Gloria Sachdev has spent years challenging the health care industry, trying to bring down the high cost of care.

It’s working, even in an unlikely place: Indiana, which has had some of the nation’s highest hospital prices. Over the past few years, Indiana lawmakers have passed bills pushed by Sachdev that target complex and sometimes wonky health policy issues.

Sachdev, 55, trained as a pharmacist and for years led a coalition of Indiana businesses. In her quest to shake up the status quo, she sparked the creation of a national report on hospital pricing. She won over powerful Republican donor Al Hubbard, who has championed her proposals. She’s convened health care experts from across the country to tackle cost transparency. In turn, all this has elevated her profile in Indiana and beyond.

Now, this disruptor has ascended to a position of power in the Hoosier State. Indiana’s new Republican governor, Mike Braun, appointed her to a newly created Cabinet position overseeing the state’s health care agencies.

Republican leaders in Indiana have been receptive to Sachdev’s work, persuaded by her argument that the free-market approach of limited government intervention, long favored by the GOP, doesn’t work with health care.

“I believe in a free market, too,” she said.

But health care isn’t like a grocery store where shoppers have lots of options in the cereal aisle and can see the prices. Too often, Indiana patients are left with few choices and no price transparency, Sachdev said. That messaging has resonated with Indiana Republicans, she said, because they see it in their own communities.

A decade ago, when she began representing frustrated employers as chief executive of the Employers’ Forum of Indiana, she asked the businesses within that coalition to identify their biggest pain point: “They unanimously said health care affordability.”

Sachdev had spent years training as a pharmacist, pursuing a career in health care like her father. He was a researcher at the University of Oklahoma who made advances in decoding cystic fibrosis, a life-threatening genetic disorder that damages the lungs.

In her own career, Sachdev said, she has always sought answers to seemingly simple questions, driven by data and her belief that sound policy stems from rigorous analysis of the available evidence. So to examine the employers’ concerns, she sought to find out how health care prices in Indiana compared with those in other states. No such data existed at the time.

She cold-called Chapin White, then an economist at the Rand Corp. research organization, and persuaded him to help her find the answer. After some initial studies of Indiana, Rand published a study in 2019 that analyzed the prices paid by private health plans to more than 1,500 hospitals across the nation.

The results shocked her: Indiana landed at the top of the list, with the highest hospital prices among the 25 states initially studied. Sachdev was incredulous that her adopted state had earned such a dubious distinction. “We’re not New York City,” she said.

The results emboldened her — and state lawmakers — to take action. “When we’re highlighted like that, it certainly requires our attention,” said Chris Garten, the majority floor leader in the Indiana Senate and a former chair of the General Assembly’s oversight task force on health care costs.

The push for transparency also gained momentum nationally, leading President Donald Trump to issue an executive order in his first term that required hospitals to publicly disclose prices.

“Gloria was the catalyst for getting this started,” said Brown University economist Christopher Whaley, one of the other authors of the price transparency report while at Rand.

Consolidation has fueled higher prices in medical care. But Indiana is an outlier in how it chose to respond to consolidation, at least among red states, said Katie Gudiksen, executive editor of The Source on Healthcare Price and Competition, an online resource from the University of California Law-San Francisco.

Over the past few years, Indiana legislators have enacted laws to combat consolidation, banning large hospital systems from tacking on extra fees, restricting employers from imposing non-compete contracts on primary care physicians, and requiring health care companies to report pending mergers to the state’s attorney general.

Sachdev called the move to ban extra fees in some hospitals a major victory. Across the U.S., hospitals may add an extra charge to a bill, known as a facility fee, even when the visit happens outside the hospital at an affiliated doctor’s office. Indiana’s law not only lowers prices, she said, but also removes an incentive for hospitals to buy up physician practices for the purpose of tacking on a facility fee.

“All of our efforts are really in this space of increasing competition,” she said.

Last spring, Sachdev drew national medical pricing experts to Indianapolis for a conference on health care transparency. Celebrity entrepreneur Mark Cuban, a critic of high prices in the industry, was a keynote speaker.

At the conference, the latest installment of the Rand report was unveiled. Indiana had fallen from the top spot to the state with the ninth-highest prices.

Last fall, however, a hospital merger threatened to undo some of Sachdev’s wins in Indiana. Rival hospitals in Terre Haute were seeking to merge. The deal would have left the city and those in the surrounding rural areas with a hospital monopoly, and such consolidations elsewhere have been shown to raise medical prices.

Under the state’s Certificate of Public Advantage law, the deal would have been shielded from federal anti-monopoly restrictions. Two dozen states have had COPA laws on their books at some point, despite warnings from the Federal Trade Commission that such hospital mergers can become difficult to control and may decrease the overall quality of care.

The deal faced immense pushback. Doctors, health economists, and the FTC called on the Indiana Department of Health to deny Union Health’s application to merge with HCA Healthcare-owned Terre Haute Regional Hospital.

In an opinion piece in The Indianapolis Star, Sachdev urged regulators to consider the harm that came after similar mergers elsewhere.

“The evidence shows how deals, like the one in Terre Haute, can crush communities,” Sachdev wrote with Zack Cooper, a health economist and associate professor at Yale University.

In November, just days before the state was due to rule on the deal, Union Health withdrew its merger application.

“I was thrilled,” Sachdev said. “The writing was on the wall that it would have been denied.”

Now, Indiana state Sen. Ed Charbonneau, a Republican and chair of the Senate health committee, has introduced a bill to repeal the state’s COPA law. Indiana would become the sixth state to roll back such a law.

Describing Sachdev as aggressive and analytical, Charbonneau said she regularly shares her thoughts about the COPA law and other health care issues. “Gloria is not at all reluctant to come and talk to me or call me or text me,” he said.

When Braun appointed her as secretary of health and family services, he said in a statement that her “proven track record of transforming healthcare delivery and costs makes her the ideal choice to lead Indiana’s health initiatives.”

Braun’s health care agenda targets prices that “are robbing Hoosiers’ paychecks,” according to his campaign platform, which adds, “Without intervention, the strain will only get worse.”

In his second week as governor, Braun signed multiple executive orders seeking to increase transparency, directing state agencies to review the practices of pharmacy benefit managers and evaluate pricing. He also has said he plans to build on the legislature’s “ambitious work” of tackling affordability. With Republicans in control of the legislature, Braun is unlikely to encounter political gridlock, a reality that excites Sachdev.

“I’ve been working from the ground up, and we’ve made progress,” she said. “If I’m helping Gov. Braun from the top down, we can make faster, greater progress.”

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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During her annual OB-GYN visit, Callie Anderson asked about getting off the birth control pill.

“We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered to retired state police.

“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson said.

She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well.

“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus.

Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs. Last year, federal health officials recommended doctors discuss pain management with patients beforehand, including options such as lidocaine shots and topical anesthetics.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

It’s unclear how many Americans have such coverage. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of covered workers were still on “grandfathered” plans.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she said.

Mike McMullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

The Pennsylvania State Troopers Association, which offers some retirees the plan that covered Anderson, did not respond to requests for comment. Highmark Blue Cross Blue Shield, the insurer, referred questions to the state.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”

A benefit handbook for the plan identifies it as grandfathered and lists a variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, said Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

She said most insurers cover the devices, but coverage can vary, too. For instance, some cover only certain types or brands of contraceptives. Generally, an IUD insertion costs $500 to $1,500, she added.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she said.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income.

“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she said. The billing office, she said, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”

Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

With birth control, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn said. “It’s incredibly hard to be an advocate for yourself.”

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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Covered California, el mercado de seguros de salud del estado, ha alcanzado un récord de 1,8 millones de inscritos y la cifra podría aumentar aún más antes de la fecha límite de inscripción abierta del 31 de enero, debido en gran parte a una mejora en los subsidios que ha hecho que los planes sean más asequibles.

Pero el progreso del estado en la extensión de la cobertura de salud a todos los residentes podría frenarse con la segunda administración Trump y un Congreso republicano cuyo liderazgo ha sido hostil durante mucho tiempo a la Ley de Cuidado de Salud a Bajo Precio (ACA), la ley federal de 2010 también conocida como Obamacare.

La principal preocupación de los funcionarios de Covered California es la inminente expiración de los subsidios federales adicionales para pagar las primas de los seguros, aprobados por el Congreso en 2021 como parte de un paquete de ayuda durante la pandemia de covid. Eso resultó en primas más bajas para las personas de todo el país, especialmente los hogares de clase media, que compran seguros de salud a través de los mercados establecidos por ACA.

“Estamos siguiendo de cerca si se tomarán medidas para extender los subsidios mejorados, lo que tendrá un gran impacto”, dijo Jessica Altman, directora ejecutiva de Covered California, quien señaló que el programa tenía alrededor de 1,5 millones de inscritos antes de los subsidios mejorados.

Los republicanos han criticado el costo de los subsidios y no está claro si los renovarán.

Sin una extensión, los investigadores del Centro Laboral de la Universidad de California-Berkeley estiman que las primas de Covered California para los inscritos subsidiados se dispararían en un promedio de $967 al año a partir de 2026, y aproximadamente 69.000 californianos perderían su cobertura.

California tomó sus propias medidas el año pasado para hacer que la cobertura fuera más asequible, eliminando los deducibles y reduciendo otros costos de bolsillo en todas las pólizas de nivel medio conocidas como planes “plata”.

Sin embargo, es probable que el gasto en atención médica del estado enfrente nuevas presiones si los republicanos en Washington siguen adelante con sus planes de larga data de recortar la financiación de Medicaid, el programa de seguro médico para estadounidenses de bajos ingresos, conocido en California como Medi-Cal.

Además de reforzar Covered California, el estado también ha presionado agresivamente para expandir Medi-Cal, incluso para los inmigrantes sin papeles, y ahora gasta $161 mil millones al año en ese programa, aproximadamente la mitad pagados por el gobierno federal.

Cerca de 144.000 de los 1,8 millones de inscritos en Covered California al 14 de diciembre estaban adquiriendo cobertura por primera vez, y casi el 90% de todos los inscritos califican para recibir ayuda financiera.

Covered California ha extendido el período de inscripción hasta el 8 de marzo para los residentes de los condados de Los Ángeles y Ventura debido a los incendios forestales, y también ha emitido extensiones relacionadas con la gripe aviar y un terremoto en el norte de California.

Los residentes de bajos ingresos pagan poco o nada por las primas mensuales, mientras que para aquellos que ganan más, las primas están limitadas a un porcentaje de los ingresos del hogar. Con los subsidios federales mejorados, nadie está obligado a gastar más del 8,5% de sus ingresos en primas, siempre que elija un plan Silver. Sin embargo, estos planes pueden tener redes de proveedores más pequeñas y gastos de bolsillo significativos.

Según Covered California, la prima mensual promedio es de $136 para quienes reciben subsidios, dos tercios de los cuales pagan $10 o menos al mes. Pero las personas con ingresos más altos pueden terminar pagando bastante más. Por ejemplo, una familia de cuatro que gana $200.000 en el área de Los Ángeles pagaría más de $1.000 al mes por un plan Silver, según una calculadora de costos.

Si bien los subsidios federales y estatales han aumentado de manera significativa la cantidad de asistencia disponible, el costo subyacente del seguro ha seguido aumentando. Las primas de Covered California han aumentado un 7,9% en promedio para 2025, pero los subsidios adicionales protegen a la mayoría de los inscritos de este aumento.

“El gasto de bolsillo de la gente probablemente sea menor que el que hemos visto”, dijo Dylan Roby, profesor de salud, sociedad y comportamiento en la Universidad de California-Irvine. “Eso no significa necesariamente que las primas estén bajando. Solo significa que el gobierno estatal o federal está pagando una parte mayor de las primas que antes, en nombre de los inscritos”.

Ni Trump ni los líderes entrantes del Congreso han dado señales claras sobre cómo ven el futuro de los subsidios, pero ambos tienen un historial de intentar derogar y debilitar el Obamacare. Mike Johnson, presidente de la Cámara de Representantes, ha prometido una “reforma masiva” de la ley de atención médica, aunque sin dar muchos detalles.

Expertos, incluido Roby, dicen que los republicanos podrían extender los subsidios para evitar que los consumidores, las aseguradoras de salud, los hospitales y otros que se han beneficiado, protesten. La inscripción en los planes del mercado es especialmente alta en los estados controlados por los republicanos que no han ampliado Medicaid, porque ofrece a las personas de bajos ingresos una forma de acceder a un seguro de salud asequible.

“No creo que los miembros republicanos de la Cámara de Representantes estén tan inclinados a hacer que todas ls primas médicas de los estadounidenses aumentan”, dijo Roby. “Soy bastante optimista en cuanto a que [los subsidios] se renovarán”.

Pero la incertidumbre sobre el futuro de los subsidios, incluso si finalmente se renuevan, podría afectar el costo de los planes del mercado, dijo Rachel Linn Gish, directora de comunicaciones de Health Access California, una coalición de defensa del consumidor. Esto se debe a que las aseguradoras ya están comenzando a planificar sus tarifas para el próximo año y probablemente incluirán en los precios el riesgo de no renovar, dijo.

“Vamos a luchar durante el próximo año para tratar de salvar esos subsidios mejorados y, posteriormente, todos los demás marcos y financiamiento de la Ley de Cuidado de Salud a Bajo Precio”, dijo Linn Gish. “Porque si se revierte algo de eso, la gente perderá la cobertura de atención médica”.

Este artículo fue producido por KFF Health News, que publica California Healthline, un servicio editorialmente independiente de la 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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Covered California, the state’s health insurance marketplace, has hit a record 1.8 million enrollees and the number could climb higher ahead of a Jan. 31 open enrollment deadline, due in large part to enhanced subsidies that have made plans more affordable.

But the state’s progress in extending health coverage to all residents could come to an abrupt halt as the second Trump administration takes power alongside a Republican Congress whose leadership has long been hostile to the Affordable Care Act, the 2010 federal law also known as Obamacare.

Top of mind for Covered California officials is the looming expiration of the additional federal subsidies for health insurance approved by Congress in 2021 as part of a covid pandemic relief package. That resulted in lower premiums for people around the country — especially middle-class households — who buy health insurance through the exchanges established by the Affordable Care Act.

“Whether there will be action to extend the enhanced subsidies — that’s a big impact that we are closely tracking,” said Covered California Executive Director Jessica Altman, who noted the program had about 1.5 million enrollees prior to enhanced subsidies.

Republicans have criticized the cost of the subsidies, and it’s not clear they’ll renew them.

Without an extension, researchers at the University of California-Berkeley Labor Center estimate, Covered California premiums for subsidized enrollees would soar by an average of $967 a year beginning in 2026, and an estimated 69,000 Californians would lose their insurance.

California took its own steps last year to make coverage more affordable, eliminating deductibles and reducing other out-of-pocket costs on all mid-tier policies known as “silver” plans.

However, the state’s health care spending is likely to face fresh pressure if Republicans in Washington follow through on long-standing designs to cut funding for Medicaid, the health insurance program for low-income Americans, known in California as Medi-Cal. In addition to bolstering Covered California, the state has also aggressively pushed to expand Medi-Cal, including to immigrants living in the U.S. without authorization, and now spends $161 billion a year on that program, about half paid by the federal government.

About 144,000 of Covered California’s 1.8 million enrollees as of Dec. 14 are first-time buyers, and nearly 90% of all enrollees qualify for financial help. Covered California has extended the enrollment period to March 8 for residents in Los Angeles and Ventura counties due to wildfires, and has also issued extensions related to the bird flu and an earthquake in Northern California.

Low-income residents pay little or nothing for monthly premiums, while for those earning more, premiums are capped at a percentage of household income. With the enhanced federal subsidies, no one is required to spend more than 8.5% of their income on premiums, provided they stick to a silver plan. Such plans, however, can have smaller provider networks and significant out-of-pocket costs.

According to Covered California, the average monthly premium is $136 for those who receive subsidies, two-thirds of whom pay $10 or less a month. But people with higher incomes can end up paying significantly more. For example, a family of four making $200,000 in the Los Angeles area would pay well over $1,000 a month for a silver plan, according to a calculator for estimating costs.

While federal and state subsidies have significantly boosted the amount of assistance available, the underlying cost of insurance has continued to go up. Covered California premiums are up by 7.9% on average for 2025, but the extra subsidies shield most enrollees from the increase.

“You end up with people’s out-of-pocket spending probably being lower than we’ve seen,” said Dylan Roby, a professor of health, society, and behavior at the University of California-Irvine. “That doesn’t necessarily mean that premiums are going down. It just means that the state or federal government is paying a larger share of premiums on behalf of enrollees than before.”

Neither Trump nor incoming congressional leaders have given clear signals about how they view the future of the subsidies, but both have a history of seeking to repeal and weaken the Affordable Care Act. House Speaker Mike Johnson has vowed “massive reform” of the health care law, though without offering specifics.

Experts including Roby say Republicans could extend the subsidies to avoid an outcry from consumers, health insurers, hospitals, and others who have benefited from them. Enrollment in marketplace plans is especially high in Republican-controlled states that have not expanded Medicaid, because it offers low-income people a way to access affordable health insurance.

“I don’t think Republican House members are that inclined to make all of their constituents’ health insurance premiums go up,” Roby said. “I’m kind of optimistic that [the subsidies] will be renewed.”

But uncertainty over the future of the subsidies, even if they eventually get renewed, could affect the cost of marketplace plans, said Rachel Linn Gish, communications director for Health Access California, a consumer advocacy coalition. That’s because insurers are already starting to plan their rates for next year and will likely price in the risk of nonrenewal, she said.

“We are going to be fighting for the next year to try to save those enhanced subsidies and subsequently all of the other frameworks and financing of the Affordable Care Act,” Linn Gish said. “Because if any of that gets rolled back, people will lose health care coverage.”

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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This story can be republished for free (details).