurance cliff” for Americans who are turning 26 and don’t have a job that provides medical coverage.

Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.

Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.

If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.

Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.

They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.

The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.

“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.

“The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”

(Ethan Evans)

(Maxwell Frost)

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

(Elizabeth Mathis)

(Kayla Anderson)

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, ‘What if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

(Daisy Creager)

(Madeline Nelkin)

(Valeria Chávez)

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “easy pricing” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

KFF 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 KFF.

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It was supposed to be easier than this.

When the Affordable Care Act was passed in March 2010, the goal was to help more Americans get health insurance. And, indeed, the establishment of online marketplaces and a broadening of the eligibility guidelines for Medicaid accomplished that.

Fifteen years later, however, that system is anything but user-friendly.

Young adults looking for health insurance will likely benefit from talking with so-called navigators who work for the online marketplaces. But if you want to go it alone, here are some tips about shopping for a plan, based on the advice of policy experts and people who have spent hundreds of hours helping others navigate this unwieldy set-up.

Buckle up.

Start Here

Begin your search at least two months before your 26th birthday. In some cases, you can sign up for a plan in advance so that it takes effect on your birthday.

First, find out if your family plan ends on your birthday or at the end of your birthday month. A few states allow young adults to stay on their family plan until they are 29, with certain conditions and, generally, higher costs. A navigator will know more.

You may have the option to stay, for a limited time, on your family’s plan under COBRA, a federal program that allows those with group health plans to extend their coverage past age 26. Odds that you will be approved for an extension are even higher if you can claim a disability.

Be aware, though, that this option will involve a considerable expense, since you will be required to pay the entire premium (the employer will no longer pay what is usually a substantial share). Those who claim a disability can often stay on the family plan after age 26, depending on the type of insurance the family holds.

If you’re undergoing medical treatment and can’t change hospitals or doctors, paying this premium may be your best course. You don’t have this option, however, if your family is insured through an Obamacare plan.

Before you start your search, make a list of the medicines and physicians you rely on, and highlight those you can’t do without. Rank them, even.

It’s quite likely that you will have fewer choices on the marketplace than you had on a parent’s plan. Be prepared to make some switches and trade-offs.

Find the Right Marketplace

Thirty-two states have adopted the federal marketplace as the place residents can go to compare and buy insurance policies. The rest run their own online marketplaces. You can find out here where to shop for insurance policies in your state.

Make sure you land at an official ACA website. There are many look-alikes run by private insurance brokers. The federal marketplace is found at healthcare.gov and nowhere else.

Note that official state marketplaces sometimes have unusual names. The New York State of Health, Kynect (Kentucky), Covered California, and CoverMe (Maine) are examples.

In states that use the federal marketplace, shoppers can find assistance here. On the state-based marketplaces, there is often a “find local help” button or a tab that directs you to a person who can help you find a good plan.

You will generally be asked to choose a broker, who is paid a commission if you sign up, or an “assister,” who provides the service at no cost. Assisters have received special training in the marketplace they serve, and, because they provide the service free, they have no financial incentive to steer you to a plan that pays a commission to the seller.

Assisters are often navigators who are funded by the marketplace, but in some cases they work for hospitals, health plans, or local nonprofits. You’ll have to ask.

While navigators are generally a surefire option for sound advice, they may become harder to find now that the Trump administration has cut funding for them in states that rely on the federal marketplace. (States that run their own marketplaces are unaffected.)

Many nonprofits and states run excellent programs that offer free assistance. And if, for example, you’re in the middle of cancer treatment, an assister affiliated with your hospital may offer better advice on picking a plan, since they will know which ones have contracts that may cover more of your expenses.

Ideally, these experts will walk you through the process and know which buttons to push to ensure you get the best coverage for your needs at the best rate for which you are eligible.

Sign Up

Once you’re on an official website that markets plans under the ACA, you will be asked to enter your personal information as well as an estimate of your income.

Forty states and the District of Columbia cover single young adults with no children under Medicaid if their income is low enough to qualify. If you’re eligible, you should be redirected to the Medicaid website to start the enrollment process, or you may enroll directly on the marketplace site.

But be aware that the Republicans’ recently passed domestic policy bill has increased the requirements and the paperwork required to get on, and stay on, Medicaid.

Medicaid, a joint federal and state program that provides health insurance to low-income Americans, does not charge its members a premium, and it covers medications at a nominal cost or free. The caveat is that those enrolled in the program have a smaller number of in-network doctors and hospitals to choose from.

If your income is above the threshold for Medicaid, you will need to shop on the marketplace for a policy.

On most sites, a search tool allows you to check whether your doctor or hospital is in a particular plan’s network. But beware: The directories on which this search relies are notoriously inaccurate, despite federal laws mandating otherwise.

So, before you select a plan, call the doctor or hospital to confirm they accept the insurance plan you’re considering purchasing.

Do the Math

When it comes to the math, it’s better to work on a computer than a phone. Generally, you can compare the costs of, and coverage offered by, only three plans at a time.

The following factors include premiums (taking account of any subsidy you get based on your income), as well as other expenses you’ll have to pay, called collective cost sharing:

• The deductible — the amount you generally have to pay out-of-pocket before your insurance kicks in. (You may get a few “covered” visits with a primary care doctor; these won’t count against the deductible.)
• Copayments — a fixed payment that you owe for any visit to a doctor or emergency room.
• Coinsurance (this one can break the bank) — a percentage of the total bill, generally applied to hospital bills, that you have to pay. The plan may make it sound small, say, 10% to 30%. But if you have, for example, the common 80-20 split (in which the insurer pays 80% and you pay 20%), that can add up to a substantial sum. A single day in the hospital can cost tens or even hundreds of thousands of dollars, and 20% percent of that is a large amount.
• The out-of-pocket maximum — the most you’ll have to pay out in a year, so long as you stay in network and pay the deductible.

Doing the math means looking at this holistically, balancing what you can pay in a premium against what you can afford for the above charges. If the deductible is over $3,000 and the out-of-pocket maximum allowed yearly is $9,200 — do you have that much money on hand?

Generally, the lower the monthly premium in a plan, the higher the share of costs you’ll have to pay should you need medical care. Note that an insurer may offer very different plans on the same marketplace, with different payment policies and networks.

People with incomes up to 2½ times the poverty level may gain some relief from cost-sharing charges, but only if they sign up for silver plans. Plans are typically labeled bronze, silver, gold, and platinum; each tier reflects the percentage of your medical expenses that your plan pays overall. Bronze plans offer the least amount of coverage.

Choose Wisely

Once you’ve narrowed your choices to a few plans, study each closely.

A plan with a low deductible might require a $1,000 daily copayment, or 50% coinsurance (you pay 50%) for hospital stays. A plan that lists your desired hospital system as in-network may include only some of its locations, and not necessarily the ones close to you or that offer the type of care you need.

When looking at a plan’s details, make sure to scroll down and read its “summary of benefits and coverage” for examples of the plan’s coverage of common medical needs. Pay close attention to which services require preauthorization and, for example, how many physical therapy visits they’ll cover each year. Preauthorization can be a long and cumbersome process.

Generally, the lower the premium, the more preauthorization will be required and the more limited the coverage will be. And check what drugs the plan covers (called the formulary) to see if yours are included, as well as its network of providers, to see whether your doctors are in it.

Marketplace plans tend to have limited offerings compared with job-based insurance; there aren’t as many doctors and hospitals to choose from. Click on the “provider directory” to see if an insurer’s network includes doctors and specialists you’re most likely to need, and hospitals that are acceptable and accessible to you.

Check to see if the policy offers any coverage for out-of-network providers. Some will pay, say, 60% or 70% of approved charges. It’s a useful perk if you need to see an out-of-network specialist, or if the wait for an in-network appointment is too long.

One study found that patients with marketplace plans have access to only 40% of doctors near their home, on average, and in some areas that figure was as low as 25%. It’s quite likely even lower for mental health providers.

A Backstop

If you’ve tried to choose a plan and you’re still confused, look for one of the “easy pricing” or standard plans. These conform to certain basic standards laid out by the federal Centers for Medicare & Medicaid Services, which oversees the marketplaces for the federal government. These plans offer some primary care appointments before you have to start paying the deductible.

The government says these plans must carry the label “easy pricing” on federal marketplace sites. But they may be identified differently on state-run marketplaces. In New York state, for example, they are simply marked with an ST (for standard).

Still, funding for premium subsidies is in place for this year at least, and free expert assistance is still out there, so don’t delay. There are good deals to be had, if only you put in the work.

Good luck.

KFF 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 KFF.

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KFF Health News Montana correspondent Katheryn Houghton discussed Medicaid work requirements on The Majority Report with Sam Seder on Aug. 7.

• Click here to watch Houghton on The Majority Report with Sam Seder.
• Read Houghton’s “Republicans Call Medicaid Rife With Fraudsters. This Man Sees No Choice but To Break the Rules.” and “New Medicaid Federal Work Requirements Mean Less Leeway for States,” co-reported with Bram Sable-Smith.

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed what’s fueling the rise of colon cancer in adults under 54 on CBS News 24/7’s “The Daily Report” on Aug. 4.

• Click here to watch Gounder on “The Daily Report.”

KFF 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 KFF.

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Despite recent efforts to bolster California’s behavioral health workforce, the state is operating with only about two-thirds of the psychiatrists and therapists it needs. The problem is so severe it’s making it hard to backfill retiring practitioners, particularly in the state’s rural areas. 

“It feels helpless, because there is more than you can fix. There’s more people than you can help that need it,” said Nick Zepponi, a social worker at the Hill Country Community Clinic CARE Center in Redding in Northern California. The county’s suicide rate is more than double the state average and during the covid-19 pandemic overdose deaths increased more than threefold.

For years, experts have warned of California’s severe shortages of psychologists, psychiatrists, and other professionals in the mental health and substance use fields, exacerbated by many providers’ nearing retirement. Demand has also skyrocketed, due in part to the pandemic. 

Roughly 11 million Californians live in mental health professional shortage areas, the most after Texas, according to KFF, a health information nonprofit that includes KFF Health News. Democratic Gov. Gavin Newsom’s quest to make mental health and homelessness two of his signature issues have brought additional resources into California’s behavioral health system. 

State legislators have dedicated more than $1 billion for recruitment and training and California is now tapping $1.9 billion in Medicaid funds to attract and retain behavioral health workers, enticing them with scholarships and loan repayments, and helping schools fund new residencies and fellowships. 

But the Medicaid-backed initiative took effect only in January, and proponents are unsure whether the Trump administration will maintain such investments. In a statement, U.S. Department of Health and Human Services spokesperson Emily Hilliard said the Centers for Medicare & Medicaid Services has made clear that approved waivers remain in effect. 

“That said, states should not rely on temporary demonstration funding as a substitute for sustained, direct investment in their healthcare workforce,” Hilliard added, saying the agency would continue to evaluate California’s experiment, which sunsets at the end of 2029. 

One of California’s biggest bottlenecks is its acute shortage of psychiatrists — licensed medical doctors who can prescribe antidepressants and antipsychotic drugs. While the state has opened more training slots in recent years, they can cost as much as $250,000 a year and require 12 years of postsecondary education. 

Only a tenth of the target for expanded psychiatry residencies has been met, according to the California Health Care Foundation. 

As a result, existing personnel are buckling under the workload while patients without quick access to help during a crisis are turning to costly emergency care. In 2022, patients with mental health or substance use disorders accounted for 1 in 3 inpatient hospitalizations and 1 in 6 emergency room visits, state data shows. In ERs, doctors can often do little more than temporarily stabilize these patients, since long-term treatment beds are nearly impossible to find.

KFF 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 KFF.

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MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act’s Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.

Instead, the Republican-passed budget law that includes many of President Donald Trump’s priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.

For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.

The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.

The budget law, which Republicans called the “One Big Beautiful Bill,” will cause sweeping changes to health care across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.

Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn’t make it into the law.

“Politicians in non-expansion states should be furious about that,” said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.

The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.

For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.

Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she’d splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.

Cham choked up describing the “safety net” that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.

“Obamacare has been my lifesaver,” she said.

If the enhanced ACA subsidies aren’t extended, “everyone will be hit hard,” said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for the Centers for Medicare & Medicaid Services.

“But a state that hasn’t expanded Medicaid will have marketplace people enrolling at lower income levels,” she said. “So, a greater share of residents are reliant on the marketplace.”

Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven’t are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.

KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.

Brandon Charochak, a spokesperson for McMaster’s office, said South Carolina’s Medicaid program focuses on “low-income children and families and disabled individuals,” adding, “The state’s Medicaid program does not anticipate a large impact on the agency’s Medicaid population.”

Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.

The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump’s budget law.

“That is problematic and scary for us,” said Eric Boley, president of the Wyoming Hospital Association.

He said his state, which did not expand Medicaid, has a relatively small population and hasn’t been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would “collapse the insurance market.”

As the uninsured rate rises in non-expansion states and the budget law’s Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.

Those states got slightly favorable treatment under the law, but it’s not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.

“Kansans’ ability to access affordable healthcare will be harmed,” Hoge said in an email. “Kansas, nor our rural hospitals, will not be able to make up for these cuts.”

For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.

Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.

Richard Roberson, president of the Mississippi Hospital Association, said the state’s use of what’s called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi’s rural hospitals stay open.

“That payment program has just been a lifeline,” Roberson said.

The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.

Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.

“Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,’” she said.

Those funds are not affected by Trump’s new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. “This is paying hospitals, but it’s not giving people health care,” she said. “It’s not giving people prevention.”

States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.

Mary Mayhew, president of the Florida Hospital Association, said the state’s Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.

“Children don’t have timely access to dentists,” she said. “Expectant moms don’t have access nearby to an OB-GYN. We’ve had labor and delivery units close in Florida.”

She said the law will cost states more in the long run.

“The health care outcomes for the individuals we serve will deteriorate,” Mayhew said. “That’s going to lead to higher cost, more spending, more dependency on the emergency department.”

KFF 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 KFF.

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