The Host Julie Rovner KFF Health News @jrovner 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.

President-elect Donald Trump is continuing to staff his incoming administration, and his picks so far for key health policy positions are particularly polarizing. He said he’ll nominate prominent vaccine skeptic Robert F. Kennedy Jr. to head the Department of Health and Human Services and Mehmet Oz — a controversial heart surgeon, former Senate candidate, and TV host — to run the Centers for Medicare & Medicaid Services, which oversees coverage for more than 160 million Americans.

Meanwhile, on Capitol Hill, the lame-duck Congress has just weeks to finish its work for the year, including health priorities such as pandemic preparedness, while the incoming Congress starts to lay out plans for changes to Medicaid and the Affordable Care Act.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, Riley Griffin of Bloomberg News, and Sandhya Raman of CQ Roll Call.

Panelists Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Riley Griffin Bloomberg @rileyraygriffin Read Riley's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Trump has named Kennedy as his choice for HHS secretary and Oz as head of CMS. Their appointments could create interesting tensions for Trump’s second administration. Kennedy’s crusade against ultra-processed foods could translate into more regulations in an otherwise regulation-averse administration, and Oz’s embrace of Medicare Advantage — a program that has drawn attention for costing more than traditional Medicare — could run afoul of efforts to slash government spending.
• There’s another facet of the Kennedy pick that could cause hiccups for the confirmation process: He supports abortion rights and is set to lead an agency that many in the GOP hope could play a major role in restricting abortion access nationwide. Could that detail prove problematic for Republican senators considering his nomination? Time will tell.
• With Trump transition officials vowing to clean house, especially among public health agencies, it is worth noting the broad authority granted to the HHS secretary. Congress regularly passes legislation that leaves the details to the agencies. The question, though, is how state health officials will interpret federal guidance — as considerable power on matters like vaccination policy is also left to the states.
• In the halls of Congress, congressional committees are poised for a shake-up. Many members of key health committees, such as the Energy and Commerce Committee in the House of Representatives and the Finance Committee in the Senate, are not returning. That personnel drain has broader implications: Those departing lawmakers take with them a lot of health policy knowledge.

Also this week, Rovner interviews Sarah Varney, who has been covering a trial in Idaho challenging the lack of medical exceptions in that state’s abortion ban.

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

Julie Rovner: ProPublica’s “How Lincare Became a Multibillion-Dollar Medicare Scofflaw,” by Peter Elkind.  

Sandhya Raman: ProPublica’s “How UnitedHealth’s Playbook for Limiting Mental Health Coverage Puts Countless Americans’ Treatment at Risk,” by Annie Waldman.  

Riley Griffin: The New York Times’ “A.I. Chatbots Defeated Doctors at Diagnosing Illness,” by Gina Kolata.  

Rachel Cohrs Zhang: CNBC’s “Dental Supply Stock Surges on RFK’s Anti-Fluoride Stance, Activist Involvement,” by Alex Harring.  

Also mentioned in this week’s podcast:

• Bloomberg News’ “Deep in the Jungle, Virus Hunters Are Working to Stop the Next Pandemic,” by Riley Griffin.
• Stat’s “RFK Jr. Is Exploring a Plan To Upend Medicare’s Physician Payments System,” by Rachel Cohrs Zhang.

Credits Lonnie Ro Audio producer Taylor Cook Audio producer Emmarie Huetteman 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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The Host Julie Rovner KFF Health News @jrovner 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.

Come January, Republicans will control the House of Representatives, Senate, and White House, regaining full power for the first time since 2018. That will give them significant clout to dramatically change health policy. But slim margins in Congress will leave little room for dissent.

Meanwhile, President-elect Donald Trump has vowed not to touch Medicare, though there are Medicare-related issues — including drug price negotiations and physician pay — that will soon demand attention.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Rachel Roubein of The Washington Post, and Lauren Weber of The Washington Post.

Panelists Anna Edney Bloomberg @annaedney Read Anna's stories. Rachel Roubein The Washington Post @rachel_roubein Read Rachel's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

• Republicans will control the House and the Senate beginning next year, potentially offering Trump crucial votes in support of his nominees and agenda. However, the party will govern with only a narrow majority in both chambers, which could hamper its ability to make sweeping or controversial changes. Regardless, the GOP will steer legislative efforts, such as setting government spending levels and limits, and control committees that decide what to prioritize and oversee.
• Trump this week named several people he intends to nominate to his Cabinet. Yet many of his picks lack relevant experience or have staked out controversial policy positions — or both — raising the question: Can they clear the Senate confirmation process? Trump has suggested using recess appointments to get around that, a method that would largely bypass the Senate and limit his Cabinet secretaries’ authority.
• Meanwhile, among the issues on Robert F. Kennedy Jr.’s health agenda are some that resonate with Democrats, such as cracking down on ultra-processed foods and food dyes. Notably, those sorts of initiatives — which could tighten rules for businesses, for instance — have not been part of the traditional conservative playbook.
• And, looking ahead, there’s a lot the Trump administration could do to further erode abortion rights, and the GOP is likely to see this as a moment for trying things.

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

Julie Rovner: KFF Health News’ “In Vermont, Where Almost Everyone Has Insurance, Many Can’t Find or Afford Care,” by Phil Galewitz.

Anna Edney: The Atlantic’s “Throw Out Your Black Plastic Spatula,” by Zoë Schlanger.

Rachel Roubein: Politico’s “‘Been a Long Time Since I Felt That Way’: Sexually Transmitted Infection Numbers Provide New Hope,” by Alice Miranda Ollstein.

Lauren Weber: JAMA Network Open’s “Medical Board Discipline of Physicians for Spreading Medical Misinformation,” by Richard S. Saver.

Also mentioned in this week’s podcast:

• The Washington Post’s “RFK Jr. Faces Battles in Question To Change America’s Food,” by Rachel Roubein, Lauren Weber, Michael Scherer, and David Ovalle.
• CNN’s “Lunchables Removed From National School Lunch Program,” by Madeline Holcombe.
• Politico’s “Abortion Opponents Prepare To Undermine Just-Passed Ballot Measures,” by Alice Miranda Ollstein.
• The Wall Street Journal’s “The Sickest Patients Are Fleeing Private Medicare Plans — Costing Taxpayers Billions,” by Anna Wilde Mathews, Christopher Weaver, and Tom McGinty.

Credits Taylor Cook Audio producer Lonnie Ro Audio producer Emmarie Huetteman 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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The Host Julie Rovner KFF Health News @jrovner 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.

Health care might not have been the biggest issue in the campaign, but the return of Donald Trump to the presidency is likely to have a seismic impact on health policy over the next four years. 

Changes to the Affordable Care Act, Medicaid, and the nation’s public health infrastructure are likely on the agenda. But how far Trump goes will depend largely on who staffs key health policy roles and on whether Democrats take a majority in the U.S. House, where several races remain uncalled. 

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Stat, and Alice Miranda Ollstein of Politico.

Panelists Rachel Cohrs Zhang Stat News @rachelcohrs Read Rachel's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories.

Among the takeaways from this week’s episode:

• As of Friday morning, it remained unclear which party will control the House next year. A Democratic-controlled House would offer a check against Republican policy changes and some control of key government oversight committees. A Republican House would give the party full control of Congress and the presidency. Either way, the party in control will have a slim majority.
• Majorities of voters in eight states voted to protect abortion rights — though the ballot measures passed in only seven states. (More than half of voters in Florida voted for the abortion rights measure, but the state requires at least 60% support for ballot measures to pass.)
• Robert F. Kennedy Jr. — now a key voice in the Trump transition team — is telegraphing big plans for health policy. Who ends up in Trump’s Cabinet will make a difference, as the president-elect is seemingly outsourcing much of his health policy planning in favor of focusing on issues such as the economy, immigration, and trade.
• And conservative appointees throughout the judicial system are likely to remain friendly to Trump administration causes, which could open the door to more challenges to federal policies. Several important legal challenges are already winding through the courts.

Also this week, Rovner interviews KFF Health News’ Jackie Fortiér, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month” feature, about a 2-year old who had an expensive run-in with a rattlesnake. Do you have a medical bill that is exorbitant, baffling, infuriating, or all of the above? Tell us about it!

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

Julie Rovner: KFF Health News’ “Dentists Are Pulling ‘Healthy’ and Treatable Teeth to Profit From Implants, Experts Warn,” by Brett Kelman and Anna Werner of CBS News. 

Alice Miranda Ollstein: Politico’s “The Election’s Stakes for Global Health,” by Carmen Paun. 

Rachel Cohrs Zhang: KFF Health News’ “As Nuns Disappear, Many Catholic Hospitals Look More Like Megacorporations,” by Samantha Liss. 

Also mentioned in this week’s podcast:

• The New York Times’ “R.F.K. Jr. Lays Out Possible Public Health Changes Under Trump,” by Remy Tumin.
• KFF Health News’ “Toddler’s Backyard Snakebite Bills Totaled More Than a Quarter Million Dollars,” by Jackie Fortiér.

Credits Zach Dyer Audio producer Emmarie Huetteman 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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In the final days of the campaign, stark disagreements between Vice President Kamala Harris and former President Donald Trump over the future of American health care are on display — in particular, in sober warnings about abortion access, the specter of future cuts to the Affordable Care Act, and bold pronouncements about empowering activists eager to change course and clean house.

Trump and his campaign have been vague about plans on health care policies, though current and former Trump aides have published blueprints that go well beyond reversing programs in force under the Biden administration, to overhauling public health agencies and enabling Trump to quickly fire officials who disagree.

Harris, on the other hand, has staked out positions primarily preserving and protecting existing health care access — on abortion, transgender health care, insurance coverage, and more.

Here are some of the most consequential changes in health policies that could hinge on who wins the White House.

ACA Premiums

The election is likely to affect the cost of health insurance for millions who buy coverage on the Affordable Care Act marketplaces.

That’s because extra, pandemic-era subsidies that lower the cost of premiums will expire at the end of 2025 — unless Congress and the next president act.

Harris has pledged to make the enhanced subsidies permanent, while Trump has made no such commitment.

Letting them expire “would reduce fraud and waste,” said Brian Blase, a former Trump adviser who is president of the Paragon Health Institute, a conservative policy research firm.

About 19.7 million people with ACA coverage benefit from a subsidy — 92% of all enrollees. The expanded subsidies, started in 2021, helped increase ACA enrollment to a record high and reduce the uninsured rate to a record low.

They have also cut premium payments by an estimated 44%. Many pay no premiums at all.

Without congressional action, almost all ACA enrollees will experience steep increases in premium payments in 2026, according to KFF. The Urban Institute estimates 4 million people could wind up uninsured.

Letting the subsidies lapse could cause blowback for Republicans in 2026, said Jonathan Oberlander, a health policy expert at the University of North Carolina’s School of Medicine: “Is it worth the pain politically?”

— Phil Galewitz

Abortion

When he was president, Trump promised — and delivered — Supreme Court justices who would vote to overturn the constitutional right to an abortion. In the event of a second term, he has promised to leave abortion policy to the states — though he would have significant leeway to reduce access nationwide.

Harris has promised to restore the protections of Roe v. Wade, though doing so would require Congress’ help. At the very least, a Harris presidency would mostly preserve existing protections and prevent new federal restrictions.

Trump’s first actions would likely mirror those of many Republican presidents since the 1980s: defunding Planned Parenthood and the United Nations’ family planning agency, and, more recently, allowing employers with religious or moral objections to contraception to decline coverage through job-sponsored health plans.

But Trump could go considerably further, effectively banning abortion even in states where it is legal. For instance, the FDA could reduce availability of the abortion pill mifepristone or cancel its approval. This has been the subject of numerous lawsuits, including one before the Supreme Court that was recently revived.

Trump could also order the Justice Department to enforce the Comstock Act, an 1873 law that bans mailing “every article or thing designed, adapted, or intended for producing abortion, or for any indecent or immoral use.” That could apply not just to abortion pills, but also to supplies for abortion procedures.

— Julie Rovner

Drug Prices

Both campaigns say they are committed to lowering drug prices. Trump has offered few specifics, though the America First Policy Institute, a think tank led by close Trump allies, has put forward policies that are considerably less aggressive than Harris’ proposals.

Harris has said she would expand drug pricing negotiations and out-of-pocket drug spending caps enabled by the Inflation Reduction Act. She has also called for more transparency requirements for pharmacy benefit managers, or PBMs, the powerful drug-industry middlemen.

America First’s plan would cut costs by lowering reimbursements to doctors for some expensive infused drugs, using trade policy to force other developed countries to increase what they pay for drugs, and making more prescription medications available over the counter.

The plan makes no mention of bipartisan legislation under consideration in both chambers of Congress that seeks to achieve lower drug prices through new transparency requirements for PBMs.

— Arthur Allen

Trans People’s Health

The presidential election could determine whether transgender Americans hold on to broad protections ensuring access to gender-affirming medical care. Trump has said he would seek to ban hormone replacement therapy, gender reassignment surgery, and other treatments for minors — and make the services more difficult for adults to receive.

In the closing days of the campaign, Trump and his political action committees have leaned into divisive ads attacking Harris for past comments supporting access to care for transgender people who are incarcerated.

Backed by Republicans eager to stoke culture-war social issues, Trump has pledged to repeal Biden policies affecting transgender health care, including rules prohibiting federally funded providers and insurers from discriminating based on gender identity.

As some states passed legislation that opposed transgender rights, the Biden administration expanded coverage for gender-affirming care and increased research funding for the National Institutes of Health.

In a video on his campaign site, Trump vowed to order federal agencies to “cease all programs that promote the concept of sex and gender transition at any age” and bar government programs such as Medicare and Medicaid from paying for gender-affirming care.

Trump also said he would strip federal funding from hospitals that provide such care, create a right to sue doctors who perform gender-affirming procedures on children, and investigate whether the pharmaceutical industry and hospitals have “deliberately covered up horrific long-term side effects” of transition treatments.

Harris has been largely silent on the Trump campaign’s rhetoric targeting trans people. But she has said she would “follow the law” in providing transgender Americans the same right as others to access medically necessary care.

— Daniel Chang

Medicaid

Though the word “Medicaid” was barely uttered on the campaign trail this year, the election will determine future benefits for its 80 million primarily low-income and disabled enrollees.

“The stakes are very high,” said UNC’s Oberlander.

While Harris has described Medicaid as a key program to improve health, Trump has framed it as a broken welfare program in need of cuts.

Nearly half of Medicaid enrollees are children, and the program pays for about 40% of births nationwide.

The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level, or $20,783 this year. All but 10 states, which are GOP-led, have opted to expand their program.

The Biden administration has largely focused on efforts to protect and expand Medicaid to reduce the number of uninsured people.

The Trump administration, and GOP proposals since then, sought to reduce Medicaid spending by stiffening eligibility standards, such as adding work requirements, and by changing federal financing to a block grant, which would put more burden on states.

— Phil Galewitz

Shaking Up Biomedical Agencies

Trump said at an Oct. 27 rally in New York City that he would give anti-vaccine activist Robert F. Kennedy Jr. free rein to “go wild” on health and food policy in a second term.

Even a Republican-controlled Senate would be unlikely to confirm Kennedy for any top government position. Regardless of whether he had a specific role, RFK Jr.’s influence could be powerful, said Georges Benjamin, executive director of the American Public Health Association.

Kennedy said Trump promised to give him “control” of public health, including naming leaders of the NIH, FDA, and the Centers for Disease Control and Prevention. He has advocated for a doctor who made a name for herself as a right-wing health guru, Casey Means, to head the FDA. This week, in a discussion on CNN during which he put forward the debunked theory that vaccines cause autism, Trump transition team co-chair Howard Lutnick said Kennedy wanted data on vaccines “so he can say these things are unsafe,” at which point “the companies will yank the vaccines right off … the market.”

Numerous Trump allies have urged disempowering public health agencies — stripping the CDC of much of its research and promotional authority while streamlining NIH and adding congressional oversight over its grant-making.

Project 2025, the Heritage Foundation blueprint disavowed by Trump but whose authors include many former Trump officials, says the drug industry and other corporations have “captured” regulatory agencies: “We must shut and lock the revolving door” between agencies like the NIH, CDC, and FDA, and the industries they regulate, it states.

Kennedy recently posted on the social platform X that “FDA’s war on public health” — by which he meant restrictions on disproven therapies and cure-alls like raw milk and ivermectin — “was about to end.”

He warned FDA employees who are “part of the corrupt system” that they should “1. Preserve your records, and 2. Pack your bags.”

— Arthur Allen

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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Conservative groups are working to undermine support for Montana’s Medicaid expansion in hopes the state will abandon the program. The rollback would be the first in the decade since the Affordable Care Act began allowing states to cover more people with low incomes.

Montana’s expansion, which insures roughly 78,800 people, is set to expire next year unless the legislature and governor opt to renew it. Opponents see a rare opportunity to eliminate Medicaid expansion in one of the 40 states that have approved it.

The Foundation for Government Accountability and Paragon Health Institute, think tanks funded by conservative groups, told Montana lawmakers in September that the program’s enrollment and costs are bloated and that the overloaded system harms access to care for the most vulnerable.

Manatt, a consulting firm that has studied Montana’s Medicaid program for years, then presented legislators with the opposite take, stating that more people have access to critical treatment because of Medicaid expansion. Those who support the program say the conservative groups’ arguments are flawed.

State Rep. Bob Keenan, a Republican who chairs the Health and Human Services Interim Budget Committee, which heard the dueling arguments, said the decision to kill or continue Medicaid expansion “comes down to who believes what.”

The expansion program extends Medicaid coverage to adults with incomes up to 138% of the federal poverty level, or nearly $21,000 a year for a single person. Before, the program was largely reserved for children, people with disabilities, and pregnant women. The federal government covers 90% of the expansion cost while states pick up the rest.

National Medicaid researchers have said Montana is the only state considering shelving its expansion in 2025. Others could follow.

New Hampshire legislators in 2023 extended the state’s expansion for seven years and this year blocked legislation to make it permanent. Utah has provisions to scale back or end its Medicaid expansion program if federal contributions drop.

FGA and Paragon have long argued against Medicaid expansion. Tax records show their funders include some large organizations pushing conservative agendas. That includes the 85 Fund, which is backed by Leonard Leo, a conservative activist best known for his efforts to fill the courts with conservative judges.

The president of Paragon Health Institute is Brian Blase, who served as a special assistant to former President Donald Trump and is a visiting fellow at FGA, which quotes him as praising the organization for its “conservative policy wins” across states. He was also announced in 2019 as a visiting fellow at the Heritage Foundation, which was behind the Project 2025 presidential blueprint, which proposes restricting Medicaid eligibility and benefits.

Paragon spokesperson Anthony Wojtkowiak said its work isn’t directed by any political party or donor. He said Paragon is a nonpartisan nonprofit and responds to policymakers interested in learning more about its analyses.

“In the instance of Montana, Paragon does not have a role in the debate around Medicaid expansion, other than the testimony,” he said.

FGA declined an interview request. As early as last year, the organization began calling on Montana lawmakers to reject reauthorizing the program. It also released a video this year of Montana Republican Rep. Jane Gillette saying the state should allow its expansion to expire.

Gillette requested the FGA and Paragon presentations to state lawmakers, according to Keenan. He said Democratic lawmakers responded by requesting the Manatt presentation.

Manatt’s research was contracted by the Montana Healthcare Foundation, whose mission is to improve the health of Montanans. Its latest report also received support from the state’s hospital association.

The Montana Healthcare Foundation is a funder of KFF Health News, an independent national newsroom that is part of the health information nonprofit KFF.

Bryce Ward, a Montana health economist who studies Medicaid expansion, said some of the antiexpansion arguments don’t add up.

For example, Hayden Dublois, FGA’s data and analytics director, told Montana lawmakers that in 2022 72% of able-bodied adults on Montana’s Medicaid program weren’t working. If that data refers to adults without disabilities, that would come to 97,000 jobless Medicaid enrollees, Ward said. He said that’s just shy of the state’s total population who reported no income at the time, most of whom didn’t qualify for Medicaid.

“It’s simply not plausible,” Ward said.

A Manatt report, citing federal survey data, showed 66% of Montana adults on Medicaid have jobs and an additional 11% attend school.

FGA didn’t respond to a request for its data, which Dublois said in the committee hearing came through a state records request.

Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, also declined to comment. As of late October, a KFF Health News records request for the data the state provided FGA was pending.

In his presentation before Montana lawmakers, Blase said the most vulnerable people on Medicaid are worse off due to expansion as resources pool toward new enrollees.

“Some people got more medical care; some people got less medical care,” Blase said.

Reports released by the state show its standard monthly reimbursement per Medicaid enrollee remained relatively flat for seniors and adults who are blind or have disabilities.

Drew Gonshorowski, a researcher with Paragon, cited data from a federal Medicaid commission that shows that, overall, states spend more on adults who qualified through the expansion programs than they do on others on Medicaid. That data also shows states spend more on seniors and people with disabilities than on the broader adult population insured by Medicaid, which is also true in Montana.

Nationally, states with expansions spend more money on people enrolled in Medicaid across eligibility groups compared with nonexpansion states, according to a KFF report.

Zoe Barnard, a senior adviser for Manatt who worked for Montana’s health department for nearly 10 years, said not only has the state’s uninsured rate dropped by 30% since it expanded Medicaid, but also some specialty services have grown as more people access care.

FGA has long lobbied nonexpansion states, including Texas, Kansas, and Mississippi, to leave Medicaid expansion alone. In February, an FGA representative testified in support of an Idaho bill that included an expansion repeal trigger if the state couldn’t meet a set of rules, including instituting work requirements and capping enrollment. The bill failed.

Paragon produced an analysis titled “Resisting the Wave of Medicaid Expansion,” and Blase testified to Texas lawmakers this year on the value of continuing to keep expansion out of the Lone Star State.

On the federal level, Paragon recently proposed a Medicaid overhaul plan to phase out the federal 90% matching rate for expansion enrollees, among other changes to cut spending. The left-leaning Center on Budget and Policy Priorities has countered that such ideas would leave more people without care.

In Montana, Republicans are defending a supermajority they didn’t have when a bipartisan group passed the expansion in 2015 and renewed it in 2019. Also unlike before, there’s now a Republican in the governor’s office. Gov. Greg Gianforte is up for reelection and has said the safety net is important but shouldn’t get too big.

Keenan, the Republican lawmaker, predicted the expansion debate won’t be clear-cut when legislators convene in January.

“Medicaid expansion is not a yes or no. It’s going to be a negotiated decision,” he 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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When open enrollment for the Affordable Care Act, or Obamacare, starts nationwide this week, a group that had previously been barred from signing up will be eligible for the first time: The “Dreamers.” That’s the name given to children brought to the United States without immigration paperwork who have since qualified for the Deferred Action for Childhood Arrivals program.

Under a Biden administration rule that has become contentious in some states, DACA recipients will be able to enroll in — and, if their income qualifies, receive premium subsidies for — Obamacare coverage. The government estimates that about 100,000 previously uninsured people out of the half-million DACA recipients might sign up starting Nov. 1, which is the sign-up season start date in all states except Idaho.

Yet the fate of the rule remains uncertain. It is being challenged in federal court by Kansas and 18 other states, including several in the South and Midwest, as well as Montana, New Hampshire, and North Dakota.

Separately, 19 states and the District of Columbia filed a brief in support of the Biden administration rule. Led by New Jersey, those states include many on the East and West coasts, including California, Colorado, Nevada, New Mexico, New York, Oregon, and Washington.

The rule, finalized in May, clarifies that those who qualify for DACA will be considered “lawfully present” for the purpose of enrolling in plans under the ACA, which are open to American citizens and lawfully present immigrants.

“The rule change is super important as it corrects a long-standing and erroneous exclusion of DACA recipients from ACA coverage,” said Nicholas Espíritu, a deputy legal director for the National Immigration Law Center, which has also filed briefs in support of the government rule.

President Barack Obama established DACA in June 2012 by executive action to protect from deportation and provide work authorization to some unauthorized residents brought to the U.S. as children by their families if they met certain requirements, including that they arrived before June 2007 and had completed high school, were attending school, or were a veteran.

States challenging the ACA rule say it will cause administrative and resource burdens as more people enroll, and that it will encourage additional people to remain in the U.S. when they don’t have permanent legal authorization. The lawsuit, filed in August in U.S. District Court for the District of North Dakota, seeks to postpone the rule’s effective date and overturn it, saying the expansion of the “lawfully present” definition by the Biden administration violates the law.

On Oct. 15, U.S. District Judge Daniel Traynor, who was appointed in 2019 by then-President Donald Trump, heard arguments in the case.

Plaintiff states are pushing for fast action, and it is possible a ruling will come in the days before open enrollment begins nationwide in November, said Zachary Baron, a legal expert at Georgetown Law, who helps manage the O’Neill Institute Health Care Litigation Tracker.

But the outlook is complicated.

For starters, in a legal battle like this, those who file a case must demonstrate the harm being alleged, such as additional costs the rule will force the states to absorb. There are only about 128 DACA recipients in North Dakota, where the case is being heard, and not all of them are likely to enroll in ACA insurance.

Furthermore, North Dakota is not among the states that run their own enrollment marketplace. It relies on the federal healthcare.gov site, which makes the legal burden harder to meet.

“Even though North Dakota does not pay any money to purchase ACA health care, they are still claiming somehow that they are harmed,” said Espíritu, at the immigration law center, which is representing several DACA recipients and CASA, a nonprofit immigrant advocacy group, in opposing the state efforts to overturn the rule.

During the hearing, Traynor focused on this issue and noted that a state running its own marketplace might be a better venue for such a case. He ordered the defendants to present more information by Oct. 29 and for North Dakota to respond by Nov. 12.

On Monday, the judge denied a motion from the federal government asking him to reconsider his order requiring it to provide the state with the names of 128 DACA recipients who live there, under seal, for the purpose of helping calculate any financial costs associated with their presence.

In addition, it’s possible the case will be transferred to another district court, but that could lead to delays in a decision, attorneys following the case said.

The judge also could take a number of directions in his decision. He could postpone the rule’s effective date, as requested in part of the lawsuit, preventing DACA recipients from enrolling in Obamacare while the case is decided. Or he could leave the effective date as it stands while the case proceeds.

With any decision, the judge could decide to apply the ruling nationally or limit it to just the states that challenged the government rule, Baron said.

“The approach taken by different judges has varied,” Baron said. “There has been a practice to vacate some regulatory provisions nationwide, but a lot of judges, including justices on the Supreme Court, also have cited concerns about individual judges being able to affect policy this way.”

Even as the case moves along, Espíritu said his organization is encouraging DACA recipients to enroll once the sign-up period begins nationally in November.

“It’s important to enroll as soon as possible,” he said, adding that organizations such as his will continue to monitor the case and give updates if the situation changes. “We know that getting access to good affordable health care can be transformative to people’s lives.”

This case challenging the rule is wholly separate from another case, brought by some of the same states as those opposed to the ACA rule, seeking to entirely end the DACA program. That case is currently in the appeals process in federal court.

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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Cuando comience el período de inscripción abierta para adquirir cobertura médica en los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio, conocida como Obamacare, un grupo que antes no podía inscribirse será elegible por primera vez: los “Dreamers”. Ese es el nombre de los niños traídos a los Estados Unidos sin papeles que están bajo el programa de Acción Diferida para los Llegados en la Infancia (DACA).

Bajo una normativa de la administración Biden, que ha sido objeto de controversia en algunos estados, los beneficiarios de DACA podrán inscribirse para la cobertura del Obamacare y, si cumplen con los requisitos de ingresos, recibir subsidios para pagar sus primas.

Del medio millón de beneficiarios de DACA, el gobierno estima que alrededor de 100.000 que anteriormente no tenían seguro podrían inscribirse a partir del 1 de noviembre, fecha de inicio de la temporada de inscripción en todos los estados excepto Idaho.

Sin embargo, el destino de esta normativa sigue siendo incierto. Está siendo impugnada en un tribunal federal por Kansas y otros 18 estados, incluidos varios en el sur y el medio oeste, así como Montana, New Hampshire y Dakota del Norte.

Por otro lado, 19 estados y el Distrito de Columbia presentaron un escrito en apoyo a la normativa de la administración de Biden. Liderados por Nueva Jersey, estos estados incluyen a muchos en las costas este y oeste, como California, Colorado, Nevada, Nuevo México, Nueva York, Oregon y Washington.

La normativa, finalizada en mayo, aclara que aquellos que califican para DACA serán considerados como “presencia legal” para el propósito de inscribirse en lo planes médicos bao ACA, los cuales están abiertos a ciudadanos estadounidenses e inmigrantes con papeles.

“El cambio de normativa es muy importante, ya que corrige una exclusión errónea y de larga data de los beneficiarios de DACA para la cobertura de ACA,” dijo Nicholas Espíritu, director legal adjunto del National Immigration Law Center, que también ha presentado escritos en apoyo a este cambio.

El presidente Barack Obama estableció DACA en junio de 2012 mediante una acción ejecutiva para proteger de la deportación y proporcionar autorización de trabajo a algunos residentes sin documentos, que habían sido traídos al país de niños por sus familias. Esto si cumplían con ciertos requisitos, incluidos haber llegado antes de junio de 2007 y haber completado la escuela secundaria, estar asistiendo a la escuela o haber servido en las fuerzas armadas.

Los estados que impugnan la normativa de ACA dicen que causará cargas administrativas y de recursos a medida que más personas se inscriban, y que fomentará que más personas permanezcan en el país sin papeles. La demanda, presentada en agosto en el Tribunal de Distrito de EE.UU. para el Distrito de Dakota del Norte, busca posponer la fecha de entrada en vigencia de la normativa y anularla, argumentando que la expansión de la definición de “presencia legal” por parte de la administración Biden viola la ley.

El 15 de octubre, el juez de distrito de EE.UU., Daniel Traynor, nombrado en 2019 por el entonces presidente Donald Trump, escuchó los argumentos en el caso.

Los estados demandantes están presionando para que se actúe rápido, y es posible que se emita un fallo antes del inicio de la inscripción abierta a nivel nacional, dijo Zachary Baron, experto legal en la Facultad de Derecho de Georgetown, quien ayuda a administrar el O’Neill Institute Health Care Litigation Tracker.

Sin embargo, el panorama es complicado.

Para empezar, en una batalla legal como ésta, quienes presentan el caso deben demostrar el daño que se alega, como los costos adicionales que la normativa obligará a los estados a absorber. Solo hay alrededor de 128 beneficiarios de DACA en Dakota del Norte, donde se está llevando a cabo el caso, y no todos probablemente se inscribirán en el seguro de ACA.

Además, Dakota del Norte no se encuentra entre los estados que administran su propio mercado de inscripción. Depende del sitio federal cuidadodesalud.gov, lo que hace que sea más difícil cumplir con la carga legal.

“Aunque Dakota del Norte no gasta dinero para adquirir atención médica de ACA, aún están afirmando de alguna manera que están siendo perjudicados,” dijo Espíritu, del centro de leyes de inmigración, que representa a varios beneficiarios de DACA y a CASA, una organización sin fines de lucro de defensa de los inmigrantes, en oposición a los esfuerzos estatales por anular la normativa.

Durante la audiencia, Traynor se centró en este tema y señaló que un estado que administre su propio mercado podría ser un mejor lugar para un caso así. Ordenó a los demandados presentar más información antes del 29 de octubre, y a Dakota del Norte responder antes del 12 de noviembre.

El lunes 28 de octubre, el juez denegó una moción del gobierno federal que le solicitaba reconsiderar su orden de proporcionar al estado, bajo sello, los nombres de 128 beneficiarios de DACA que residen allí, con el fin de ayudar a calcular los costos financieros asociados con su presencia.

Además, es posible que el caso sea transferido a otro tribunal de distrito, lo que podría causar demoras en una decisión, según los abogados que siguen el caso.

El juez también podría tomar decidir en varias direcciones. Podría posponer la fecha de vigencia de la normativa, como se solicita en parte de la demanda, impidiendo que los beneficiarios de DACA se inscriban en Obamacare mientras se resuelve el caso. O podría dejar la fecha de vigencia tal como está mientras el caso avanza.

Con cualquiera de las opciones, el juez podría decidir aplicar el fallo a nivel nacional o limitarlo solo a los estados que impugnaron la normativa gubernamental, explicó Baron.

“El enfoque adoptado por diferentes jueces ha variado”, dijo Baron. “Ha habido una práctica de anular algunas disposiciones reglamentarias a nivel nacional, pero muchos jueces, incluidos jueces de la Corte Suprema, también han expresado preocupaciones sobre que jueces individuales puedan afectar la política de esta manera”.

A medida que el caso avanza, Espíritu dijo que su organización está alentando a los beneficiarios de DACA a inscribirse apenas comience el período de inscripción a nivel nacional.

“Es importante inscribirse lo antes posible”, dijo, agregando que organizaciones como la suya continuarán monitoreando el caso y dando actualizaciones si la situación cambia. “Sabemos que obtener acceso a atención médica buena y asequible puede transformar la vida de las personas”.

Este caso que impugna la normativa es completamente separado de otro caso, presentado por algunos de los mismos estados que se oponen a la normativa de ACA, que busca terminar por completo el programa DACA. Ese caso actualmente está en el proceso de apelación en un tribunal federal.

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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