Refugees. Sex-trafficking victims. People fleeing war. They’re among the hundreds of thousands of immigrants living in the country legally who no longer qualify for Medicaid. The change, in effect since Oct. 1, is part of the 2025 Republican tax law, which cuts Medicaid spending by an estimated $900 billion through 2034.

KFF Health News rural health reporter Andrew Jones joined WAMU’s Health Hub on Oct. 21 to explain which Medicaid enrollees are affected in the Washington, D.C., region and what other cuts to health services for immigrants are next.

US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims

The Congressional Budget Office estimated 100,000 more immigrants will be uninsured by 2034 because of Medicaid eligibility changes under President Trump’s One Big Beautiful Bill Act that take effect Oct. 1. A KFF Health News survey of nine states found many more are at imminent risk of losing health coverage.

By Phil Galewitz, Andrew Jones, and Claudia Boyd-Barrett Sept. 30, 2026 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.

Consumers who buy Affordable Care Act health insurance are going to see changes both big and small as open enrollment for 2027 coverage kicks off. These include premium increases, possible additional identity checks, potential delays in working with a broker, and new limits on which immigrants can get subsidies.

Shoppers need to plan accordingly.

Open enrollment starts Nov. 1 in most states. Idaho, Connecticut, and Massachusetts start earlier, and some states are already allowing “window shopping” to check premium rates.

A continued decline in overall enrollment is expected, mainly because of the expiration of enhanced subsidies at the end of 2025. Policy experts say the end of those subsidies led millions to drop or lose coverage through the first few months of this year.

But the Trump administration sees victory in the falling enrollment, crediting its various efforts to reduce fraud, including the August cancellation of policies covering 760,000 enrollees suspected to be improperly signed up. A small number of those enrollees have regained coverage.

Have Your ID Ready

One of the biggest changes will be increased scrutiny of both consumers and agents via requirements aimed at thwarting fraud or improper enrollments. For consumers, it could slow the enrollment process.

The new rules, outlined in a Centers for Medicare & Medicaid Services FAQ, affect only consumers using agents or brokers to help them enroll through the federal marketplace, which serves 29 states. They do not apply to state-based exchanges, which have their own rules and have in most cases been more successful at preventing fraudulent sign-ups.

For starters, all consumers using an agent in the federal marketplace will need to get a one-time confirmation code or link to authorize a specific agent to enroll them or make changes on their behalf. It will be sent to consumers by text message, email, or an automated phone call from one of the private enrollment platforms used by their agent. Returning consumers who have incorrect or outdated contact information will first need to call the federal marketplace themselves or submit an application online to update it.

Additionally, consumers and policyholders deemed “high-risk” must verify their own identity before authorizing an agent. CMS defines as “high-risk” first-time applicants or those with existing coverage whose applications involve a change of state, as well as consumers working with a new or different agent or with a monthly premium payment of $30 or less.

Joshua Brooker, who oversees an insurance agency in Pennsylvania, said CMS appears to have selected people in those groups for greater scrutiny because “someone who is moving to a new state or switching brokers — that could be a broker trying to impersonate a consumer.”

The $30-a-month cutoff may be tied to concerns that plans with no or low monthly premiums are easier for bad agents to target for unauthorized enrollments because the policyholder may never get a bill. Some rogue agents even pay the low monthly amount themselves and still make a profit from the commission, Brooker said.

The broad nature of the new rules, though, has Brooker concerned “that up to 1 in 5 consumers is going to have to do extra identity proofing” and may just give up and not get insured.

Consumers designated high-risk must prove their identity through a CMS-approved third party such as credit company Experian, which generally asks questions only the consumer should be able to answer. People who fail this test may be asked to call Experian’s help desk or submit their applications themselves by creating a healthcare.gov account, which requires them to upload identification such as a driver’s license, a passport, immigration papers, or another form of ID.

“Some people may have trouble not because they’re not real, but because they don’t have a credit file, or have moved, or have changed names,” said Stacey Pogue, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University.

She said the changes might “be an appropriate response by CMS that targets fraudulent enrollments but might also create extra hurdles.”

There May Be Fewer Brokers

CMS in September issued a rule that places a moratorium on brokers new to offering ACA coverage. Agents not registered with the federal marketplace in 2026 will not be allowed to assist with enrollments for 2027 until February at the earliest, past the end of open enrollment season.

CMS said it took this step because a disproportionate number of “significant compliance concerns” in 2026 came from newly registered agents or brokers. Additionally, the agency has kicked out “hundreds of non-compliant agents and brokers” this year.

Jason Fine, who runs a brokerage in Florida, said he agrees with the concept behind these changes. He has reported multiple times to CMS, for instance, that rogue agents have switched his clients’ coverage without authorization, wanting the agency to take action against them. But he said the updated rules also raise concerns.

“Everything they are doing in the long term makes sense,” he said. However, in the short term, “I don’t know if they care about the chaos it will cause.”

That’s because the moratorium will make it much harder for small brokers to help clients this year. His agency and others often pare their staffing after open enrollment but hire again toward the end of the year. He was planning to add up to 10 agents to his core staff of about five but has been told by recruiters that he’s unlikely to be able to find anyone who was registered for 2026 and is still available.

He suggested that the move unintentionally benefits larger call centers, some of which were doing much of the marketing that regulators feared led to unauthorized switching. Call centers often maintain larger staffs.

“They can afford to keep a staff of 25 or 40 people all year long,” Fine said.

Groups representing agents are very unhappy with the directive. One, the National Association of Benefits and Insurance Professionals, filed a lawsuit Oct. 15 against the Trump administration over the moratorium, saying it unfairly targets 19,000 agents who may want to sell ACA plans for next year.

“Just because you’re a new agent doesn’t mean you are fraudulent,” said Ronnell Nolan, president of Health Agents for America, another sales agent group, which on Oct. 21 filed suit seeking a temporary restraining order on the moratorium. “All these agencies who have trained new agents and paid thousands of dollars now have people who won’t be able to work.”

It all leads to an important piece of advice from Georgetown’s Pogue: Consumers should not delay making appointments. “If you rely on an agent or broker, and a lot of people do, their slots might fill up faster because there will be fewer of them to help with enrollment. I would reach out early.”

Costs Will Continue To Be an Issue

This year, after Congress did not renew the expiring enhanced subsidies, most people getting ACA coverage saw what they had to pay increase. Higher earners lost subsidies entirely. Add in double-digit premium increases, and most people had to pay substantially more for their coverage.

But most people who buy ACA coverage for next year will still receive a subsidy. It will just be less generous than it was before the enhancements expired at the end of 2025.

The subsidies are pegged to the premium costs of benchmark plans, the name given to the second-lowest-price silver-tier plan in an area.

This helps offset premium increases.

“For most folks, overall affordability will stay about the same,” said Louise Norris, a health policy analyst for HealthInsurance.org. “That’s not to say it’s great, but if you were able to manage the premiums this year, it should be similar to that.”

But there are other factors at work, too.

Last year’s average premium increase of 26% was the largest in years. It was driven in part by insurers’ fear that the expiration of subsidies would cause healthier people to drop out of the marketplace. Other drivers often cited for such increases include a rise in overall medical care costs, inflation, and labor shortages.

For the upcoming year, those dynamics remain a concern, with premiums slated for double-digit increases, although, at 15%, slightly lower than last year.

Subsidies are income-based and cut off for households earning more than four times the federal poverty rate. During this open enrollment season, that amount is $63,840 for a single person, $86,560 for a couple, and $109,280 for a family of three, for example.

“The biggest issue we will face is affordability,” said Anne Petry, who, with her father, owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, and helps customers purchase health insurance, including ACA plans. “There definitely will come a breaking point for people.”

Agents and other experts say consumers should not allow their plans to automatically renew and should instead go online to compare premiums and coverage, which can change each year even for the same plan. There may be less expensive alternatives, including plans from new insurers, so they suggest looking at not just premiums, but also deductibles and other costs. At the same time, several insurers, including Cigna, have dropped all or part of their ACA coverage areas.

“If you just sit on the sidelines and let the policy auto-renew, you might miss out on what could be a better opportunity,” Norris said. She said it is important to check options because the cap on out-of-pocket maximums for ACA plans is also increasing.

That amount, which represents the most a consumer must pay toward deductibles, copayments, and coinsurance before the policy is expected to cover remaining in-network medical costs, was $10,600 for an individual and $21,200 for a family plan this year. In 2027, it will grow by 13% to $12,000 for an individual and $24,000 for family coverage. Lower caps on out-of-pocket maximums are set for households earning up to 2.5 times the federal poverty level.

The One Big Beautiful Bill Act, which Congress passed last year, also strips subsidy eligibility from many lawfully present immigrants, including people holding temporary H-1B work visas, refugees, asylees, people with temporary protected status, and those with pending green-card applications.

Three immigrant groups can still get ACA subsidies: green-card holders, who have permanent legal status; certain Cuban and Haitian immigrants; and citizens of Micronesia, the Marshall Islands, or Palau.

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 issues continue to be front and center in the midterm campaigns. Democrats are hammering Republicans on the federal funding cuts to Medicaid included in 2025’s One Big Beautiful Bill Act, even before many of the reductions take full effect. Republicans, for their part, are accusing Democrats of failing to fight fraud and abuse in federal programs.

Meanwhile, President Donald Trump this week unveiled initiatives aimed at improving women’s health and rewarding whistleblowers who uncover fraud, despite the fact that there are long-standing federal programs addressing both issues. It’s unclear what’s new that the programs will bring to the table.

This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Amanda Seitz of KFF Health News, and Liz Essley Whyte of The Wall Street Journal.

Panelists Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Amanda Seitz KFF Health News @AmandaSeitz aseitz@kff.org Read Amanda's stories. Liz Essley Whyte The Wall Street Journal @l_e_whyte Read Liz's stories.

Among the takeaways from this week’s episode:

• As Election Day approaches, Democrats and Republicans are working to keep their healthcare messages front of mind for voters. Democrats, seeking to win control of Congress, are pointing fingers at the GOP for high health costs and insurance coverage losses, particularly among Medicaid enrollees. Republican candidates in turn are pointing to the rural health funding Congress approved alongside the Medicaid spending reductions, though their Democratic opponents note that the funding amounts to a fraction of the cuts.
• Meanwhile, Republicans are pushing their own message targeting fraud, waste, and abuse in federal healthcare programs. The Trump administration has announced another major deferment of federal Medicaid funding for California, citing dramatic growth in home care costs. Trump officials say that growth suggests potential fraud and warrants action, while California officials say it represents actual increases in costs and demand.
• In other administration announcements, Trump unveiled a new women’s health initiative with first lady Melania Trump by his side. Yet the initiative has no concrete policy goals or funding, leaving it unclear what exactly it will accomplish.
• New research is illuminating the inherent flaws in Health and Human Services Secretary Robert F. Kennedy Jr.’s push to stop recommending the birth dose of the hepatitis B vaccine. Plus, the board of the National Institutes of Health research hospital denounced the launch of Kennedy’s Vaccine Injury Center, accusing the health secretary of undermining trust in science.

Also this week, Rovner interviews Ollstein, whose new book, Side Effects: How Abortion Bans Impact Everyone’s Health, comes out Oct. 27.

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

Julie Rovner: Vox’s “America’s Next Big Healthcare Reform Might Already Be Underway,” by Rachel Cohen Booth. 

Alice Miranda Ollstein: Stat’s “I Was a Theranos Whistleblower. In ‘You Can See Everything,’ Elizabeth Holmes Is Still Lying,” by Tyler Shultz.

Liz Essley Whyte: Stat’s “How the No Surprises Act’s Nonprofit Arbitrators Are Operating Like ‘Mini Gods’ and Getting Rich Doing It,” by Tara Bannow.

Amanda Seitz: The New York Times’ “Why Drug Companies Are Rushing To Market Ketamine Medicines,” by Andrew Jacobs.

Also mentioned in this week’s podcast:

• Politico’s “Medicaid Cuts Haunt Republicans in Battleground States,” by Alice Miranda Ollstein.
• KFF Health News’ “After Booting 760K People From ACA Plans, Trump Administration Has Added Some Back,” by Julie Appleby.
• The New York Times’ “Kennedy’s Vaccine Plan Could Cause Surge in Hepatitis B, Study Finds,” by Apoorva Mandavilli.
• The New York Times’ “N.I.H. Hospital Board Rebukes Kennedy Over New Vaccine Injury Clinic,” by Sheryl Gay Stolberg.
• Bad Blood: Secrets and Lies in a Silicon Valley Startup, by John Carreyrou.

click to open the transcript Transcript: Medicaid Is Now a Campaign Issue

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

Julie Rovner: Hello, from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News. And, as always, I’m joined by some of the best and smartest health reporters covering Washington. We’re taping this week on Thursday, Oct. 22, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. Today we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Liz Essley White of The Wall Street Journal. 

Liz Essley Whyte: Hi. 

Rovner: And my KFF Health News colleague Amanda Seitz. 

Amanda Seitz: Hey, thanks for having me. 

Rovner: Later in this episode, we’ll have my interview with Alice here, whose brand-new book, Side Effects: How Abortion Bans Impact Everyone’s Health, comes out officially next week. But first, this week’s news. 

Let’s start with Medicaid. Election Day is less than two weeks away, and, despite the fact that Republicans tried to backload the Medicaid cuts in their 2025 budget bill so that most of them wouldn’t start until next year, Democrats appear to be making some headway using them as a campaign issue already this year. Alice, you wrote about this. Start us off. 

Ollstein: Yeah. So the cuts are hitting people already. People are already feeling them, and that’s for a few different reasons. One, some states have decided to pull the trigger early on work requirements, and even those that are waiting until the congressionally set January deadline, they’re already receiving notices, and so they’re freaked out about their coverage. Also, even though the cuts are not taking effect, states have to make their budgets in advance to prepare for them. Hospitals need to make their budgets in advance to prepare for them. And so you’re already seeing cutbacks in other areas — in services, in programs — and so people are feeling that. And the impact is happening way outside Medicaid as well: People on private insurance, whether they get it on the individual market or through their job, are seeing really big increases in costs. And Democrats are capitalizing on that and are connecting what the pain people are feeling to Republicans’ basically one major piece of legislation that they passed over their two years in power, which is the quote-unquote “One Big Beautiful Bill” that had all these healthcare provisions tucked into it. And so I found that in basically every single Senate debate that I’ve been watching in these battleground states, there was almost identical exchanges, where Democrats attacked about the Medicaid cuts, Republicans responded by pointing to the rural health funding in the bill and saying, You know, I fought for that, and I guess you hate rural health because you criticize this bill. Then Democrats responded, OK, the rural health funding is great, but it’s just a fraction of what states are losing on other federal health funding. And so this is just playing out again and again and again — in Michigan and Maine and Alaska and all of these states that have these close races. 

Rovner: Yeah, and we’ll talk about this more next week. But the KFF annual employer survey is out just this morning, and it shows not only, I mean, what we already knew, which is that premiums are going up, but it also shows that employers are starting to pass along the cost of those increased premiums to their employees. So it kind of balloons the idea that people are really feeling the increases in healthcare costs. 

Seitz: Yeah, I think the issue is less about the Medicaid cuts themselves and more about that idea that healthcare costs are rising at every level, and no one has offered a solution to really fix that. If you recall, President [Donald] Trump said that he had “concepts of a plan” to fix the ACA [Affordable Care Act]. Well, instead, all we got were cuts to Medicaid, higher ACA premiums, higher premiums for private insurance. So I think that people see there’s kind of no real road map being offered here to get out of this situation of continuously rising costs and access to care becoming increasingly more difficult. But I think the hard part now for Democrats, in particular, becomes OK, what is your plan? And they have not offered a clear, unified vision for what they will do. We’re still kind of waiting to see what that might be. So if they do succeed in taking back control of Congress, for example, that’s going to be a real challenge for them to quickly come up with a plan so they’re not in the same position two years from now. 

Rovner: Right. I mean, at some point they’re going to have to fight about what it is they want to do. But right now, they could just point to what the Republicans have done. Well, meanwhile, the Trump administration this week is doubling down on its healthcare fraud fight, announcing it will freeze another $1.2 billion in federal Medicaid funding to California. That’s on top of the $2.2 billion already withheld this year, mostly about home care programs. The administration says the program’s rapid growth signals something fraudulent, although it hasn’t provided evidence. California says it’s just responding to growing demand, and that, by the way, providing home care is actually cheaper than paying for institutional care that patients might otherwise need. How’s the whole fraud thing playing with voters? Is there any traction, and does it make, I wonder, an impact that they seem to be mostly going after blue states — first Minnesota, California, apparently now New York? 

Ollstein: I see this as sort of under the umbrella of “things that have long been popular in theory becoming less popular once people see the impact in real life.” And so I think that has also been true of the concept of Medicaid work requirements. When people were polled about it before, in theory, people are, like, “Yeah, you should have to work, etc.” And now, when they’re seeing people losing their insurance who are working or have a legitimate health issue, that popularity is crashing. And I think the same is true of these fraud crackdowns, where they are popular when polled on, you know, the general concept of them. But these cuts are hitting a lot of real patients, and, like you noted, it has the appearance of being very politicized because it’s mainly been targeting California, Minnesota — states run by Democratic governors, and not just any Democratic governors, but those that have clashed with the administration very openly. 

Rovner: Yeah, I think the other thing is when you get into the details of some of this, you know, they say when they’re talking about fraud, you know, Oh well, these are people who are carrying groceries and doing things that family members should be doing for free. But in a lot of these cases, when you’re paying a family member for care, they’re doing things like changing IV lines and helping people go to the bathroom. It’s not just running errands. This is, in many cases, real medical care that family members are providing in lieu of going to other jobs. And it’s basically, as I said, keeping people out of institutions, which, in the long run, is a lot cheaper to pay somebody to care for their own loved one than it is to put them in a nursing home. I just, I feel like this is sort of being missed in this whole fight. 

Seitz: I also think that it’s really hard for this to resonate when, frankly, people aren’t seeing any result from this fraud push. Their taxes aren’t necessarily going down as a result of these busts. The federal deficit is continuing to skyrocket in this administration, as we talked about: Healthcare costs are rising. So it’s like, as Alice was saying, it’s a really good talking point, especially for conservatives who oppose big government. But I don’t know that it’s going to move the needle if voters aren’t seeing any change in their daily life. 

Rovner: Yeah, that’s a good point. 

Whyte: I do think Republicans think it’s worth spending time on because we’re seeing near-daily announcements about some kind of fraud crackdown from CMS [Centers for Medicare & Medicaid Services] or DOJ [Department of Justice] or Vice President [JD] Vance’s task force. I mean, it’s a deluge of these announcements, including the one yesterday about New York’s adult daycare program, which Dr. [Mehmet] Oz called “a plague to the state.” 

Rovner: Yeah, they are definitely playing it up. It seems to be their major campaign issue. … This is all goes with the whole “drain the swamp” thing. Well, in a preview of what we can expect if Democrats retake the majorities in the House and/or Senate, three top senators on the Senate Finance Committee that oversees Medicare and Medicaid are calling for the administration to impose more standards on the private contractors who run most state Medicaid eligibility computer systems. The systems — say possible incoming Finance chair Ron Wyden of Oregon, along with Elizabeth Warren of Massachusetts and Raphael Warnock of Georgia — have already demonstrated that they don’t always accurately reflect who is and isn’t eligible for Medicaid, and that the coming implementation of the work requirements in January could mean that millions of people could be bounced off their health insurance wrongly. I would think this would be something to watch pretty closely come January. I think no matter who is in charge of Congress, this is, I know, a big concern. You know, the administration keeps saying, “Oh, we’ve got these computer systems, and they’re going to do all of this in the background, and everything’s going to be fine.” And you know, I know, Alice, I keep asking you to reiterate this, but the last time we tried this in 2018 with the work requirements, things were not so fine with the eligibility systems.  

Ollstein: That’s right. So the states that had a sort of pilot version of this before it became mandatory for everyone found that the work requirements did not increase employment. It did not cause more people to get off the couch and work, and, you know, which is sort of how it’s been framed in the public discourse. Instead, it led to a lot of people who should have been eligible — either because they were working or they had a legitimate claim on one of the exceptions: caregiving, going to school, having a medical condition, etc. — they lost their insurance because they were unable to navigate the bureaucracy, not because they were not actually eligible. And so that is what is predicted to happen again on a much bigger scale now. 

Rovner: Well, this is definitely one to watch, and I would think that even if Republicans keep the Senate, they’re going to have to keep a wary eye on this because if things go sideways, they will say that is not what they intended. Meanwhile, over at the White House, President Trump, with first lady Melania Trump at his side, signed an executive order on Monday establishing a White House Women’s Health Task Force and a, quote, “new” Women’s Health Division at the National Institutes of Health. Except the NIH has had an Office of Women’s Health since 1990. I covered its creation, which came after a gigantic bipartisan effort by women members in the House and in the Senate. The office was codified in legislation that was passed in 1993, and women’s health offices intended to address disparities in research and treatment into women’s health ailments were further expanded in the Affordable Care Act in 2010. Does President Trump really think that insisting something is his idea will automatically get people to believe him? Are people believing him that this has never existed before, and that he thought of it, or I guess that Melania thought of it? 

Seitz: Well, I think we can look back to November of 2023, when Jill Biden rolled out a similar measure, and I don’t know that it had any impact on how people felt about the election. I thought the timing of this was also really interesting because the administration has sort of lost its MAHA Mom momentum, and that effort also fizzled out. I mean, you had, at one point, you had all these high-level people in the administration meeting for these MAHA Mom meetings, and then you had “The MAHA Report.” But, like, we didn’t really see a lot of outcome from that. We didn’t see anything happen from that. So I think it will be interesting to see if this task force tries to veer into that direction at all, if it touches on some of the things that we’ve seen, you know, the MAHA crowd focus on — for example, like increasing the fertility rate, educating people on how to get pregnant, menopause research, weaning off of antidepressants, like that’s been the focus. So I’m very curious to watch how much it goes in that direction. 

Rovner: It also goes directly against the whole DEI thing because, you know, diversity, equity, and inclusion includes minorities, but it’s also included women over the years. I’m still sort of shaking my head at the whole thing because it’s just sort of the polar opposite of a lot of what this administration has been working towards for its first two years. Or is it just me? 

Whyte: When I talked to sources about this, it was clear it was a Melania-driven initiative, and even health officials weren’t really sure what it was going to accomplish. I mean, this was while it was being developed, so maybe they have a clearer picture now. But it didn’t seem like they thought it would be substantively impactful. 

Rovner: Also, there’s no money attached to it. 

Ollstein: I was just gonna say that. I think that’s really the biggest tell here. There’s no new funding. In fact, many programs that focus on women’s health have been cut significantly by this administration. Grants have been canceled, etc. Some grants focused on women’s health have been canceled because they’ve been labeled DEI, as you noted, and there’s also no deadline for any kind of delivery from this initiative. And so I kind of think of it in a similar category as the fertility announcements, which talked a big game and didn’t have a lot of new funding or meaningful programs behind it. 

Rovner: Or policy, for that matter. It’s just sort of statements of intent. Well, the president also this week “discovered,” air quotes, the idea of rewarding whistleblowers who help uncover fraud in federal programs, announcing something called the Fraud Whistleblower Incentive Program to crowdsource tips on federal program fraud. This is also something that is not new. The Federal False Claims Act actually dates back to 1863, during the Civil War, and, in fact, Republican Sen. Charles Grassley of Iowa has spent much of his career pushing for expansions to make it easier for whistleblowers to receive compensation for uncovering fraud. Now, this sounds great, and it does go hand in hand with the administration’s focus on fraud, but again, are voters actually going to believe that he’s the first person to think of this? 

Whyte: I don’t know if voters will believe that, but what I would more wonder is whether any of that is breaking through at all. I mean, the voters …  

Rovner: Yeah, are they even going to hear it? 

Whyte: Yeah, polls show affordability is at the top of voters’ minds. Fox News had a poll recently that said corruption was at the top of voters’ minds. They have bigger fish to fry, I think, when they’re going to the polls than whistleblower payments, regardless of whether it’s a good policy idea or not. 

Rovner: I did see a social media post that people have been flooding this new fraud whistleblower line with tips about corruption in the administration, which was not the intent, I don’t think. We’ll see how that plays out. All right. Next: news about the Affordable Care Act. You might remember that last month the administration announced it was dropping three-quarters of a million enrollees from ACA plans, saying that their enrollments were likely fraudulent and that they were likely not even real people. Now, according to my KFF Health News colleague Julie Appleby, they’re adding a, quote, “small number” back. Apparently, those are people who turned out not to be made-up ghosts after all, but actual enrollees whose applications might have lacked required information and who haven’t filed a claim. Now, it is not clear how many people are being added back. The Washington Post editorial page suggests that it’s only 51 people so far. But isn’t it possible that there are way more of those people who just don’t yet know they’ve lost their coverage because they’re healthy and they haven’t tried to use it? After all, the people who got cut off are people who, by definition, haven’t filed any claims. 

Seitz: Julie, you and I have talked about this, like, in the newsroom — just, you know, I didn’t even go to my primary care doctor until like a week or two ago, so that’s totally possible. I think what I find most interesting, though, about this is that there’s clearly a problem, right, with the broker system. 

Rovner: Absolutely. 

Seitz: And both sides of the aisle have raised concerns about insurance brokers. And in normal times, this would be kind of one of those issues that you might see some legislation on. But it seems they’re not really working toward any sort of thing around that, and it’s a missed opportunity, frankly, for folks to come together and look into regulating this industry a little tighter. 

Rovner: Yes, and another hat tip to Julie Appleby, who helped break some of the stories about the broker fraud. Indeed, they’re, you know, one of the problems when they created these zero-premium plans is that they actually gave brokers an incentive to switch people without their knowing it, or to sign up fake people so that they could get the commissions. It is a problem. Everybody acknowledges it’s a problem. But pulling off people who didn’t have their entire Social Security number, or, you know, they haven’t filed a claim. Not all those people are going to be fraudulent, and I’m just wondering if, yeah, if it’s only a couple of 100 people, there probably won’t be a backlash. But if there’s many thousands of these people who eventually discover that they are not covered and that they thought they were, there could be a backlash. I see nods. All right. Well, they’re talking, apparently, the administration is looking at another half a million enrollees with the intention of perhaps cutting them off. So we will see how this one plays out. All right. We’re going to take a quick break. We will be right back. 

Turning to news out of the Department of Health and Human Services, two new studies out this week suggest that Secretary Robert F. Kennedy Jr.’s policy change to stop recommending a birth dose of the hepatitis B vaccine could dramatically increase cases of the chronic disease that can cause liver cancer and other lifelong health problems. One study in the journal Annals of Internal Medicine modeled what could happen if the policy is changed from recommended to what’s called shared decision-making [and] found it could result in half of all children entering adulthood susceptible to the highly contagious virus, and a more than 80% increase in cases. The other study that was presented at an infectious disease meeting by Kaiser Permanente researchers found that most young children who were exposed to the virus were exposed by someone other than their mothers. That suggests that even if a mom is tested and tests negative, that doesn’t necessarily protect the baby. I don’t expect that these studies are going to change any minds, though, among the sort of anti-vaccine activists and the, I guess what we could call, the vaccine-skeptical and vaccine doubters, right? 

Ollstein: I do think it’s notable that The New York Times’ reporting specifically on these vaccine studies and policy considerations seems to really have hit a nerve with the administration because they are going all out on attacking the individual reporters, accusing them of having sources who are making up information, etc. And so that sort of shows that at least they are, you know, worried about this maybe hitting home for folks. 

Rovner: Maybe a little sensitive? 

Seitz: And Julie, I think that, too, I mean, it will help down the road, right? Because this is what we have heard from public health researchers or anyone who’s really worked in public health, doctors, is this exact concern: that this is how this would play out, reducing the recommendations. And … 

Rovner: Not to mention Senate HELP [Health, Education, Labor, and Pensions] Committee Chairman Bill Cassidy. 

Seitz: Yes, that was on my list as well — the liver doctor who warned that this is exactly what will happen. So it gives us, one, a road map to what our future will look like, and helps public health researchers prepare in that sense. And then also, it gives a lot of fodder down the road for We knew that this was going to happen, and here is, we predicted it would happen, and no one listened. So it really puts a lot of culpability in the administration’s hands. 

Rovner: Well, in related vaccine news, The New York Times reported that the board that oversees the hospital on the NIH campus here in Bethesda, Maryland, delivered a public rebuke of the secretary over his establishment of a new office to study vaccine injuries and accused the secretary of undermining trust in science. Now, this board is made up of people outside the government, so I imagine it’s easier for them to criticize the secretary without fearing for their jobs. But still, I can’t imagine they won’t be rather quickly replaced?  

Seitz: That was exactly my first thought: Is how quickly is Kennedy going to try and replace this board? And we know that the White House has been forcing Jay Bhattacharya into some very uncomfortable positions over the last couple weeks, and some very uncomfortable conversations with folks. So, you know, this is yet another one that he’s probably going to be tasked with tackling, I would guess.  

Rovner: I have to say, I live up the street from the NIH Clinical Center — I pass it multiple times week — I had no idea there was an independent board that oversees literally the running of the hospital and for safety and efficiency services. I mean, this is the large hospital on the NIH campus where people who are in clinical trials can be cared for. I mean, lots of people are in clinical trials in other places in the country, but there are some people who end up coming to NIH, and the Clinical Center is where they end up if they need to be hospitalized. So, I mean, it is a rather substantial-sized facility. I was just, I was surprised to see them, of all people, standing up and saying this is not necessarily a great thing to do. We will watch how that one plays out too.  

Well, finally this week the administration has delayed a policy change that was to take place today that would have made it harder for people to order cheaper drugs from licensed pharmacies in Canada and other countries that have, you know, price controls. While it’s always been technically illegal to buy drugs through the mail from other countries, U.S. officials have long looked the other way at small amounts that are imported for personal use. According to a study from 2020, more than 2 million Americans purchase their medications from other countries. Now, the administration isn’t canceling the policy change that’s going to make it basically impossible for people to get their drugs this way — it’s just pushing it back 90 days, so safely beyond Election Day. Still, it’s kind of hard to square this with the administration’s claims that drug prices are coming down, unless they say that drug prices are coming down enough that you don’t have to buy your medicine from Canada anymore, that it won’t be cheaper? 

Whyte: I think there’s enough people doing this that it just seems like it would actually be a bad move politically ahead of the midterms. You know, people are reliant on these cheaper drugs, and to have that pathway cut off, I imagine, would cause a kerfuffle. But, so it wasn’t surprising to see this delay. I was kind of surprised they were going to do it in the first place. 

Rovner: It’s funny. It’s been on the podcast rundown every week for, like, the last three weeks. I keep putting it off because it’s getting closer. And then, of course, last week at almost the very last minute, the administration announced, “Never mind, we’re not going to do this right now.” But yeah, also, I mean, all through August and September, people were starting to get these letters that said, “Hey, you know …” — when they were getting their drugs, it’s like: “You know, after Oct. 22, we’re not going to be able to do this anymore.” So now it’s going to be after January-something. I mean, I’ll be interested to see if they actually go through with this because I think you’re right, Liz. There are a lot of people who — and I’ve seen other estimates that it’s as many as 4 million people who are getting their drugs this way. And it is not a way to make friends and influence people, shall we say? Particularly when lowering drug prices is one of your administration’s big, you know, achievements, according to what the president keeps saying at all of these rallies. 

All right, that is this week’s news. Now we’ll play my interview with Alice about her book, and then we’ll come back and do our extra credits. 

I am pleased to welcome to the interview portion of the podcast my friend, colleague, and podcast panelist Alice Miranda Ollstein, whose brand-new book, Side Effects: How Abortion Bans Impact Everyone’s Health, comes out next week. Alice, thanks for being here. 

Ollstein: Thank you, Julie. 

Rovner: So, as our regular podcast listeners know well, you’ve been covering the impact of the Supreme Court’s overturn of Roe v. Wade since it happened. What made you want to take some extra time and write a book about it? 

Ollstein: Yeah, so over the course of my reporting for Politico, I was traveling all around the country, and readers of Politico know that the focus is politics. So it was a lot about the political impact of the Dobbs ruling and state abortion bans and how people were reacting to them, the ballot initiatives, the candidates, etc. But as I was doing that reporting, I kept hearing over and over from patients, from doctors, from medical researchers, from all kinds of people who are involved in the healthcare system in some way bringing up these impacts that they were seeing that I just thought were not getting enough attention. These were impacts not only on care for pregnant people but healthcare for everyone — for men, for people living in blue states, for people living in red states, for old people, for young people — and this just kept coming up over and over. And I really wanted to write this book to sort of capture that bigger picture and capture that even though these laws were tailored to really go after abortion, they were having these broader impacts across the healthcare system. And it’s just very, very hard to separate. 

Rovner: What’s the most unexpected consequence or far-flung consequence that you found after nearly half the states banned abortion? 

Ollstein: Two things: one, the impact on healthcare for people with chronic conditions, pregnant or not, and then the other is the impact on medical research. How medical research, both on abortion, on pregnancy, on contraception, and on completely unrelated areas of healthcare were compromised. Some medical studies were delayed, some were made more burdensome and expensive, and some were scuttled altogether as a result of post-Dobbs restrictions. And that just kept cropping up in really interesting. In surprising ways. So, back to the care for people with chronic conditions, what happened after Dobbs is that in lots of different places — in states with bans, in states with abortion protections — patients who depend on certain medications to manage their chronic illnesses, drugs like methotrexate, which is sometimes used to terminate an ectopic pregnancy, and lots of different kinds of drugs — neurological drugs, drugs for autoimmune conditions that have the potential to cause a birth defect if you take them while pregnant. So doctors, pharmacists, insurers became a lot more scared of dispensing these drugs to patients with chronic conditions, even though they had completely valid diagnoses of lupus, Crohn’s, all kinds of conditions where they depend on these medications. 

Rovner: Yeah, rheumatoid arthritis is a big one, right? 

Ollstein: Mm-hmm. Absolutely. And so I just kept hearing about patients who, in some cases, had been taking these drugs for years and years and years, and really depended on them just to get through the day, honestly, and not experience, like, a flare-up of inflammation or other symptoms. And suddenly they were being, you know, grilled on what are you using this for? They experienced days of delays, and some of them were unable to get the medication altogether, and it really had an impact on their health. And so there were some lawsuits related to this, there were some advocacy campaigns related to this, the Biden administration took action on it, and the Trump administration rolled back those actions. And so I just really wanted to shine a light on how this was hitting people who aren’t even physically capable of being pregnant. In some of these medication-denial stories, I found, you know, it was happening to prepubescent children. In one of the circumstances, it happened to someone who had had a hysterectomy. So there’s no way an abortion could happen even accidentally. And you know, it happened to a lot of people who were taking contraception or who were just too chronically ill to sustain a pregnancy. And it still had this, you know, big impact because of the fear and confusion throughout the medical system. 

Rovner: And what about the research part? 

Ollstein: Yeah, absolutely. So that took a lot of different forms. So one category was research on abortion drugs specifically, to look into potential other uses for them. There are a lot of promising studies going on, some in the U.S. and a lot in other countries that don’t have the same restrictions about other uses of the drug mifepristone for cancer, for uterine fibroids, for all kinds of things. Some of those studies are still moving forward, but there were all kinds of delays and hurdles because they were taking place in a state with a ban, and the researchers had trouble even obtaining the medication. Even, in one circumstance I write about in detail, on a study that is only testing the medication on older male veterans of Operation Desert Storm. And still the researcher had a lot of trouble obtaining the drug, obtaining permission to do the study, obtaining funding, etc., and faced years of delays. And so these veterans that could really benefit from this medication, according to her research, still can’t get it. 

Rovner: I would say, people who are clearly not going to be using it to terminate a pregnancy. 

Ollstein: Exactly, these are older men. So those studies are still moving forward, but face years and years of delays. Other studies, including a study out of Indiana testing whether mifepristone could help people with breast cancer, especially people who were getting preventive mastectomies because they had the gene that put them at high risk, they were testing whether maybe taking mifepristone could help them avoid having to do that major surgery. That study was canceled altogether because the researcher was so concerned about losing access to mifepristone in the middle of the study and of, you know, facing potential legal consequences because she was based in a state with a ban that she just abandoned it altogether. In addition to the impact on studies on mifepristone, there’s all kinds of impacts that I found happening in the research space. It’s become harder to study abortion, even though we sort of need those studies more than ever because we want to know what are the medical and sociological and all kinds of impacts of these bans? You know, the government and the healthcare system can’t help people if they don’t know what’s happening. But those studies that depend on interviewing patients who are considering abortion to determine what factors push someone one way or another, those have become much harder because there is a fear among researchers that they could be charged under these so-called aiding and abetting laws in certain states. They don’t know if it could be considered aiding and abetting if they even talk to a study participant about what they’re thinking, and if that study participant goes on to get an abortion, you know, could they be charged? They’re not sure, and so those studies have become much harder to do. And I also found impacts on clinical trials that have nothing to do with abortion, nothing even to do with pregnancy. But there is a concern that representation of women of reproductive age in these clinical trials — which is already quite bad, women of reproductive age are really underrepresented in medical research, and only were included at all more recently. You know, we just don’t know if all kinds of drugs even work on women because they were only tested on men. And researchers are concerned now that we’re going to backslide on the little progress we have made on that front because they’re saying, look, how can a woman feel comfortable participating in a clinical trial of a new drug if, you know, that new drug could cause birth defects? She becomes accidentally pregnant during the course of the study, and she’s not able to get a termination based on what state she’s in. How can she feel comfortable participating at all? Meanwhile, bioethicists and experts told me that if research is only limited to states that allow abortion, that could completely skew the data because people have different health status, and those, you know, it’s important to study people in many geographic areas of the country in order to get good data, and now that’s under threat. 

Rovner: Lots of things that I think people didn’t anticipate. Another trend you highlight is the increased activism of the medical community itself. I always used to say that the American Medical Association was allergic to abortion, in that it never wanted to address the issue because it had members on both sides of a very hot topic and it didn’t want to anger any of its constituency. That’s changed, too, in the wake of the overturn of Roe, hasn’t it? 

Ollstein: Absolutely. So both these big national organizations, like the AMA, but also state-level organizations that also used to really try to steer clear of abortion because, you know, they didn’t want to alienate any of their members or their members’ patients. And it was just seen as this, you know, sort of political third rail. But as a result of seeing the impacts of these restrictions on their members’ ability to practice medicine, the organizations have decided to take a stronger stand. They’re writing amicus briefs. They’re passing resolutions. They’re lobbying their state and federal legislators.  

Rovner: Some of them are running for office.  

Ollstein: Exactly. So, I think combined with the institutions really changing their behavior, individual doctors are really changing their behavior. And, like you said, they’re running for office. They’re out on the campaign trail campaigning for the candidates they feel, you know, will uphold abortion access and keep the government from meddling in medicine in other ways. They are, you know, participating in lawsuits. You know, getting active in all kinds of ways we’ve never seen before. You know what I also found was that abortion providers, as a group, have been politically active and very vocal for a long time. You know, a lot of times they felt like they had to be. But what’s really new post-Dobbs is that physicians of lots of different specialties, including many that don’t have anything to do with abortion or pregnancy, have really come off the sidelines, and some of them told me that they were motivated to do so because they did see how this was impacting their work. It was, you know, for instance, going back to the chronic illness thing, you know, I talked to rheumatologists and oncologists who felt like they couldn’t have the conversations with patients freely that they used to be able to have. They couldn’t prescribe certain medications that they wanted to prescribe. But some told me that, Hey, I haven’t really felt the impacts of this at all personally, but I feel motivated to do something because I’m concerned that if the government can and feels emboldened to interfere in medicine in this way, like, what else could they do? What could they do next? And so they wanted to get involved in ballot initiative campaigns and other things to sort of draw that line in the sand. 

Rovner: Alice, lots of really interesting stuff. I think everybody should read the book. Congrats again, and thanks for joining us, as always. 

Ollstein: Thank you so much. 

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

Whyte: Sure. My extra credit is a Stat story by Tara Bannow [“How the No Surprises Act’s Nonprofit Arbitrators Are Operating Like ‘Mini Gods’ and Getting Rich Doing It”]. It’s a great investigation into the middlemen who are now in charge of doing the arbitration for the No Surprises Act, so it starts out with this amazing anecdote of this company that was thinking about getting acquired. I mean, it was really struggling financially, and now three years later has a 70% profit margin. Its revenue has grown thirteenfold. It’s just rolling in the dough, and it’s not alone. I mean, there’s all these middlemen now that are just raking in money from being arbitrators here in a way that is, really, you can’t object to it. I mean, she had a great quote from someone representing employers who referred to them as “mini gods.” And they’re siding with doctors in over 80% of cases. So the insurers and employers are really bent out of shape about this, and they’re also awarding huge sums of money. So she gave the example of a common spine surgery, typically costs $1,400 in-network, and now fetches $34,000 in arbitration at the median, with some providers getting over $100,000. So doctors are loving this, obviously. But there’s a number of lawmakers on the Hill who are looking at this and saying, “Ooh, we have a real problem here. This is not what we were going for.” And now there’s some possible solutions on the table for fixing it. 

Rovner: Yes. I think, of the things that I think that Congress is actually going to tackle at some point in the not-too-distant future, this is, like, pretty high on the list because this was not what they intended when they did the No Surprises Act. Alice. 

Ollstein: My piece is an op-ed in Stat by one of the whistleblowers from Theranos who helped expose Elizabeth Holmes as a fraudster, and the piece is called “I Was a Theranos Whistleblower. In ‘You Can See Everything,’ Elizabeth Holmes Is Still Lying.” This is his take on the movie. I hesitate to call it a documentary because it’s more of an art piece. But he’s pointing out that if you just watched the movie and you didn’t know anything else about the background of this case, you would not get an accurate picture of what happened. He notes that she shows pieces of a machine, and it’s not the machine she says it is. He notes that, you know, while this movie sort of poses the question: Did she intentionally lie, or is she just sort of this misunderstood, you know, neurodivergent genius who didn’t communicate things in the way other people did? And he notes that hard evidence came out in trial that she knew she was lying about certain things and very aggressively moved to cover it up and punish the people who tried to expose it. So I think it’s just a good supplement if people do end up watching that movie, which, according to my group chats, many, many people are fascinated and eager to see.  

Rovner: For the record, I am not. But as I said on social media, I’m not interested in hearing your takes on the movie unless you have read the book Bad Blood by John Carreyrou. And I will link to it in our show notes just in case people are more interested.  

Ollstein: And this whistleblower who wrote this op-ed was one of the sources for Bad Blood. 

Rovner: Yes, it was. Named. Tyler Shultz, so … 

Ollstein: Yes. 

Rovner: Amanda. 

Seitz: My extra credit this week is “Why Drug Companies Are Rushing To Market Ketamine Medicines,” by Andrew [Jacobs] for The New York Times. This piece looked at how companies are racing to develop new ketamine products to treat depression or substance use disorders in an effort that, as one person described, is feeling “unethical and cash-grabby,” which I just loved that quote. This ketamine arms race of sorts is being promoted, prompted in part by Secretary Kennedy’s embrace of psychedelics, but also the success of a ketamine-like drug developed by Johnson &  Johnson, which is this nasal spray that the FDA recently approved to be used for stand-alone treatment for depression. 

Rovner: It’s quite the eye-opening story. All right, my extra credit this week is from Rachel Cohen Booth at Vox. It’s called “America’s Next Big Healthcare Reform Might Already Be Underway.” It’s about Colorado, which is one of three states that have used the Affordable Care Act’s waiver authority to create a so-called public option health plan — that’s the unicorn that Democrats have talked about for most of this century. Today, roughly half of Colorado’s marketplace customers are now in so-called Colorado option plans, which are state-designed but privately run, and they’re saving roughly $100 per month in premiums for mid-tier coverage, which isn’t a ton of money, but it also isn’t nothing. It hasn’t been smooth sailing, but I think more and more people are now looking at what Colorado and Washington and now Nevada are doing, and it is well worth a read. 

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

Seitz: I’m on X @AmandaSeitz. 

Rovner: Alice? 

Ollstein: On X @AliceOllstein and on Bluesky @alicemiranda. 

Rovner: Liz. 

Whyte: I am on X @l_e_whyte and on Bluesky, @lizessleywhyte. Just Google it; it’s too long to say. 

Rovner: You’re findable. We will be back in your feed next week. Until then, be healthy. 

Credits Francis Ying Audio producer Emmarie Huetteman Editor

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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.

Rising healthcare costs aren’t a problem just for those who buy their own health insurance. Increases hit employers and their workers this year, too, and more are expected for 2027 plans — adding to growing concerns about affordability heading into the midterm elections.

Polls show that healthcare costs — and affordability, in general — are among top concerns cited by likely voters. Much attention has been focused on mounting costs and declining enrollment in Affordable Care Act plans, the insurance used by roughly 19 million people who buy their own. But work-based plans are adding financial pressure for the more than 150 million Americans covered through their jobs.

One of the biggest changes this year, for instance, came in the amount workers pay toward their own coverage, rising an average of 9% to $7,471 annually for a family, according to a broad annual survey released Oct. 22 by KFF, a health information nonprofit that includes KFF Health News. That’s up from the 7.6% jump seen from 2024 to 2025.

Their employers, too, faced additional costs, with the average family coverage premium rising 5% to hit $28,303, according to the survey.

In response to that increase — which comes on the heels of a 6% increase the previous year — 44% of large employers, with at least 200 employees, said they upped what workers had to pay toward coverage.

“When we start to see higher use or higher prices, there are only a limited number of things employers can do” to try to slow premium increases, said Matthew Rae, associate director of the Program on the Health Care Marketplace at KFF.

Employers reported taking other actions in the past year to hold down their costs, such as increasing deductibles (the amounts people pay toward their care before insurance pitches in), changing insurers, adding preapproval for some services, or offering workers a narrower choice of healthcare providers, the KFF report said.

Workers’ earnings rose an average of 3.7% this year, the survey found, while overall inflation was 2.7%.

People who work for small companies, with fewer than 200 employees, paid more for healthcare than their counterparts at larger companies.

For example, health plans at large companies had a $1,772 average annual deductible for an individual employee, while small workplaces averaged $2,624.

Overall, though, the share workers pay toward the total premium across all companies ticked up only slightly from the previous year, hitting 27% of the cost for family coverage and 18% for individual coverage, with employers picking up the remainder.

Driving Up Costs

Other groups have recently posted projections of what employers might face next year.

Consulting firm AON, for example, projected employers could pay 9.5% more next year, the fourth consecutive year of big increases, while a similar company, Marsh, estimated 8.2%, the highest jump since 2003. Costs are going up for many reasons, from people utilizing more services to skyrocketing prices of prescription drugs and rapidly rising hospital prices, the reports say.

Also helping drive up costs is artificial intelligence, say other reports, including one from the Business Group on Health, a membership organization of self-insured employers. The report said hospital systems and other medical providers use the technology to maximize insurer and patient billing.

The business group predicted a median premium increase of 9.2% next year, although employers might reduce that by making benefit changes.

Until recently, employers absorbed the lion’s share of cost increases, “but that’s starting to change a bit,” said Jim Winkler, chief strategy officer for the group. “When open enrollment starts, most people will see their out-of-paycheck costs and probably their out-of-pocket costs going up.”

Looking ahead, the group suggests employers take further action to forestall increases in 2028, Winkler said. One idea is to offer lower copayments for some health providers based on their prices or quality, similar to “tiered networks,” a strategy employers and insurers have tried, with only 4% of companies sticking with it, according to the KFF survey. “What’s old is new again,” Winkler noted, saying it might work better now because it’s easier than ever for apps to show consumers the providers with the lowest copayments, which would be set by an employer or insurer.

Overlooked in much of the discussion on rising health costs, said Elizabeth Mitchell, president and CEO of the large employer organization Purchaser Business Group on Health, is the role played by the healthcare industry — from hospitals to drugmakers to insurers.

She asked: Why are the customers — the employers, in this case — being asked what they are doing about it? “The industry is doing absolutely nothing to control costs, as evidenced by the relentless growth in costs,” she said.

Businesses are using new pricing information made available under federal rules to contract directly in some cases with hospitals and other providers and to invest in primary care.

Mitchell and others say Congress should also get involved. Health policy researchers at Georgetown University, for example, suggest capping annual deductibles, setting hospital price caps, and extending lower drug prices negotiated by Medicare to the private sector.

Keeping Costs Flat

Not all companies saw an increase this year.

Take KFF survey respondent Phifer Inc., a company based in Tuscaloosa, Alabama, that makes insect screens and precision woven products, such as outdoor furniture fabric. Its health costs remained flat this year, likely because it has put a strong focus in recent years on providing zero-cost primary care to its workers through on-site clinics and direct contracts with doctors’ offices, said Russell DuBose, the company’s vice president of human resources.

Only 7% of companies in the KFF survey reported having an on-site clinic, although 24% said they had one on-site or nearby.

Workers get in quickly to see a primary care doctor, DuBose said, and that can help with both prevention of disease and catching problems early. The company also directly contracts with other types of specialists.

“We steer plan members to the best providers that we can find,” DuBose said. “When we do that, we’re paying a more reasonable price.”

The company is self-insured, like many employers. That means it pays all the bills itself and buys what’s called stop-loss insurance to help with very high bills. That coverage has also jumped in price, DuBose said.

He often gets calls from other employers asking about his company’s strategy — and how to control costs. Now, far more so than in recent years, he said, employers are nervous, worried about costs continuing to rise and what that would mean.

“The worry is ‘Could the rising cost of healthcare be the next job killer?’” he said.

Among other findings from the annual KFF report:

• Twenty-nine percent of all companies surveyed said covering GLP-1s, a new class of weight loss drug, had a “significant” effect on their drug costs.
• Many companies — about 29% of large ones — reported difficulty getting information on how much their plans paid for medical care or price comparisons among providers.
• About 9% of companies with 50 or more workers buy prescription drugs from outside the U.S. to save money.

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.

Heading into the midterm elections, high healthcare costs rank among voters’ biggest concerns. But lately, there’s a twist giving the issue new momentum on campaign agendas: a focus on fraud in government health programs.

The administration of President Donald Trump has used claims of widespread wrongdoing to justify investigations, suspensions of billions of dollars in payments to states, and the cancellation of Affordable Care Act health coverage for hundreds of thousands of people.

The effort has opened a broader political fight over the extent of fraud and the administration’s response to it. Republicans say they’re safeguarding taxpayer dollars by going after bad actors. Democrats contend the administration has relied on insufficient evidence to target blue states and cut programs Republicans have long tried to shrink. Meanwhile, Trump’s pardons of executives convicted of healthcare fraud, administration moves to weaken some protections against abuses, and a high-profile error by Trump regulators stand in contrast with the administration’s proclaimed fraud-fighting goals.

The dispute is becoming a talking point for both parties leading up to the November election.

Republican candidates are trying to win voters’ confidence by emphasizing their efforts to halt what they say is the misuse of taxpayer dollars in federal health programs.

“Going after fraud gives Republicans a healthcare message when they would otherwise just be defending cuts to Medicaid and the Affordable Care Act,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. The approach, he said, helps “blunt” those attacks.

Democrats, however, traditionally have an advantage on healthcare in general, with polls showing voters are more likely to trust them with such issues. Now Democrats are portraying Republicans’ fraud crackdown as a cover for the GOP’s weakening of safety net programs. But the GOP messaging could resonate at the ballot box.

About 44% of voters — and 54% of Republican voters — say fraud in government programs is “extremely important” for candidates to talk about, according to a KFF poll conducted in mid-September, suggesting the fraud focus might be connecting with the GOP base. Such fraud is also the top issue rural Republican voters want candidates to talk about, based on a separate survey by KFF and the Associated Press.

It’s an issue that is hardly new, and government watchdogs have repeatedly documented fraud by health providers and brokers, as well as improper enrollment in government health programs. A report by the Government Accountability Office in March warned that the “sheer amount of payments in the Medicare program creates significant fraud risks.” And in a separate probe, GAO investigators were able to get subsidized insurance for fake ACA enrollees.

What has changed is the prominence the issue now occupies in national politics.

Administration’s Fraud Targets

Trump administration authorities have this year charged hundreds of people, including doctors, in alleged billing schemes. It has announced audits of state Medicaid fraud units and increased scrutiny of enrollment in federal programs, withholding billions of dollars in federal Medicaid payments over claims of lax oversight — with what Democrats say is a laser focus on blue states despite a lack of evidence.

The administration’s more expansive claims about fraud — and the actions it has taken in response — have generated fierce political clashes.

Most recently, the Centers for Medicare & Medicaid Services canceled ACA enrollments covering 760,000 people. While Democrats have questioned the methods that found them to be fraudulent, federal officials said they included nonexistent consumers whose applications were submitted by brokers or agents who can earn commissions from insurers.

CMS Administrator Mehmet Oz said at a press event that the cancellations included people who had coverage through the ACA but hadn’t used it. He also said some had no Social Security numbers, calling that evidence of problems.

“About 35% of current people on the Obamacare system — 35%, more than a third — had never used the program. They haven’t bought a prescription medication. They haven’t seen a doctor. That just is not possible,” Oz said. “So we know there is fraud.”

Democrats and some health policy analysts challenge that conclusion. They say that younger and healthier people are much less likely to use their insurance and that not using their coverage doesn’t mean they were improperly enrolled. Critics also say the absence of Social Security numbers doesn’t necessarily establish fraud; for example, newborns can be added to their parents’ plans before receiving a number.

“This is yet another attempt by the Trump administration to kick hundreds of thousands of vulnerable Americans off their healthcare,” Rep. Melanie Stansbury (D-N.M.) posted on the social media site X. “Millions are already struggling to access healthcare—and this is their plan?”

There are political risks for the GOP as well. The disenrollment of alleged phantom accounts is likely to ensnare legitimate consumers, say health analysts and ACA advocates, leading to a potential backlash against Republicans if scores of people lose coverage just before the midterm elections.

States that tend to deliver for GOP candidates will be hit especially hard, they say, because ACA enrollees are concentrated in those states. The 4.5 million people in Florida and 4.1 million in Texas who have marketplace coverage account for nearly 40% of the country’s ACA enrollment, according to a KFF analysis.

Conservative health policy advisers say the administration took multiple steps to avoid canceling legitimate coverage, including attempts to contact consumers and requirements that additional criteria be met before coverage was terminated.

“Those criticizing the action either don’t understand it or see some political advantage in mischaracterizing it,” said Brian Blase, president of Paragon Health Institute and a former Trump health policy adviser.

Democrats, meanwhile, highlight inconsistencies in the administration’s broader anti-fraud campaign.

They note that the Department of Health and Human Services last year recertified hundreds of insurance brokers and agents who had been suspended in 2024 by the Biden administration for suspected fraud or abuse. The Trump administration also laid off about 200 employees from a CMS office involved in regional oversight of the ACA marketplace.

On Oct. 3, Trump called on Congress to pass legislation with mandatory prison terms for defrauding Medicare and Medicaid, eliminating probation as an option.

But Trump has also pardoned health industry executives convicted of major fraud schemes, including people who are connected to his political allies or who spent heavily on lobbying on their behalf. The pardons included a nursing home operator sentenced to three years in prison for a nearly $40 million tax scheme and, in Trump’s first term, five executives at a Florida company convicted for Medicaid fraud.

Trump’s pardons in 2021 of executives who profited from massive public healthcare fraud spurred criticism from the National Health Care Anti-Fraud Association. Critics now say the administration is portraying cuts to Medicare and Medicaid as necessary for weeding out waste, fraud, and abuse while exonerating criminals who have engaged in some of the biggest schemes in federal health programs.

Blue State Allegations

HHS has raised concerns about Medicaid fraud and program integrity in several states, and the administration has deferred or threatened to cut federal Medicaid funding while disputes are investigated.

Democrats say the administration is itself engaging in fraud by using unsubstantiated allegations of abuse to politically target blue states.

One of the most striking clashes occurred in New York.

Federal officials launched an investigation of the state’s Medicaid program after claiming that personal care services — including help with bathing, dressing, and meal preparation — had been provided to more than 5 million people, which would have amounted to roughly three-quarters of the state’s Medicaid population — an almost impossibly large proportion.

“It is time for New York to come clean about its Medicaid program,” CMS’ Oz posted in March on X.

CMS later acknowledged its calculations were wrong. The agency said that it had misunderstood the state’s billing codes and that the actual number of beneficiaries who received the services was closer to 450,000. The administration continued its scrutiny of the New York program, however, and later suspended millions of dollars in federal funding for the state’s Medicaid fraud unit, saying the division wasn’t producing enough indictments.

The administration also withheld about $2 billion in Medicaid funding from California, citing concerns about program integrity and oversight of some home medical services. State officials deny the allegations, saying spending on home services has grown because of factors such as higher wages for home health aides and an increase the number of older people receiving care.

The White House announced plans to defer more than $500 million in federal funds from Minnesota, claiming the state had failed to protect its Medicaid program from abuse. State officials have defended their oversight and gone to court to challenge the decision.

Vice President JD Vance, who chairs Trump’s Task Force to Eliminate Fraud, and other administration officials announced the state deferrals at the White House, giving what traditionally would have been technical disputes between state and federal health officials a much higher political profile. Vance’s office did not respond to KFF Health News questions about the administration’s anti-fraud activities related to healthcare.

“I’ve never seen anything like this,” said Andy Schneider, a Georgetown University research professor and a senior adviser at CMS during the Obama administration. “It’s a deferral, not a finding of fraud. This is being elevated by political decision-makers.”

Republican candidates have pounced on the investigations and allegations. In Minnesota, Republican gubernatorial candidate Lisa Demuth, who is speaker of the Minnesota House, released a September ad claiming that her Democratic opponent, U.S. Sen. Amy Klobuchar, “has never done anything to stop the fraud here in Minnesota.” Klobuchar has said that as governor she would “launch a top-to-bottom audit of state government to root out fraud.”

In New York, Attorney General Letitia James, a Democrat whose office runs the Medicaid fraud unit, criticized the decision to withhold funds and said weakening the operation would benefit criminals. Her Republican challenger in the November election, Saritha Komatireddy, has cited the Trump administration’s claims during her campaign, telling Fox News Digital that James is “totally failing to prosecute Medicaid fraud.”

The administration says its actions are necessary because fraud diverts taxpayer money from people who legitimately qualify for government programs.

“The fraud doesn’t just steal money — it steals our trust,” Oz said in August on CBS’ Face the Nation.

Democrats and healthcare advocates say the White House’s anti-fraud crusade is being used by Republicans to distract from criticisms over its sweeping funding cuts to Medicaid, the ACA, and other federal health programs.

Republican-backed legislation enacted last year is projected to reduce federal Medicaid spending by hundreds of billions of dollars over a decade.

Congressional Republicans also declined to extend enhanced ACA premium subsidies that expired at the end of 2025, increasing premium costs for many people who buy insurance through the marketplaces. Enrollment has since declined by millions.

Overall, the combined effect of GOP-led changes will result in 16 million more uninsured people by 2034, according to an analysis by the Congressional Budget Office.

Those changes have given Democrats an opening to campaign on protecting healthcare coverage and affordability while Republicans seek to shift some of the debate toward fraud and government spending.

“It’s really a way to distract and reframe the cuts in a different way, to say it’s part of an anti-fraud effort,” said Anthony Wright, executive director of Families USA, an advocacy group focused on expanding health coverage. “Fighting fraud shouldn’t result in people losing coverage.”

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.

In March 2025, when California ran out of Medicaid funds to pay doctors and hospitals, the state borrowed $3.4 billion to keep the program afloat. It was, as a spokesperson for Gov. Gavin Newsom insisted, nothing new. Indeed, a handful of times over the years, the state had taken out internal, short-term loans to sustain its healthcare program for the poor and disabled.

The unprecedented move came a few months later, when Newsom and Democratic state lawmakers agreed to pay down the loan — which grew to $4.4 billion — over 10 years instead of later in the year. California’s healthcare safety net, it seemed, was buckling.

Rising healthcare costs systemwide were partly to blame. But so were several state-led expansions that made California’s Medicaid program, known as Medi-Cal, one of the nation’s most generous.

Now, with congressional Republicans’ One Big Beautiful Bill Act expected to reduce federal Medicaid spending by more than $900 billion over 10 years, California and dozens of other states must contemplate the limits of their generosity. The problem is particularly acute in the nation’s most populous state, which spends more on Medicaid than New York and Texas combined.

“We know we can’t afford to serve everybody we want to serve in the model that we have today,” said Mark Ghaly, the former top Newsom health official who now co-chairs the Future of Medi-Cal Commission, a 29-person panel with the goal of modernizing and sustaining California’s Medicaid program for those who need it. “What can we do differently? What can we do smarter?”

The 2025 law that Newsom, a Democrat, has dubbed President Donald Trump’s “Big Ugly Bill” is expected to leave millions more Americans without health insurance, mostly because of new work requirements. It also curbs the use of healthcare provider taxes and other strategies states have deployed to maximize federal funds. Some state lawmakers and consumer advocates have argued the federal cuts, along with rising costs, present an opportunity for the next governor to overhaul a program plagued by long appointment wait times, low reimbursement rates for healthcare providers, and volatile financing.

“If we continue to just give millions and millions into the same system and expect something different — I’m sick and tired of that,” said Caroline Menjivar, a Democratic state senator representing a Los Angeles-area district where roughly half of constituents rely on Medi-Cal.

Democratic lawmakers, who have often clashed with Newsom on Medi-Cal rollbacks, succeeded in getting him to delay a number of painful cuts until 2027 in hopes that a new governor might reverse them.

So far, neither of the candidates running in the November election to replace Newsom have offered substantive proposals for weathering the upheaval health policy experts say is on the horizon for a program that covers 1 in 3 Californians — roughly 13.6 million people.

Republican Steve Hilton, a former Fox News commentator, wants to pare back Medi-Cal eligibility and has promised to end coverage for immigrants without legal status, citing that benefit as an example of “wildly unsustainable” state spending. Democrat Xavier Becerra, who has spent decades trying to expand government-funded healthcare, has promised to protect Californians from the massive federal cuts.

Expanding Coverage

President Lyndon B. Johnson signed the law that established Medicaid and Medicare in 1965 to cover certain low-income groups, such as families with children, older people, and those with disabilities. Over the past six decades, states have substantially widened that pool, most notably under the Affordable Care Act’s Medicaid expansion to childless adults.

Starting in 2024, California offered healthcare coverage to all low-income residents, regardless of age or immigration status, although lawmakers scaled that back this year. At the same time, the state opted to cover a slew of non-mandated benefits such as physical therapy, hospice care, and housing assistance.

“California has always struggled with wanting to have as broad a program as possible but then having to figure out a way to pay,” said Jennifer Kent, who oversaw Medi-Cal under Gov. Jerry Brown, a Democrat. “There is no population that we have met that we don’t want to offer coverage to, and we’ve never met a benefit that we don’t like.”

Since 2010, California’s Medi-Cal enrollment has nearly doubled while spending has ballooned from $50 billion a year to $222 billion. It now makes up more than 40% of overall state spending, according to the nonpartisan Legislative Analyst’s Office.

Conservatives argue the program is bloated and rife with fraud. They say the federal changes will force states to refocus resources on the neediest.

“The role of the safety net programs was just that — to be a safety net,” Hilton said in an interview. “I don’t think it’s a particularly positive boast to say 40% of Californians should be on a program that was designed for people living in poverty.”

Becerra declined an interview request.

Nelly, a 59-year-old from Los Angeles County, was one of millions who have benefited from the state’s Medi-Cal expansion, but she was initially reluctant to sign up.

For years after she left her corporate job to care for her ailing mother, Nelly said, she didn’t consider applying. She remained uninsured until three years ago, when she woke up and couldn’t see out of her left eye.

She enrolled in Medi-Cal in the emergency room. It now covers her appointments with specialists and transportation to and from. While her condition may exempt her from the new Medicaid work requirements, Nelly said, she’s still worried about losing coverage after experiencing numerous paperwork hiccups simply trying to renew.

Nelly, who asked that her full name not be used, because she hasn’t told her family about her condition, said she understands not everyone on the program may need it. But, she added, “it should be there for someone like me.”

Tough Choices Ahead

When Republican state lawmakers got wind of Newsom’s plan to stretch the debt repayment over a decade, they accused Democrats of trying to “paper over” the state’s structural deficit.

“This leaves future governors and legislatures to clean up the mess,” stated a July 2025 memo from GOP senators. The Legislative Analyst’s Office later called the maneuver “unusual.” That could leave Becerra, the favorite to succeed Newsom in the overwhelmingly liberal state, as the face of staggering changes to a program he spent his career defending.

More than 2 million Californians under age 65 could lose health coverage over the next four years as a result of the state and federal policy changes, according to recent estimates by the University of California-Berkeley Labor Center and the UCLA Center for Health Policy Research. At least 730,000 residents have already disenrolled since June 2025.

State agencies are scrambling to implement new federal work requirement rules for adult Medicaid enrollees under 65, hoping to automate as much verification as possible to blunt coverage losses. And in 2028, states will be required to charge some enrollees fees for many services, making it harder for them to maintain coverage.

Disability rights activists say new asset limits will prevent Californians from getting needed home care, which they say is more cost-effective and humane than nursing homes. Counties, deemed by state law to be healthcare providers of last resort, say they need immediate funding for the millions of uninsured patients they anticipate in the new year.

Hospital administrators have urged policymakers to help them keep their facilities stable, and the state’s most recent budget included some $390 million to assist public and distressed hospitals.

Martin Luther King Jr. Community Hospital in Los Angeles treats five times the patients it was designed to serve, and 80% of patients are uninsured or on Medi-Cal. Demand is so high in the chronically underserved area, MLK Community Healthcare CEO Elaine Batchlor said, that the hospital has erected tents in the parking lot. Most emergency room patients are now treated there.

“We already have an extremely overcrowded, overburdened emergency department,” Batchlor said. “Insured care will turn into uncompensated care, and the financial burden for that will fall on providers.”

Becerra has said he opposes the state’s recent freeze on enrollment for adult immigrants without legal status, as well as new monthly premiums set to take effect next year, saying such moves will only saddle taxpayers with higher bills for ER care.

If elected, Becerra will probably need to wade into the politically toxic debate over whether to raise more revenue, cut benefits further, or do both.

Aside from promising to find and eliminate billions in administrative waste from the industry, the nation’s former top health official has not explained how he would cobble together the tens of billions of dollars the state is likely to need just to maintain status quo.

The next governor must tread carefully, Kent warned. “When people come and say, ‘Well, you should just do this because it’s the right thing,’” she said, “all of those right things have fiscal consequences.”

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.

The midterm elections are less than a month away, and a new poll from KFF shows voters are very concerned about rising health costs and trust Democrats more than Republicans to address the issue. In an apparent attempt to close the gap, President Donald Trump is sending checks, some dubbed as “refunds,” to some Medicare and Affordable Care Act enrollees, but those checks are for far less than most patients’ costs have risen in 2026.

Meanwhile, Republicans had planned for the healthcare cuts included in their signature 2025 budget law to take effect after the midterms. But many states and healthcare providers have jumped the gun, cutting funding and services now in anticipation of fewer federal funds in 2027.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico, and Paige Winfield Cunningham of The Washington Sun.

Panelists Anna Edney Bloomberg News @annaedney @annaedney.bsky.social Read Anna's stories. Alice Miranda Ollstein Politico @AliceOllstein @alicemiranda.bsky.social Read Alice's stories. Paige Winfield Cunningham The Washington Sun @pw_cunningham Read Paige's stories.

Among the takeaways from this week’s episode:

• Healthcare affordability is a top issue for voters heading into the midterms, a political reality prompting Trump to talk up his deals with drug companies and promise checks to Americans affected by government healthcare policies. Meanwhile, a new poll shows “Medicare for All” is at its highest popularity in at least a decade, suggesting some Americans are so squeezed by medical bills that they’re willing to support a major healthcare overhaul.
• While Republican lawmakers wrote the One Big Beautiful Bill Act so that most changes to the Medicaid program would take effect after the midterms, people are starting to feel the bite. Clinics, hospitals, and state governments are already making cuts in anticipation of the drop in federal funding. Plus, Nebraska’s early implementation of the law’s Medicaid work requirement is showing that most of those losing coverage are being dropped for procedural reasons.
• In infectious disease news, the measles outbreak in Pennsylvania has topped 1,000 cases. Those who contract the disease are likely to experience long-term effects, because it can have serious repercussions for the body’s immune system. And the death of a lab worker in Siberia from an unknown pneumonia has raised plague concerns and is making headlines as Russia shares little with the international community about the case.
• Plus, the Trump administration disclosed in court filings this week that the findings of its safety study of the abortion pill mifepristone will be released next year. And the practice of lethal injection is under scrutiny after the botched execution of a Tennessee woman. Many pharmaceutical companies refuse to even supply the drugs needed for lethal injections to correctional facilities, raising questions about the source and handling of the drugs used.

Also this week, Rovner interviews Michelle Andrews, who reported and wrote the latest KFF Health News “Bill of the Month,” about a patient who got a bill from a hospital emergency department though she never got out of the waiting room. If you have a medical bill that’s baffling, outrageous, or inscrutable, you can submit it to us here.

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

Julie Rovner: The Atlantic’s “When Anesthesia Goes Wrong,” by Sarah Zhang.

Alice Miranda Ollstein: Politico’s “Trump Is Conditioning Foreign Aid on Deals,” by Carmen Paun.

Paige Winfield Cunningham: The New York Times’ “Battle of Hospital A.I. vs. Insurer A.I. Is Pushing Medical Costs Higher,” by Reed Abelson and Teddy Rosenbluth.

Anna Edney: ProPublica’s “A Girl Nearly Died After Drinking Raw Milk. The State Did Little To Punish the Unlicensed Farmer Who Sold It,” by Annie Waldman.

Also mentioned in this week’s podcast:

• KFF’s “KFF Health Tracking Poll: Health Care Issues in the Lead-Up to the 2026 Midterm Election,” by Shannon Schumacher, Isabelle Valdes, Mardet Mulugeta, Audrey Kearney, Ashley Kirzinger, and Liz Hamel.
• KFF’s “A Guide to the Role of Health in the Midterms,” by Drew Altman.
• KFF Health News’ “Confusion and Angst Follow State’s Early Rollout of Medicaid Work Rules,” by Aaron Bolton, MTPR.
• Politico’s “Republicans Tried To Punt Health Care Cuts Until After the Midterms. It Didn’t Work,” by Alice Miranda Ollstein.
• The Center for Infectious Disease Research and Policy’s “Measles Outbreaks Could Leave Thousands Vulnerable to Infectious Diseases for Years,” by Liz Szabo.
• The New York Times’ “Texas Pediatricians Face Paxton Investigations for Vaccinating Children,” by Christina Jewett.
• KFF Health News’ “Witnessing the Failed Execution of Christa Pike: ‘We Could All Hear Her Breathing,’” by Catherine Sweeney, WPLN.

Credits Francis Ying Audio producer Emmarie Huetteman 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.

As Americans grow increasingly frustrated with their healthcare system, a proposal that has long been kicked around on the Democratic periphery is showing up in debates and on political platforms: “Medicare for All.”

According to a 2025 Economist-YouGov poll, nearly 60% of Americans favor a system of Medicare for All, while 85% of Democrats support it. For years, Democrats in Congress have proposed symbolic Medicare for All bills that have had no chance of passage but have been supported by dozens of members.

Democratic Sen. Chris Van Hollen of Maryland added his support in December. “I was listening to my constituents,” he said. “It’s just reached the complete breaking point. Our system is unaffordable and unsustainable with premiums going up, copays going up and up.”

At a time when more than 100 million Americans carry medical debt, it’s easy to get behind a promise of free, or free-ish, no-hassle health care. But turning an inspirational slogan into law gets gnarly. Those three words, Medicare for All — a pledge to bring universal healthcare to every American — mean not one thing to supporters but many. And all versions of such a system face considerable obstacles to enactment.

“Medicare for All is a slogan, not a concrete proposal, so it’s hard to have an opinion on,” said Amy Finkelstein, a Massachusetts Institute of Technology economist who, with Stanford’s Liran Einav, wrote We’ve Got You Covered, which laid out what the pair considered a realistic and fiscally responsible plan for providing basic insurance to every American.

“What we can afford is a basic plan — what we call a shack, not a chateau,” Finkelstein said. Its bedrock would be a government-funded skinny plan less generous than Medicare, with potential constraints such as a limited number of physical therapy visits or stricter criteria for getting a knee replacement, but guaranteed robust basic coverage for catastrophic medical conditions. She estimated that most Americans would opt for supplemental coverage.

The most high-profile political proponent of Medicare for All this election season is Abdul El-Sayed, the Democratic senatorial candidate in Michigan, who has made a more sweeping proposal central to his platform — far more chateau than shack. It would create one plan that covers a suite of medical needs with no cost to patients, including dental and vision care, which traditional Medicare doesn’t cover.

(Traditional Medicare has increasingly come to resemble private insurance with premiums and coinsurance, and, unlike standard commercial plans, it has no annual out-of-pocket maximum. To fill such gaps, patients buy separate Medigap and drug plans.)

“The most important thing is just to make Medicare whole — meaning no charge for medical care — rolling back the complexity and costs of the last 10 years,” El-Sayed told KFF Health News.

His program would start off covering children and adults five years younger than the current eligibility age for Medicare and close the gap over a period, he has estimated, of eight years. To ease the transition for the healthcare system, he would initially set the Medicare payment rates to mirror the totals doctors and hospitals receive now to avoid a “price shock” to their operations. Future increases would be limited to the rate of inflation.

One big question is how to make the financing work in a highly profitable industry. National health spending was projected to hit $5.7 trillion in 2025, or nearly 20% of the U.S. gross domestic product.

The United States spends twice as much on healthcare per person than many peer countries. And health insurance is often a company’s second-largest expense after payroll.

But how will the government divert financial outlays of employers and households into a new Medicare for All system without new taxes or massive government spending?

When polls ask voters whether they would support Medicare for All if it meant losing their insurance or paying new taxes, support often drops.

“You could decide to raise taxes and cover more,” Finkelstein said. “If you don’t want to cut current Medicare benefits, you could decide to bust the budget, which seems to be a common practice.”

Joe Biden said that, as president, he would veto any Medicare for All bill, given the cost, which was estimated at up to $40 trillion over 10 years. The bills in Congress don’t include very detailed financing plans.

Economists who have mapped out the possibilities are divided on a realistic path.

A group of Yale researchers estimated that converting to a Medicare for All program could save $450 billion annually. That’s in part because a government plan could negotiate — or simply set — far better prices for hospitals, doctors, drugs, and devices than private insurers. It would reduce the overhead created by private insurance with its army of negotiators, coders, and claim deniers — and reduce profits.

Strong forces are pushing back against such “rightsizing” of exorbitant prices, most notably: insurers, hospitals, and drug and device manufacturers. In 2022, they spent over $700 million on lobbying and have been a powerful force for job creation. But a grand Medicare for All proposal may simply be a strategy to open the debate to lesser possibilities. President Barack Obama’s initial Affordable Care Act proposal contained ambitious ideas — such as drug price negotiation — that fell by the wayside to get the votes for passage.

Texas Democratic Senate candidate James Talarico supports what he calls “Medicare for Y’all” — allowing people under 65 to buy into Medicare.

“There are versions of Medicare for All that could potentially include our proposal, and versions that could look extremely different,” Finkelstein said.

Support in some parts of the industry is growing.

According to one survey, more than half of all physicians have said they’d prefer some sort of single-payer system. Though the American Medical Association is opposed, its student and resident sections are pressing to overturn the opposition. The American College of Physicians, the nation’s second-largest physician group, also supports Medicare for All. Obama called the ACA a “starter house.” It was “an improvement, but it has not met the need,” Van Hollen said.

Now the growing number of Medicare for All proponents will have to define exactly what kind of new house they can accept and afford.

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.

LANSING, Mich. — Christina Starks-Clay doesn’t know how “Medicare for All” would work exactly, but she’s willing to bet it’d be better than what she has now.

Standing in line for U.S. Senate candidate Abdul El-Sayed’s town hall in the state’s capital in September, she whipped out her phone to pull up a screenshot. It was of the $1,000 cashier’s check she’d picked up at the bank that day to pay down a chunk of her son’s dental bills. An early childhood special education paraprofessional, she still owed $389, even with good dental insurance. Her own cleaning a few weeks before cost $600.

She tried to talk herself down at the bank, to focus on being grateful for what she could afford.

“I’m like, ‘Tina, OK, you were in a position for this moment to do this,’” she said. “A lot of people couldn’t do what I had to do today. I couldn’t do it. But I did it. So I need to hear, how are you going to make this better for everyone?”

Many who waited in the hot sun that afternoon in a line stretching blocks through downtown Lansing shared similar anxieties. A man ahead of Starks-Clay talked about watching his brother rack up thousands of dollars in medical debt. A professor emeritus at nearby Michigan State University worried aloud about his grandkids’ medical care, because his adult kids were struggling to meet a $9,000 insurance deductible. Healthcare workers who’d turned up for the event described patients choosing between affording medication or food, or how they themselves had been financially devastated by a medical crisis.

They all knew Michigan Democrat El-Sayed’s rallying cry by heart, chanting it when the candidate took the stage: “Money out of politics! Money in your pocket! Medicare for All!”

Abdul El-Sayed (D-Mich.) speaks at a rally in Detroit on Aug. 7. (Emily Elconin/Bloomberg via Getty Images)

Support for Medicare for All is at its highest in at least a decade, according to a new KFF poll. The survey found two-thirds of Americans now favor expanding the government health program that largely covers seniors (about half of whom are enrolled in private plans through Medicare Advantage).

But many people don’t actually know how to define Medicare for All. Traditionally, the idea has been to establish a single health insurance program, run by the federal government, that would guarantee coverage for Americans and minimize or even eliminate private insurance. How much people like the idea depends on what they’re told about it, pollsters have found.

Still, at a time when fewer than half of Americans say they can afford their healthcare, Medicare for All has become a progressive shorthand for radical, systemic change.

“Too many people don’t have health insurance, too many people who do have insurance can’t afford medical care, and many people are terrified about the costs of being sick,” said Jonathan Oberlander, a professor at the University of North Carolina-Chapel Hill who specializes in the politics of healthcare reform.

“And in an electorate that wants change, that is disenchanted with the status quo, Medicare for All is an important symbol,” he said.

That’s why Democrats running for Senate seats in the midterm elections in such states as Maine, Minnesota, and Florida tout their support for scrapping the current health insurance system in favor of broad Medicare coverage. But nowhere is the issue as central to a race as in Michigan, where Medicare for All has become synonymous with El-Sayed.

El-Sayed, who trained as a doctor and served as Detroit’s top public health official, has campaigned on Medicare for All since his unsuccessful bid for governor in 2018. To Starks-Clay, that means he has a plan and will “stick to it,” she said.

That’s appealing to voters right now, said Ashley Kirzinger, director of survey methodology at KFF, a health information nonprofit that includes KFF Health News. “When we ask people what do they want to hear from candidates in regards to healthcare, it’s a plan to bring down healthcare costs.”

American Dream or Pipe Dream?

Medicare for All has been the shiny object of progressive politics in previous campaigns, including Vermont Sen. Bernie Sanders’ 2016 presidential bid and the 2020 Democratic presidential primary. Its popularity rises and falls in cycles, Oberlander said. And today people are painfully aware their care is getting more expensive and harder to access.

In the first decade or so after the passage of the Affordable Care Act in 2010, the nation’s uninsured rate was cut nearly in half. Insurance companies could no longer deny people coverage based on preexisting conditions. Since then, to cover more people, 40 states plus Washington, D.C., have expanded Medicaid, the government health program for those with low incomes or disabilities.

Now it feels as if we’re moving backward, Oberlander said. “We are now, in the past two years, in an era where the Trump administration and congressional Republicans have reversed that progress.”

Michigan, a battleground state that President Donald Trump won in 2024, saw some of the steepest ACA plan enrollment drops after the GOP-controlled Congress allowed enhanced tax subsidies, which helped people afford their premiums, to expire at the end of last year. Insurance companies in Michigan hiked individual marketplace rates by an average of 20%. And up to 355,000 Michiganders are expected to lose their Medicaid coverage in 2028 because of cuts included in Trump’s signature law, the One Big Beautiful Bill Act, according to estimates from the Urban Institute, a left-leaning think tank.

At El-Sayed’s town hall in Lansing, Darleana Ash said patients at the medical diagnostics lab where she works are increasingly skipping tests because they can’t afford them. Others drive hours from rural areas because their local labs have closed or are no longer in their insurance networks. She worries about the patients who must choose between their medications and groceries some months.

“If you got somebody that’s 75, 80 years old, guess what? They’re going to go without the medication, because they got to eat,” she said.

Packed in near the front of the crowded town hall was Cindy Lou Coolich, a boisterous retiree wearing a campaign T-shirt and cowboy hat. She spent years working for a company that helped uninsured people enroll in coverage, until she got sick herself. A bout of sepsis nearly killed her and left her disabled. Suddenly, she was the one enrolling in Medicaid and living on $900 a month from Social Security.

She lost the 15-acre horse farm she’d owned, and then everything else, she said. “Except my car.” The saving grace, oddly, was the death of her ex-husband. Because they’d been married for more than 10 years, she could benefit from his Social Security benefits. “So now I’m doing quite well!” she laughed. But to her, it hardly seemed like the mark of a functioning healthcare system that someone had to die for things to get better.

A Universal Response

Democrats aren’t the only ones responding to voters’ healthcare discontent. Republican Mike Rogers, a former Michigan congressman and El-Sayed’s opponent, recently released a brief healthcare plan.

“I just can’t think of a more important issue to the people of Michigan than healthcare and costs, the rising costs,” he said. At a press conference announcing his health platform, he broadly attacked El-Sayed and Medicare for All.

“[If] the government’s going to give you something, they have to take it away from someone else,” Rogers said.

Mike Rogers (R-Mich.) at a rally in Sterling Heights, Michigan, on Aug. 31. (Sarah Rice/Bloomberg via Getty Images)

Under Medicare for All, millions of Michiganders with private health insurance would lose that coverage, he said. Pointing to estimates that Medicare for All would cost some $4 trillion per year, he said, “Guess what? People pay for that.” (A recent preprint study from Yale researchers found that the cost of implementing Medicare for All, estimated at $4.2 trillion, would save about $1 trillion in healthcare spending.) Rogers’ campaign declined an interview request from KFF Health News.

Concerns about increased taxation, disruption to the current system, and reduced access to services can make Medicare for All a political liability in a close election, Oberlander said. “It doesn’t matter if the fears that they’re spreading are actually accurate,” he said. “Politically, what matters is if they can scare people.”

But even if El-Sayed wins in November, the chances of Medicare for All replacing the current system “remain very remote in the short to medium term,” Oberlander said.

Given the staunch opposition from Republicans and many moderate Democrats, not to mention the lobbying power of the healthcare industry, massively overhauling the U.S. health system won’t suddenly be achievable because of a single Senate candidate.

Thomas “Jermaine” Carey knows this. A self-described activist, he attended a recent El-Sayed town hall in Detroit feeling “kind of sold out” by what he calls the “straight-ticket” Democratic Party. Medicare for All sounds good, he said. “Do I believe it?” He shrugged.

“It’s still America,” he said. “You still have super PACs, the lobbyists that control everything.”

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.

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.