Democratic congressional members and candidates are already planning to use any midterm election gains to expand health coverage, including boosting Affordable Care Act subsidies, reversing Medicaid cuts, and lowering the Medicare eligibility age.

But Democratic strongholds across the country — including Oregon, California, New York, and Washington — have more ambitious goals: single-payer, universal healthcare systems.

No state is closer to that goal than Oregon. A panel created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. The nine-person Universal Health Plan Governance Board seeks to establish, starting in 2032, medical, vision, dental, and mental health benefits for every state resident from cradle to grave — with no premiums, deductibles, or copayments. Lawmakers could vote on a plan during the 2027 legislative session or refer it to voters as a ballot measure in 2028.

If approved, the state would be the first in the U.S. to implement what’s called a single-payer health coverage system. It could serve as a model for other states — and potentially the nation.

Proponents of the proposal argue that the public supports universal healthcare more than ever as healthcare spending and complexity grow. Surveys show patients often delay care due to out-of-pocket costs. And medical debt remains a leading cause of bankruptcy in the nation.

States have often served as laboratories to test health policies later implemented nationally. The Affordable Care Act was modeled after Massachusetts’ attempt to achieve universal health insurance coverage, once single-payer efforts there stalled. And Canada’s universal healthcare system began with a provincial plan in Saskatchewan.

“In the short to medium term, there is no chance that ‘Medicare for All’ can be passed at the national level,” said Jonathan Oberlander, a University of North Carolina health policy professor. “That’s where the states come in. A state like Oregon provides a more hospitable political environment and a more realistic path to single-payer reform.”

But advocates of the plan expect a significant fight from healthcare behemoths, including large hospital systems, seeking to sour public opinion on making such widespread changes. Nine of the Fortune 500 companies are health insurers. The industry’s deep pockets have helped derail myriad universal healthcare efforts at the federal and state levels.

In 2011, the Vermont Legislature voted to implement a universal healthcare plan but, three years later, Democratic Gov. Peter Shumlin, who had campaigned on the promise of single-payer, pulled the plug, citing “potential economic disruption.”

States that took the issue directly to voters have fared no better. Ballot measures in Colorado in 2016, Oregon in 2002, and California in 1994 all failed by large margins.

“The aspirations of progressive reformers usually run smack into sobering political realities,” Oberlander said. “Translating a slogan into a legislative and political reality is a daunting task.”

Valdez Bravo, president of Health Care for All Oregon, speaks at the nonprofit’s annual garden party in Portland on Sept. 12. The state will soon consider a plan for universal health coverage that the state legislature ordered in 2023. (Christena Dowsett for KFF Health News)

Redirected Healthcare Dollars

Oregon’s proposal seeks to maintain the current level of spending on healthcare by government, business, and consumers with new corporate and personal taxes to replace insurance premiums and other out-of-pocket costs. Those would be combined with federal and state spending to create a single fund from which all hospitals, doctors, and other practitioners would be paid.

Board members said savings from cutting red tape, reducing fraud, and negotiating drug costs should allow the state to provide better benefits to more people.

In examples prepared for consumer focus groups, the board estimated that a 30-year-old making $55,000 and purchasing a benchmark silver-level plan through the Affordable Care Act now pays $5,478 a year for insurance premiums in Oregon, but instead could pay $2,331 in taxes under the proposed plan.

Someone making $55,000 a year with coverage through their employer now pays $3,063 in premiums and out-of-pocket costs. Under the draft plan, that person could pay nothing for health services and could see any doctor in the state.

Currently, many employers pay much of the health insurance costs for their workers. The plan seeks to maintain those contributions by establishing a corporate payroll tax for companies whose payrolls exceed $500,000. Their employees could receive a partial tax credit for the taxes their employers pay. As a result, 31% to 60% of Oregonians wouldn’t pay anything for health benefits.

More affluent people, however, could end up paying more than they do now. The exact numbers would depend on how lawmakers set tax rates and payment thresholds.

“What we are proposing is something very different,” said Miriam McDonell, executive director of the Oregon board. “Everyone contributes based on the amount that they are able to contribute and not based on utilization.”

A work group created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. Lawmakers could vote on the plan as soon as the next legislative session or refer it to a ballot measure in 2028. The nonprofit Health Care for All Oregon hosted a garden party on Sept. 12 ahead of the reveal. (Christena Dowsett for KFF Health News) Backers of the universal healthcare coverage plan will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. (Christena Dowsett for KFF Health News)

Messaging Challenge Lies Ahead

The plan’s backers will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. Currently, hospitals hire scores of workers to bill dozens of public and private health plans, each with its own coverage and billing rules. A single plan covering everyone in the state could streamline the process, saving billions.

Rural hospitals could gain financial stability. They now often struggle to stay afloat because they typically have higher rates of patients who are uninsured or on Medicaid, with its often low reimbursement rates.

Hospitals aren’t so sure.

“The universal health plan proposal preserves much of the broken, fragmented status quo and adds new taxes and complexity that Oregonians can’t afford,” said Becky Hultberg, president and CEO of the Hospital Association of Oregon. “With federal policy changes looming, we are entering a period of tremendous upheaval. This proposal could destabilize a system that is already struggling.”

Under the proposal, doctors and other practitioners would be paid somewhere between what Medicare pays on the low end and what private insurance pays on the high end. Although total payments to doctors would remain unchanged, rates would be negotiated with physician groups to shift more money into primary care and less into specialty services.

But it is unclear whether doctors would agree that more patient time, fewer administrative hurdles, and no more unpaid bills would be worth a payment structure that could cause specialists to lose out.

Rebecca Schoon, an associate professor at Pacific University who attended last month’s Health Care for All Oregon garden party, says that communicating what universal healthcare is will be one of the biggest challenges ahead for Oregon’s proposed plan. (Christena Dowsett for KFF Health News)

“There’s always winners and losers in designing something like this, and so how to distribute those is the hardest part,” said Rebecca Schoon, an associate health policy professor at Pacific University who is slated to join the Oregon board in January. “But the second-hardest part is, I think, messaging this.”

Courtni Dresser, vice president of government relations for the Oregon Medical Association, said her physicians group shares many of the board’s goals in improving access to care and reducing administrative burdens. But the group has yet to declare its support or opposition to the effort.

Health insurers haven’t formally weighed in on Oregon’s proposal either, but a single-payer system would, in essence, close off Oregon to any private healthcare plans.

“We expect insurance companies to put every ounce of money they can against this idea because our system is broken and they profit from it,” said Collin Stackhouse, communications coordinator for Health Care for All Oregon, a consumer group advocating for universal healthcare.

Wendell Potter, a former insurance company executive who now works to expose industry influence, said he expects health plans to hammer the Oregon proposal with claims of high taxes, loss of choice, and the specter of “socialized medicine.”

“Most people go year to year without testing the limits of their health insurance policy,” Potter said. “And so, they’re easily scared into thinking that something valuable will be taken away from them, and that they will have something that’s inferior in its place.”

Health insurers argue their health plans help shield consumers from the full impact of rising healthcare costs.

“Americans consistently report strong satisfaction with their health coverage, including more than 180 million covered through work and 36 million who choose Medicare Advantage,” said Chris Bond, a spokesperson for the health insurance trade group AHIP. “Policy solutions are needed to rein in the ever-higher prices charged by hospitals and drugmakers and make care more affordable for everyone.”

Volunteers converse at the Sept. 12 garden party in Portland. Oregon’s legislature created a work group in 2023 to draw up a plan to create universal healthcare in the state. The proposal is due Dec. 1. (Christena Dowsett for KFF Health News)

Federal Approval Needed

It’s unclear whether Oregon could secure federal approval to redirect Medicare and Medicaid dollars into its universal plan. Backers of the proposal do not expect the Trump administration to be receptive but say it will be years before approval is needed and hope the 2028 presidential election ushers in a more supportive administration. If federal waivers are not secured, Oregon could proceed in stages, starting with the non-Medicare population.

In California, Democratic candidates for governor are not debating whether to implement single-payer but how. New York lawmakers are debating a single-payer bill called the New York Health Act. And in Washington, state legislators have created a commission to design a universal healthcare plan.

The Oregon board has had regular contact with teams working on single-payer proposals in California and Washington, sharing approaches and looking for ways to collaborate, McDonell said.

Richard Bruno, an Oregon family physician and a member of Physicians for a National Health Program, said he could envision the other West Coast states joining Oregon in implementing single-payer, much as California, Washington, and Hawai‘i have in public health efforts to counter changes in federal vaccine recommendations.

“If our four states could do it,” he said, “that would be the momentum we would need to get it nationally.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

MISSOULA, Mont. — Bethany Zulick went back to school in January to become a high school English teacher.

Years ago, she taught English as a second language overseas and loved it.

“It’s so exciting to me to watch someone learn a new word or have that spark of understanding,” she said.

Zulick knew she could earn enough money as a substitute teacher to make going back to school financially viable — except for the cost of health insurance. She didn’t want to risk being unable to see her doctor for her allergies, or for preventative care.

The health insurance offered through Montana State University was too expensive, Zulick said, almost as much as her tuition. But then she found a solution that allowed her to make the leap: Medicaid. She wouldn’t have to pay any monthly premiums.

It worked well for a few months, as Zulick taught by day and took online classes at night.

But in June, the state sent a letter that she said left her “completely confused.” She knew Montana was rolling out a system for work requirements over the summer, but she thought she wouldn’t have to prove she met the requirements until next year, when her Medicaid enrollment came up for renewal.

Yet the letter from the Montana Department of Public Health and Human Services outlining the new requirements gave conflicting information on when Zulick would have to prove she was meeting them. First it said at her next renewal, which would be sometime next spring. Lower down it told her she would have to submit paperwork to prove compliance much earlier — “within 30 days” of the date on the letter, June 26. She wondered: Was it a boilerplate mass-mailing letter she could ignore, or was her insurance on the line?

Most states must implement the new work requirements by Jan. 1, but three states — Montana, Nebraska, and Arkansas — have already gotten started. Medicaid advocates worry that the expedited timeline in those states will lead to thousands of people losing coverage because they’re confused about the new rules, even if they are eligible for the program — and that Montana may offer a troubling preview of what will happen nationwide next year.

State health department officials maintain they are well prepared and told state lawmakers they plan to process roughly 5,000 enrollees monthly.

Growing Confusion, Dwindling Help

Rep. SJ Howell of the Montana House has gotten dozens of calls from confused constituents, specifically about letters like the one Zulick received.

“The notices coming from the department are very, very confusing, and it’s very hard to find help figuring out what’s going on,” said the Democratic legislator, who asked health department leaders about those letters at a hearing in early September. Letters being sent to enrollees have been updated to be clearer, state health officials told lawmakers at the hearing.

In Montana, nearly 71,000 people are subject to the new rules. Medicaid costs are split between the federal and state governments, and states are responsible for administering the program, which provides health insurance for people with low incomes or disabilities.

Under the new work requirements, enrollees must document that they’re working, volunteering, or studying 80 hours per month — or they must show that they qualify for one of a range of exemptions, such as being “medically frail” or being the primary caretaker for a family member.

Montana began with a soft launch of the work requirements in July and gave enrollees until Oct. 1 to comply.

Critics contend that isn’t enough time, because the state hasn’t finished setting up new computer systems or hiring the staff it said it would need. Of the 59 positions, only about 20 were filled, state health department officials told state lawmakers during the Sept. 9 hearing, adding that numbers had fluctuated amid staff turnover.

State health officials have said they’ll eventually be able to automatically verify that students are enrolled in public universities. However, that computer system isn’t expected to be up and running until next year, leaving students like Zulick to track down and submit the correct paperwork to prove their college enrollment.

However, there are fewer outside resources to help residents with these bureaucratic tasks.

For example, Cover Montana, a nonprofit that helps Montanans fill out such paperwork, lost federal funding last year, going from a staff of 18 to two part-time employees working a phone line.

The state does operate a helpline, but federal data shows that Montanans stay on hold much longer than the national average and that many callers hang up before they connect with a state employee.

“We were worried about chaos that could be generated by the state rushing,” said Aaron Wernham, CEO of the Montana Healthcare Foundation, a nonprofit aimed at improving health in the state. “Given how little information the state has provided about what they are doing, I’m much more worried about chaos.”

Wernham pointed to a similar upheaval in 2023, when states undertook a massive process to redetermine the eligibility of all Medicaid enrollees, after regular eligibility checks were paused during the pandemic.

Many Montanans who were financially eligible lost Medicaid coverage for technical reasons, such as incorrectly filling out paperwork — roughly 87,000, according to state data from two years ago.

Even vulnerable Montanans who didn’t need to file paperwork, because their coverage should have been automatically renewed, were dropped from the Medicaid rolls, including people who were homeless.

Montana House Democrat Mary Caferro addresses protesters in July at the Montana Capitol in Helena. Montana is among three states that have adopted Medicaid work requirements months ahead of the federal deadline. The new rules have confused some Montanans on Medicaid, and critics say that confusion will lead to people unnecessarily losing coverage. (Aaron Bolton/MTPR)

Long-Sought Requirements in State

The Montana Legislature passed a measure in 2019 expressing its desire to add work requirements to Medicaid, but the state didn’t have permission from the federal government to move forward until now.

Having work requirements creates accountability for people who rely on the social safety net, said Montana Senate President Matt Regier, a Republican.

“In an economy like this, if you’re an able-bodied adult that’s able to work, you really do need to step up,” he said.

Asked about confusion among enrollees about the rules, Regier responded that the Oct. 1 deadline offered more than enough time to work out the kinks in the new system.

In the end, Zulick learned she didn’t need to worry about that deadline, because she got married in July and no longer qualified for Medicaid, although she didn’t know that would be the case when she got the June letter.

But others remain scared about losing coverage, including Heather Reel, who attended a rally at the state capitol in July to push back against Montana’s early rollout.

Reel relies on Medicaid for its mental health coverage. Without it, she said, she would struggle to care for her teenage son, who has autism and is nonverbal. Between her shifts at a fast food restaurant and caring for her son, she’s scared she’ll be too busy to figure out how to report her work hours.

Montana’s Rollout a Potential Preview

The handful of states that are implementing the Medicaid work requirements early are building the plane as they’re taking off, said Akeiisa Coleman, who provides Medicaid analysis for The Commonwealth Fund, a nonprofit focused on making healthcare more equitable.

“Montana is going to be an example for what we might see nationally as things roll out,” she said.

Although most other states are sticking to the Jan. 1 deadline to build and test their Medicaid systems, they still might not have all the components in place, she said.

If states can’t automatically renew or deny coverage based on the new rules, state workers will have to do so manually, on a case-by-case basis. That could create backlogs and more disruption, leading more people to lose coverage, Coleman said.

Jon Ebelt, a spokesperson for the state’s health department, said in a statement that Montana’s Medicaid office is ready for the change on Oct. 1.

“We are committed to ensuring eligible Montanans maintain coverage while meeting requirements, and we will continue to monitor implementation closely,” Ebelt said.

Democratic state lawmakers have repeatedly asked state health officials to extend the Oct. 1 deadline for enrollees to comply with the new rules, but they’ve said they have no plans to do so.

This article is from a partnership that includes Montana Public Radio, 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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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.

Healthcare, in particular its rising costs, is a key issue for voters in both parties this fall. But lawmakers are offering a variety of remedies on the campaign trail, suggesting that neither party has an agreed-upon approach.

Meanwhile, the Trump administration has apparently backed off a plan — for now — to create a political board to review scientific grant awards from the National Institutes of Health. The pause came after public complaints from Senate Appropriations Committee Chair Susan Collins of Maine, who is fighting to retain her seat and, possibly, maintain the GOP majority in the upper chamber.

This week’s panelists are Julie Rovner of KFF Health News, Tami Luhby of CNN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Sarah Jane Tribble of KFF Health News.

Panelists Tami Luhby CNN @Luhby Read Tami's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen @joannekenen.bsky.social Read Joanne's bio. Sarah Jane Tribble KFF Health News Read Sarah's stories.

Among the takeaways from this week’s episode:

• A new KFF-AP rural-voter polling project found that affordability issues are central concerns in rural America. Overall, 48% of rural voters say the economy is worse off than it was at the start of President Donald Trump’s term, and healthcare is one of the key pain points. Findings also indicate that among rural voters — historically a strong Trump constituency — about half still approve of the president’s job performance. Some of these voters, though, said they may sit this election out. That’s notable because the midterms are often determined by who shows up.
• The Trump administration is pushing its anti-fraud agenda as an election issue, using it as a counternarrative to Democrats’ complaints that Republicans’ refusal to extend covid-era Affordable Care Act subsidies led to a large drop in ACA enrollment this year. This week, Vice President JD Vance announced that the administration was cutting 750,000 more enrollees from Obamacare, alleging they are fraudulently enrolled.
• Despite early suggestions that the administration would back away from the anti-vaccine views pushed by Health and Human Services Secretary Robert F. Kennedy Jr., both he and Trump this past week continued to push anti-vaccine efforts. Kennedy was the keynote speaker at the conference of the anti-vaccine organization he helped found, while Trump in an Oval Office event suggested that currently administered childhood vaccines be divided into five separate doses.

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’ “The Drugs and Devices Have Been on the Market for Years. But FDA-Ordered Studies Still Aren’t Done,” by David Hilzenrath.

Tami Luhby: The Wall Street Journal’s “RFK Jr.’s Enhanced Security Was Funded With Money From Minority Health Office,” by Liz Essley Whyte.

Joanne Kenen: Slate’s “The Mystery of ‘Medbeds’,” by Molly Olmstead.

Sarah Jane Tribble: Stat’s “GOP Aims To Change Medicare Adviser’s Math So It’s More Favorable to Health Insurers,” by John Wilkerson.

Also mentioned in this week’s podcast:

• KFF Health News and The Associated Press’ “Economic Frustration Tests Trump’s Standing With Rural Voters, New KFF-AP Poll Finds,” by Sarah Jane Tribble, Ali Swenson, and Linley Sanders.
• Axios’ “Midterms’ New Populism: Taking On Health Industries,” by Caitlin Owens and Adriel Bettelheim.
• The Washington Post’s “Secret Contracts Reveal Undisclosed Terms in Trump’s Drug-Pricing Deals,” by Dan Diamond and Riley Beggin.
• The Washington Post’s “White House Budget Chief Pushes for Scrutiny of NIH Grants in Oval Office Clash,” by Dan Diamond and Riley Beggin.
• KFF’s “How TrumpRx Brand-Name Drug Prices Compare to Other Countries,” by Matt McGough, Lynne Cotter, Justin Lo, Imani Telesford, Ashley Ferguson, Avni Gupta, and Juliette Cubanski.

Credits Francis Ying Audio producer Stephanie Stapleton Editor

Click here to find all our podcasts.

And subscribe to “What the Health? From KFF Health News” on Apple Podcasts, Spotify, the NPR app, YouTube, 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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

A long-running lawsuit challenging what it means to be an employee and therefore have access to work-based health plans is being closely watched by health policy analysts. Its outcome could spur the availability of lower-cost but potentially skimpier health coverage that skirts some consumer protections.

Court papers indicate a settlement in the case against the Department of Labor may be in the works, although the parameters of any such deal are unknown.

It would come amid premium surges on Affordable Care Act marketplaces that have led millions to drop coverage this year. The Trump administration has also been sharply focused on expanding access to alternative coverage, such as short-term plans that avoid ACA rules on preexisting conditions and benefit requirements.

“Depending on what happens with the settlement, this could be an even bigger expansion,” said Katie Keith, director of the Center for Health Policy and the Law at the Georgetown University Law Center. “People are worried that it is the opening salvo into promoting junk plans that don’t meet the ACA requirements.”

The plaintiff, Data Marketing Partnership, filed its case against the Department of Labor in 2019, during the first Trump administration. It wants official recognition as an employer so it can continue to allow its limited partners to buy into a type of job-based health insurance that doesn’t have to comply with state insurance rules or offer coverage as robust as required under the ACA.

But to grasp the claim, one also has to understand how the coverage works.

A consumer shopping for health insurance may come across information online or from a marketer about this concept, sometimes called “limited partnership” coverage. The pitch? Buy insurance offered through Data Marketing Partnership and handled by LP Management Services. To qualify, the consumer must download an app that tracks their internet searches. The company could then sell that data.

Some potential consumers may be turned off by the thought of their internet searches being tracked, but others may find it appealing because it allows them to become a limited partner eligible to buy into the company’s employee health insurance plans. But can these partners be considered employees?

The court’s answer has potential implications for regulators and consumers. Some health policy and market experts warn that a green light could lead to a proliferation of aggressively marketed and potentially questionable insurance with limited recourse for consumers because the plans would be exempt from state oversight.

“If this took off, you logically could see the rise of a whole bunch of what, functionally, would be unregulated insurance companies,” said Ali Khawar, who was the principal deputy assistant secretary of the Department of Labor’s Employee Benefits Security Administration during Joe Biden’s presidency and now runs his own consulting outfit.

No one knows if the department is going to change its long-running stance defending the case. But any settlement could add more uncertainty to insurance markets.

Already insurers are requesting double-digit increases in ACA premiums again next year, partly because declining enrollment often means that the healthiest policyholders are leaving. That trend could accelerate in coming years as more people are drawn into alternatives such as limited-partnership policies.

States Act as Federal Case Plays Out

The Department of Labor defended the case throughout the first Trump administration and the Biden era, issuing a sharply worded advisory opinion in early 2020 stating that people who simply download software to “capture data as they browse the Internet” are not “employees or bona fide partners.”

A district court judge in Texas, who had previously ruled the ACA unconstitutional in a decision ultimately rejected by the Supreme Court, called the advisory opinion “arbitrary and capricious” in a 2020 ruling in favor of the data marketer. The U.S. Court of Appeals for the 5th Circuit largely upheld the lower court’s decision but ordered it to reconsider whether someone who downloads software is either a “working owner” or a “bona fide partner.”

The employer-employee relationship is at the heart of the case because of a 1974 federal law designed to help large, self-insured employers offer retirement and health benefits to workers without having to meet varying rules from multiple states.

That law — the Employee Retirement Income Security Act — allows such plans to avoid most rules set by the states, which generally regulate most other types of insurance and assist consumers who report problems with their policies. As self-insured employer plans, the policies also don’t have to comply with some ACA rules, such as the requirement to cover 10 broad categories of “essential health benefits.”

“If the case goes the wrong way, it could impact consumers or hamstring the states,” said Marie Grant, Maryland’s insurance commissioner.

Arguments over what constitutes an employer plan are not new, and other organizations have tried offering such coverage. Some states have taken action against purveyors of limited-partner policies.

Maryland in 2024 fined a company, The Vitamin Patch, for offering limited-partnership insurance after investigating complaints and determining it was not licensed to sell coverage in the state.

Washington in 2021 ordered another company to stop offering its plans in the state and fined it $25,000.

Maine and Connecticut in 2024 warned consumers about this type of coverage.

“These plans do not provide comprehensive medical coverage and can leave consumers with large, unpaid medical bills,” according to Connecticut’s notice.

Maine’s announcement noted that entities offering these types of health insurance included The Vitamin Patch as well as Affiliated Workers Alliance, Consumer Data Partners, Employers Business Alliance, Socios Buenos, and Strategic Limited Partners.

State insurance commissioners filed legal arguments in the Department of Labor case citing their concerns about losing the ability to enforce consumer protections.

“This is not a Republican-Democrat thing,” Khawar said. “It’s really a story about state authority, the way such authority would be significantly undermined in insurance markets.”

What’s the Risk?

Still, these limited-partnership plans are viewed by proponents as a needed additional choice for consumers, at potentially lower cost than ACA plans.

When the case was filed, attorneys general from seven right-leaning states, for example, urged the Department of Labor to back Data Marketing’s request to designate its limited partners as employees. That would provide an option for people who “earn too much to qualify” for ACA subsidies and be an interim solution until the ACA could be repealed and replaced, they wrote. They argued that states would retain some regulatory authority and added that the Department of Labor, which oversees self-insured employer plans, could set requirements to “encourage” stable companies to enter the market.

Critics, the attorneys general wrote, might fear that ACA alternatives will draw away younger or healthier people, thus affecting those who remain, but they argued that had already happened.

Data Marketing’s attorneys emailed KFF Health News that they could not provide a comment for this article because the case is in active litigation. Neither the White House nor the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, responded to questions from KFF Health News about whether the Department of Labor has changed its stance and how the administration views limited-partnership health plans.

In court filings, however, Data Marketing said that without an employer designation, it would have to end the insurance coverage, affecting about 50,000 policyholders. That would also hurt its ability to generate revenue, it argued, because offering insurance is “a significant attractor” to get people to join its partnership and let it access their electronic data.

Ellen Montz, who helped oversee ACA implementation in the Biden administration and is now a managing director at consultancy Manatt Health, had a different take. “The only reason why these sorts of products exist is because they aren’t beholden to consumer protection rules of the ACA and can essentially make money by attracting good risk, people who are healthy,” she said.

Maryland’s Grant echoed this warning, saying that proliferation of such plans could lead to even higher premiums in the ACA markets, if those who remain are older or sicker than those who leave.

Nineteen patient advocacy groups sent a letter to the Department of Labor Aug. 11 urging it to continue its defense in the case, warning that a settlement that says such arrangements create an employer-employee relationship could “significantly” undermine “both state regulatory authority and decades of bipartisan efforts to promote stable, well-functioning health insurance markets.” Some of those groups had filed a legal brief in support of the department in 2021.

Days after the August letter, U.S. Rep. Bobby Scott (D-Va.), the ranking member of the House education and workforce committee, warned the department against increasing the availability of “questionable employment relationships” and the insurance they offer.

He cited reports of call centers’ misleading consumers “who think they are enrolling in comprehensive health insurance but instead sign up for junk coverage under the guise of creating an employment relationship with what the consumer believed to be a traditional health insurer.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Imbalance of Power — And Healthcare

Why can members of Congress remain on full taxpayer-funded salaries during prolonged medical absences while millions of working Americans cannot afford to get sick? (Kennedy, Oz Contend Fraud Crackdown, Not Skyrocketing Prices, Led Millions To Leave Obamacare, Aug. 3.) Sen. Mitch McConnell’s current extended medical absence brings that disparity into sharp focus. He has missed dozens of Senate votes while continuing to receive his $174,000 taxpayer-funded salary.

Meanwhile, I have a friend who works two jobs and still cannot afford her mortgage and utilities without a roommate. She does not even have basic medical insurance. She earns too much to qualify for government assistance but not enough to comfortably afford insurance along with the basic cost of living. What happens if she gets seriously ill?

She doesn’t have the luxury of taking months off to recover while her income continues. She could lose her income, her home, and everything she has worked for simply because she got sick. Yet she is one of the taxpayers providing that financial security to members of Congress.

McConnell’s situation is particularly striking because of his long legislative history of opposing or limiting federal family and medical leave protections.

If continuing someone’s income while they recover from a serious illness is reasonable and humane when that person is a member of Congress, why isn’t it reasonable and humane for the Americans paying their salaries?

Americans should not face financial ruin because they get sick while their elected representatives enjoy protections unavailable to the people they serve.

— Ruth Bower; Salem, Oregon

Hospice Saga Hits Home

I could really have used the information in the article “My Husband Was Kicked Out of Hospice for Dying Too Slowly” (Aug. 14) before it happened to me. I was notified on a Monday morning by my husband’s residential hospice agency that I needed to find a new place for him ASAP, and “here’s a list of places.” I asked what it would cost for him to stay a day or two — saying I would pay it myself, just tell me how much. They didn’t. So I got on the phone, and it was a hectic and horrifying day calling around for a new place.

My husband had been home twice between hospital stays, had fallen both times, requiring me to call 911, and then he was rehospitalized. I’m 64, and there was no way I could lift my 300-pound husband if he fell again. Even a half-dozen firefighters had trouble.

I spent most of his final day calling hospice agencies, and a representative from one even showed up to visit (uninvited and unexpected). It was scary how little oversight or medical professionalism there was. His life ended about 7 p.m. that evening. We had already stopped his pacemaker a few days before.

I will never forget or forgive that I wasted my last day with him because he was not dying quickly enough for the hospice. He never saw a doctor once he enrolled in hospice. There are great nurses in hospice — I’ve met a few — but there are a lot of places for which this is just an easy revenue stream, and they seem to be in it just for the money.

— Debbie Bond; Corpus Christi, Texas

On Improving the Hospice Experience

Thank you for publishing the article on hospice. As a hospice clinician and leader who has been providing hospice education for over 20 years, I, too, continue to see the need for increased awareness around hospice in our communities. This story is similar to many I have recently collected from families who are searching online, using AI tools that fall short of accuracy, and expressing they are overwhelmed.

As the article states, they were given a list of hospices to pick from; that is common and can be a major cause of panic for families. The article provides nice tips on choosing a hospice, but there is so much more to it. Picking a hospice that aligns with your values is a good first step, but we cannot overlook the idea that people and families need help walking this journey, help with exploring their care goals and wishes.

I recently took on a mission to enhance and make hospice education more accessible. In doing so, I launched an app, myHospice Companion, focused on helping people and families learn about hospice before they need it; what hospice is and how it works, when they are ready; and what to understand and expect, all the way to the end. Two important articles were posted this year: a recent one entitled “The Hospice Conversation Starts Too Late,” by Kurt Merkelz, and a staggering article published by Hospice News about how the Centers for Medicare & Medicaid Services could save $1.5 billion annually if hospice were elected just five days sooner.

The data supports that people and families are looking for reliable sources of education. However, the hospice industry as a whole has focused on providing that information once someone is admitted, which is too late.

Educational leaders in our communities need to work together to enhance end-of-life knowledge. Our mission is to give them a tool to make a meaningful impact.

— Jason Kimbrel; Columbus, Ohio

Common Ground: The Height of Folly?

Whoever is investigating common ground between the major political parties (KFF Health News’ series “Common Ground”) clearly isn’t interviewing or polling Republican members of Congress — although there are probably a few Democrats in Congress who’ve gone along with making cuts to Medicaid and the Supplemental Nutrition Assistance Program, who don’t want to tax the rich more to keep the Social Security trust funds solvent, and who would never, ever vote for national healthcare systems similar to any of those in Western Europe or the Scandinavian nations.

I’ve yet to read that any members of Congress have seriously analyzed how nations with “universal” healthcare coverage manage such a system, and how much it would cost to implement in the United States. That demonstrates that neither party is truly committed to finding a better way to provide healthcare for all of us.

Too many GOP members of Congress have, for many years, tried to privatize Medicare (with some success), cater to healthcare insurers, and in every way demonstrate that they do not share what’s supposedly a general concern: improving the healthcare system in the U.S. and improving access for anyone not superwealthy to good quality healthcare. They should not only be making it more affordable, but making pre-med training and obtaining a doctor or nurse practitioner degree far, far, far more affordable than good programs for obtaining those degrees currently are.

We also need to pay registered nurses better than what they are being paid now, and support the National Science Foundation, the Centers for Disease Control and Prevention, the National Institutes of Health, et al., so that the U.S. continues to conduct medical research and fund the FDA so it can actually regulate the drug industry. We need an affordable drug system, too. Again, too many people in the U.S. can’t afford drugs that are affordable in other nations.

There’s no way the GOP in Congress will fix this. Republican presidents, from Ronald Reagan to the present, could’ve done so and did not. That the GOP has managed to propagandize so many people on vaccines, and toleration of increasingly expensive and poor-quality healthcare (and less access), just goes to show how many in the U.S. seem willing to effectively sabotage their lives — and the lives of their children.

— Susan Hogg; Newport, Oregon

Monopolies Hurt Healthcare Providers, Too

I am a recently retired health executive. I just read the article “Same Knee Surgery, Twice the Price: Hospital Monopolies Push Up Healthcare Costs” (Aug. 10). I loved the article. Very well written. Based on my experience, it is completely accurate. Well done.

However, you omitted a critical factor. During my approximately 40-year healthcare career, I saw the competitive landscape among health insurance companies shrink incredibly. One cannot discuss “merger mania” among hospitals and other medical institutions without acknowledging the negative impact that consolidation of health insurance carriers has had on the industry.

While the article made great points, it failed to articulate the effect insurance carrier consolidation has on healthcare providers’ bottom lines and their ability to negotiate reasonable fees. Your readers deserve to hear a balanced story.

— Quinten Davis; Randallstown, Maryland

Healthcare Students Clutching at Straws

Benjamin Pinckney’s story about the new federal student loan caps upending his dream of becoming a physician assistant is one that many students and prospective students unfortunately know all too well (“He Dreamed of Becoming a Physician Assistant. New Loan Rules May Thwart Him,” June 30). I’m a nurse practitioner and educator myself, and federal student loans were instrumental in my own educational journey. I might not be where I am today without them.

There are many bright, aspiring individuals seeking to become nurses to serve our nation’s growing patient needs. Yet the new federal loan caps have the healthcare workforce clutching at straws, as many students question their ability to pursue higher education. While the goal of lowering the cost of education is worthwhile, the rule risks forcing nursing students to choose between drowning in private, high-interest loans and abandoning their educational goals entirely. Either way, it will weaken our healthcare workforce at a time when the United States is expected to face worsening shortages of advanced practice providers and nursing faculty.

Just consider a few key data points: Demand for advanced practice nurses is projected to grow by 36%, much faster than the 3% average growth for all occupations. Over 1 million nurses are expected to retire by 2030, far outpacing the projected number of new nurse graduates. And 7.2% of faculty seats across the nation currently sit vacant, with about 81% of open positions requiring advanced degrees.

Fewer students can afford nursing education. Combined with fewer opportunities for clinical educators to pursue the advanced training needed to prepare future professionals, that equals a reduced ability of the nation’s healthcare system to meet Americans’ demand for high-quality care.

For now, the healthcare workforce is relieved that the rule has been paused in the courts. Looking ahead, we must actively work not only to control graduate education costs but also expand educational opportunities by championing legislation that designates advanced nursing degrees as professional degrees. Students who wish to become nurse educators and advanced practice registered nurses should be able to secure the federal financial aid they need, which is why legislation like the Nursing Is a Professional Degree Act, the Clarity in Professional Degree Act, and the Professional Student Degree Act are all so important.

I urge Congress to listen to stories like Pinckney’s and to the countless aspiring nurses across the nation who want to pursue careers that will strengthen our healthcare system but are being held back by loan policies that stand between qualified students and the workforce our country urgently needs.

— Lorie Hacker; Bargersville, Indiana

Rural Healthcare Needs AI That Earns Its Place

Rural patients’ skepticism of artificial intelligence raises an important point (“Patients Wary of Governments, Companies Pushing AI as a Rural Healthcare Solution,” Aug. 11). At this point, there’s not a “should” around AI adoption. It’s more about whether the technology can demonstrate enough value to earn the trust of patients and clinicians.

AI can and will help rural health systems facing staffing shortages, financial pressure, and limited technology resources. But the most meaningful opportunities may initially be behind the scenes. Reducing documentation burden, streamlining referrals, improving scheduling, and automating repetitive administrative work can give clinicians something rural communities urgently need: more time to care for patients.

That’s very different from asking patients to replace a trusted relationship with an AI avatar or chatbot.

Healthcare leaders should resist measuring success by how many AI tools they deploy or how many people use them. Rural AI investments should be judged by outcomes. Did clinicians save time? Did patients get appointments sooner? Did the technology reduce costs, improve efficiency, improve access, or produce better clinical results?

Because many AI tools have been developed using data and infrastructure from large health systems, rural organizations also need rigorous evaluation, strong governance, and reliable data before scaling them.

Patient skepticism is not an obstacle to innovation. It reminds us that technology earns trust through results. If AI gives rural clinicians more capacity to deliver human care — and health systems can prove it does — it can become part of the solution without pretending to be the solution itself.

— Jason Griffin; Missouri City, Texas

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

By the time Democrat Xavier Becerra left Washington, D.C., more Americans than ever had health insurance, owing partly to his work over the years to pass, defend, and expand the Affordable Care Act.

It’s an achievement the former congressman and former U.S. secretary of Health and Human Services often touts as he campaigns for California governor against Republican Steve Hilton, a former Fox News commentator.

But should Becerra cruise to victory in November, as polling suggests, he will face what may be the steepest decline in health insurance coverage in a generation, one that will land especially hard in his home state.

By 2030, the number of uninsured Californians under 65 is expected to nearly double from 2.4 million to 4.6 million, as recently enacted state and federal cuts to Medicaid and ACA marketplaces begin to roll back historic gains in health coverage, according to a May analysis by the University of California-Berkeley Labor Center. The anticipated rise in the uninsured population could have broad implications for hospital systems, insurers, and the economy.

In February, Miranda Dietz, the labor center’s healthcare program director, told legislators the changes could end up costing California about 200,000 jobs, mostly in the healthcare industry.

Hospital executives have begun reporting more unpaid medical bills, and experts warn health plans will raise premiums further as they’re left with enrollees who are, on average, sicker and more expensive to cover.

“It’s triage,” said Jessica Altman, executive director of Covered California, the nation’s largest state-run health insurance marketplace. “That’s what the next governor is walking into.”

California achieved one of the most dramatic drops in its uninsured population in the nation, largely credited to the state’s robust adoption of the ACA. If tapped to lead the wealthy, progressive state, Becerra would wrestle with how uninsured Californians get care and who pays as the Trump administration shrinks a federal safety net he once oversaw.

Becerra has some experience pushing back against Washington, D.C. As California attorney general, he successfully defended many provisions of the Affordable Care Act, including access to birth control.

Becerra said he would issue an executive order to keep those affected by federal cuts insured. But he has not detailed how the state would backfill as much as $30 billion in federal funding California stands to lose annually.

At a policy forum hosted by Politico last month, Becerra promised Californians would not lose health coverage despite federal cutbacks, saying he would push the industry to eliminate waste from “attorneys, accountants, pencil pushers” that cost consumers billions.

“I’m going to ask them to help me extract some of that waste and put it into healthcare, which helps us cover the cost of keeping Californians insured,” he said.

His opponent, Hilton, is trying to appeal to voters opposed to President Donald Trump, despite receiving the president’s endorsement, and has stumped on cutting off coverage for Californians without legal status, which is paid for with state funds. Hilton has vowed to use those savings to issue state income tax breaks, calling it an immediate antidote to high costs.

“We all understand that the healthcare system is a mess and needs major reform,” Hilton said in an interview. “The quickest thing we can do on healthcare costs is actually to tax people less.”

Left Behind?

In 2010, Becerra was part of U.S. House Speaker Nancy Pelosi’s leadership team and helped whip up votes to pass the law. He also had a hand in crafting it, though his attempt to include a government-backed coverage option failed.

A decade later, when lawmakers considered him for the nation’s top healthcare job, Becerra said his primary mission would be to carry out President Joe Biden’s vision to expand access and cut costs under the Affordable Care Act.

Before the ACA, some 50 million Americans — roughly 1 in 6 — were uninsured. Within a few years of the law’s passage in 2010, its expansion of Medicaid eligibility and financial aid to lower-income marketplace enrollees helped slash the U.S. uninsured rate by nearly half.

Millions more gained coverage during the covid-19 pandemic after Becerra implemented a freeze on Medicaid disenrollment and administered generous but temporary tax credits that put the cost of Obamacare plans within reach for more people.

As Biden’s health secretary, Becerra launched aggressive public awareness campaigns, loosened enrollment rules, and distributed hundreds of millions in grants to pay consumer assistants, also known as healthcare navigators, to help enrollees wade through paperwork.

“One of the common things we would hear from him as a leader was, ‘Who’s being left behind?’” said Benjamin Sommers, a Harvard health policy professor who was a deputy assistant secretary under Becerra.

Under Biden and Becerra, the percentage of people with health insurance reached a historical high of 92%, or 310 million Americans having health coverage in 2024.

Republican Response

But conservatives said those policies inflated enrollment by attracting fraudulent and wasteful coverage. In response, the second Trump administration has tightened enrollment windows and toughened income reporting.

“It’s simple and easy to say, well, the numbers are up so the program must be working,” said Edmund Haislmaier, a senior research fellow at the Heritage Foundation, a conservative think tank. “My argument would be that’s the wrong metric.”

Last summer, the GOP-led Congress passed Trump’s One Big Beautiful Bill Act, which Republicans argued preserves Medicaid for those who need it most while rooting out fraud and waste. Altogether, the law is expected to cut Medicaid spending by $900 billion-plus over a decade.

Congress also allowed enhanced premium tax credits for Obamacare plans to expire last year, spiking premium payments for middle-income Americans and driving down enrollment by nearly 3 million this year.

“We are now witnessing almost a wholesale reversal of pretty much all those policies” that helped cover millions more Americans, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

For Eric Maciel, the $800 monthly cost of a Covered California plan is too much. To avoid injury, the 28-year-old stays home more and rarely plays pickup soccer at the park — the other players, he added, can get pretty rough.

“That’s another car note,” Maciel said. “I’d be left with nothing.”

Health economists say Maciel is the type of customer insurers need to stabilize their risk pools: young, healthy, and less costly.

Hilton criticized state leaders for passing a revised provider tax he asserts will send premiums soaring and said he wants to inject more competition into California’s health insurance market — but he offered no specific ideas.

Playing Defense

Higher-than-expected state costs coupled with federal cuts have prompted California to retreat on healthcare coverage. Federal funds account for one-third of the state’s budget and more than 60% of spending by Medi-Cal, the state’s Medicaid program.

Gov. Gavin Newsom has frozen enrollment for immigrants without legal status, enacted monthly premiums for some, and plans to only temporarily backfill federal assistance for legal immigrants such as asylees and refugees.

Newsom and Democratic lawmakers agreed to delay some cuts until July 2027, leaving the next governor to weigh further rollbacks against increased taxes. Becerra, a California native born to Mexican immigrants, opposes what’s known as the billionaire tax, on November’s ballot. Last month, he said he supported legislative efforts to penalize large corporations whose workers rely on Medi-Cal, arguing that taxpayers are subsidizing employers’ low wages and paltry benefits.

County governments, which are legally required to provide healthcare to uninsured residents too poor to afford care, are lobbying lawmakers for funding to treat what they describe as a fresh deluge of patients who need free care.

“It’s a pretty big cliff if all this stuff goes into effect,” said Dietz, the labor center’s healthcare program director. “And there’s a choice whether to make it less bad and maintain coverage for folks.”

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.

This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.