A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine whether care is medically necessary — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the No Surprises Act, which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for any care needed in a nursing home if the patient was not first formally admitted to a hospital for at least three days.

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is stable enough to travel to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient to sign a consent form, agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

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As shopping season opens for Affordable Care Act plans in some states, customers are confronting staggering costs for their health insurance next year. The extra federal subsidies put in place in 2021 that made coverage more affordable for millions of people will expire at the end of this year unless a gridlocked and idle Congress acts.

With Democratic and Republican lawmakers at an impasse, the federal government shut down on Oct. 1, spurred by the need for an estimated $353 billion over a decade to continue providing enhanced ACA subsidies for roughly 24 million people. Both sides have dug in, with Republicans saying Senate Democrats must vote to reopen the government before they’re willing to negotiate on the ACA’s costs.

If Congress does manage to strike a deal in the coming days or weeks to extend some subsidies, the prices and types of plans available on the online marketplaces could change dramatically, bringing unprecedented uncertainty and upheaval to this year’s open enrollment, which begins in most states on Nov. 1.

Michele Eberle, executive director of the Maryland Health Benefit Exchange, the state-run marketplace, is gaming out strategies should that happen, including the possibility of pausing enrollment so her 200-person team can update the plans to reflect any changes, should Congress pass a new bill on ACA subsidies.

“We will do whatever it takes to make sure we can provide Marylanders with the most affordable health coverage,” Eberle said. “The mechanics of how that gets done, we don’t really know until we figure out what Congress might do.”

“I think everyone realizes that, depending on what happens, we just can’t flip a switch overnight,” she added.

Exchange customers in Maryland can expect to pay, on average, about 35% more next year, even with help from the state, which agreed to offer backup subsidies should the federal government’s discounts expire at the end of this year. Eberle said notices of premium hikes — which assumed the federal subsidies would expire — already were sent to mailboxes and inboxes. One middle-income family of four in the state, for example, will see their monthly premiums go from $916 to $1,427.

People living in most states still use healthcare.gov, the federal marketplace, to enroll in coverage. The Centers for Medicare & Medicaid Services, which oversees the federal exchange, declined to answer questions about how quickly the agency could pivot on any changes Congress may make after sign-ups start.

“CMS does not speculate on potential Congressional action,” Health and Human Services spokesperson Emily Hilliard said in an email.

Like other states that run their own ACA exchanges, California has sent letters to policyholders with information about their 2026 coverage, with costs calculated under the assumption that the subsidies would expire.

But the California exchange team, too, devised backup plans to contact policyholders and revamp its online marketplace if Congress acts before year’s end.

“At no point is it too late,” said Jessica Altman, executive director of Covered California, the state’s exchange. “We are ready to move any mountain we can possibly move to make any changes as quickly as we possibly can.”

It could take about a week to reprogram the site to reflect prices that factor in more generous subsidies, if Congress were to approve them exactly as they currently are, Altman said.

States may also have to update premiums themselves to reflect new rates. Most insurers submitted two sets of premium rates to states this year in case Congress agreed to extend the subsidies.

Right now, many shoppers are seeing the set of higher rates that insurers plan to charge if the subsidies expire.

Insurers say it is necessary to raise premiums without the subsidies because they anticipate healthier, younger people will drop coverage rather than pay more. That would leave insurers with a sicker, older pool of people to cover.

If a subsidy deal is reached, insurers could lower the premiums.

The complications don’t end there.

If Congress passes a subsidy deal after customers have started picking plans, people might see the new prices and want to reconsider the type of coverage for which they already signed up. Enrollees may change plans as long as enrollment is open, through Jan. 15 in most states.

Dozens of insurers offer ACA plans across the country. Those plans range widely in the doctors or medications they cover, as well as how much customers contribute in copays, the fees owed for medical services, and deductibles, the out-of-pocket amount paid before insurers pitch in.

Some people might be willing to pay a higher monthly premium in exchange for a lower deductible. Others, especially those who don’t expect to incur major medical bills, might risk a higher deductible to keep monthly premium payments lower.

In Virginia, some customers are being presented with strikingly high deductibles for next year, said Deepak Madala, the director of Enroll Virginia, which assists people with enrolling in coverage.

He said he’s helping one family in Virginia Beach facing a jump in premium costs from $70 to about $280 a month.

To buy a plan at a similar price, the family, with a household income of about $60,000, would need to look at coverage that carries a deductible of $20,000 or more, he said. Right now, their deductible is $800.

With premiums and deductibles that high, some customers might rethink coverage entirely, he said.

They’re deciding whether “to go without or switch to a plan with a very high deductible,” Madala said of ACA customers’ options.

Pennsylvania’s state-based exchange, which last week started sending out notices detailing 2026 rates, estimates a 102% increase in premiums for its roughly 500,000 customers. About a third of customers are expected to drop coverage, said Devon Trolley, executive director of the Pennsylvania Health Insurance Exchange Authority.

The timing of any subsidy deal reached by Congress is most precarious, though, for the roughly 135,000 Idahoans enrolled in ACA coverage.

That’s because their state opened enrollment on Oct. 15, weeks before the rest of the country — and it will end earlier, on Dec. 15.

With ACA enrollees facing average increases of 75% for coverage costs, about 20% are expected to drop out of the marketplace, said Pat Kelly, executive director of Your Health Idaho, the state exchange.

Idaho is prepared to revamp its website if anything changes on the subsidies — a process that could take days — and has “notices ready to go” to inform policyholders of additional savings, Kelly said.

“We would work to do it as quickly as possible, and make sure it is done right,” he said, adding that factors such as the day of the week or proximity to the Thanksgiving holiday could add time.

If Congress waited to act until the federal subsidies expire on Dec. 31 — the date Republican House Speaker Mike Johnson has repeatedly raised as the deadline for a deal — it would be too late for people in Idaho.

“We would run out of open enrollment, and there would not be enough time to make changes,” Kelly said of any congressional deals reached after mid-December.

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The agency that oversees the ACA announced early this month that it would expand eligibility for “catastrophic” plans sold in Affordable Care Act online marketplaces. The plans require people to spend more than $10,000 a year on deductibles before the policies pay most medical costs but carry lower monthly premiums than other Obamacare policies.

The move reflects growing concern among Republicans about political backlash if Congress doesn’t extend larger tax credits put in place during the covid-19 public health emergency to help consumers pay their premiums. The extra subsidies are set to expire at the end of the year, resulting in an average 75% increase in the amount people pay for coverage, according to KFF, a health information nonprofit that includes KFF Health News.

A small, bipartisan group of House lawmakers introduced legislation to extend the enhanced covid-era subsidies for one more year, which would keep them in place through midterm congressional elections in fall 2026.

But the fate of that legislation is uncertain, with many Republicans opposed to extending the extra tax credits, with a permanent change costing at least $335 billion over 10 years. Without an extension, tax credit amounts would revert to pre-pandemic levels.

“They spent the last 15 years against the ACA, so a lot will be steadfast, but others are worried about the effect of massively spiked premiums on their constituents,” noted a Democratic Senate staffer who asked not to be identified because they weren’t authorized to speak to the media.

Republicans currently control Congress by slim margins, raising the stakes if voters who lose their ACA tax credits blame them at the ballot box.

Catastrophic plans are a little-known type of Obamacare policy that have previously been limited mainly to people under age 30. While they come with lower monthly premiums than other types of ACA plans, the coverage has higher annual deductibles, which are set at the out-of-pocket maximum for the year: $10,600 for individuals in 2026 or $21,200 for families.

A deductible is the amount patients must spend on health care before insurance plans pay for most services. Catastrophic plans do cover three primary care visits a year without having to pay the full deductible and, as with other ACA policies, policyholders pay nothing for preventive services such as some cancer screenings and vaccines.

The catastrophic plans will automatically show up on the federal marketplace, healthcare.gov, for consumers who lose tax credit coverage entirely next year due to their household income. Another category of consumers — people who continue to qualify for tax credits but not for subsidies that reduce out-of-pocket costs — may also be eligible but would have to send in paperwork.

“By expanding access to catastrophic plans, we are making sure hardworking people who face unexpected hardships can get affordable coverage that protects them from devastating medical costs,” Centers for Medicare & Medicaid Services Administrator Mehmet Oz said in a statement.

It isn’t clear whether the policy changes will make the plans more attractive to consumers. Catastrophic plans aren’t available in all states, and the size of the deductibles can be off-putting.

“It’s a ton of money,” said Louise Norris, a health insurance analyst and broker who writes regularly about the ACA. “A full-price catastrophic plan is still more expensive than some people can afford, but they’re doing this to offer a slightly more affordable option.”

Catastrophic plans have had limited appeal, with only about 54,000 out of Obamacare’s 24 million enrollees currently opting for the coverage, according to government data, Norris said.

“Uptake has always been quite low,” said Katie Keith, director of the O’Neill Institute’s Center for Health Policy and the Law at Georgetown University. “It’s not a bad option if it is the only option you have. I question whether consumers are looking for this kind of coverage.”

CMS plans to grant people a “hardship” designation to enroll in catastrophic plans if they lose eligibility for ACA tax credits next year. Most likely to qualify are people earning more than four times the federal poverty rate ($62,600 for an individual this year, or $106,600 for a family of three), who will lose access to all premium subsidies if Congress does not extend the current enhanced tax credits. It’s also unclear how much premiums will cost. Insurers, reacting to the new administration guidance, might seek to recalculate their rates based on what they estimate may be an influx of older people into the plans, Norris said.

AHIP, the insurance industry lobbying group, is pushing hard for the larger tax credits to be extended. It did not comment specifically on how the new guidance might affect catastrophic health plan premiums. Still, AHIP spokesperson Chris Bond said that “while catastrophic plans can provide important coverage for specific needs, they are not a replacement for affordable comprehensive coverage.”

There are other hurdles. Norris said insurers don’t offer plans at all in 10 states: Alaska, Arkansas, Indiana, Louisiana, Mississippi, New Mexico, Oregon, Rhode Island, Utah, and Wyoming. And where they are available, options are few. This year, for example, a 25-year-old in Orlando, Florida, had a choice of 61 “bronze” plans, the cheapest level of coverage available to all ACA shoppers, but just three catastrophic plans.

Policy experts say the expanded eligibility for catastrophic plans makes it more important than ever for consumers to consider all options when shopping for ACA coverage during the annual open enrollment period, which starts Nov. 1. In addition to the catastrophic and bronze plans, there are also “silver” and “gold” plans, each with varying premiums and deductibles.  

Bronze plans have the lowest premiums but the highest deductibles; the average bronze deductible this year is $7,186, which is still lower than the catastrophic plans, according to KFF.

Catastrophic plan deductibles, while high, are comparable to some bronze plans, Norris noted. People who choose catastrophic plans are not eligible for any ACA tax subsidies to help pay monthly premiums.

A pending court battle may provide lawmakers concerned about voter pushback on Obamacare changes an unintended reprieve.

In late August, a federal judge in Maryland temporarily put on hold some changes the Trump administration had ordered for next year. Those changes, included in a June regulatory filing by the administration, would have added additional verification paperwork requirements for some people enrolling in ACA plans, and were challenged by several cities, which cited government estimates that the changes could cause up to 1.8 million people to lose their insurance in 2026.

The court ruling stayed several provisions of the Trump administration rules, including income verification requirements that would affect people below the poverty level and those without tax return information. The move also paused verification requirements affecting people who apply outside the annual open enrollment period and blocked a $5 monthly charge for people who are automatically enrolled into plans in which subsidies cover the entire premium — unless they contact the marketplace and confirm their selection.

The Trump administration is appealing the decision, but the case may not be settled until next year, said Keith at Georgetown University.

That makes it likely that the pause of the new requirements will stay in place for this year’s open enrollment season.

Keith said the ruling was a “bigger deal” than expanding eligibility for catastrophic plans. “Consumers all across the country won’t have to deal with red tape the Trump administration rushed to put into place ahead of the new plan year,” and the ruling also “helps people keep their coverage.”

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Such drug plans are used by millions of people who enroll in what is called original Medicare, the classic federal government program that began in 1965 and added a drug benefit only in 2006. The drug plans are offered through private insurers, and enrollees must pay monthly premiums.

It’s not known whether insurers will pursue the maximum increase allowed, as premium prices for next year won’t be revealed until closer to open enrollment, which starts Oct. 15.

Increases are expected to mainly affect stand-alone Part D plans, not the drug coverage offered as part of Medicare Advantage, the private sector alternative to original Medicare. More on that later.

Policy experts say premiums are likely to go up for several reasons, including increased use of some higher-cost prescription drugs; a law that capped out-of-pocket spending for enrollees; and changes in a program aimed at stabilizing price increases that the Trump administration has continued but made less generous.

One thing is surer than ever, say many policy experts: Beneficiaries should not simply roll over their existing stand-alone Medicare drug plans.

“Everyone should shop plans in open enrollment,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.

Here are three reasons prices would rise.

1. It’s the Spending!

Every year, insurers keep an eye on what they’re spending on drugs so they can build that into their premium estimates. Spending covers both the prices charged by drugmakers and volume, meaning how many people take the medications and how often.

And it’s up. Spending by insurers and government programs for prescription drugs in 2024 across the market grew more than 10%, which is slightly greater than in recent years, according to a research report published in last month’s issue of the American Journal of Health-System Pharmacy. Estimates are not yet available for this year’s trends.

Still, in 2024, researchers found that drug prices overall decreased slightly. Spending rose because of drugs coming on the market and increased utilization, especially for pricey weight loss drugs and another category of medications that treat various autoimmune conditions, such as rheumatoid arthritis.

Such increased use is evident in Medicare. Many beneficiaries, for example, are treated for autoimmune conditions. And even though Medicare doesn’t cover treatment for weight loss, many members have diabetes or other conditions that a new type of weight loss drugs can treat.

The Trump administration, according to The Washington Post, is considering a five-year pilot program in which Medicare Part D plans could voluntarily expand access to the drugs, which can cost more than $1,000 a month without insurance. Details have not yet been provided, but the pilot program would not begin in Medicare until 2027.

Another wild card for insurers is the Trump administration’s tariffs on businesses that purchase products made overseas, which could boost drug prices because the U.S. imports a lot of its pharmaceuticals. Much, however, remains unknown about whether drugmakers will pass along any additional tariff costs to consumers.

So, while rising spending is one factor, it isn’t the only reason next year’s premium prices are expected to go up.

2. New Out-of-Pocket Caps for Consumers

Changes made to Medicare aimed at helping people with high out-of-pocket costs for expensive medications may be a bigger factor.

Here’s why: Starting this year, Medicare enrollees have a limit on how much they must pay out-of-pocket for prescription drugs. It’s capped at $2,000, a threshold that will rise each year to cover inflation.

Lawmakers in Congress set those changes in the Inflation Reduction Act under President Joe Biden. The law also shifted a larger share of the cost of drugs used by Medicare beneficiaries from the federal program to insurers.

That $2,000 cap is a big change from previous years, when people taking expensive drugs had a higher threshold to meet annually and were on the hook to pay 5% of the drug’s cost even after meeting that amount. Those additional 5% payments ended last year under the provisions of the IRA.

Before that law passed, “people would spend $10,000 or $15,000 out-of-pocket each year just for a single drug,” Dusetzina said. “The Inflation Reduction Act was necessary to make Part D proper health insurance, but there’s a cost to do so.”

While the cap is a big help for affected consumers, the reduced amounts paid by some beneficiaries — coupled with the cost shift to insurers — could lead plans to spread their increased expenses across all policyholders through higher premiums. A growing number of health plans have also begun to require enrollees to pay a percentage of a drug’s cost, rather than a flat-dollar copay, which can lead to larger-than-expected costs at the pharmacy counter, Dusetzina said.

While consumers not currently taking high-cost specialty drugs may not see a benefit in the $2,000 cap initially, they might one day, say policy experts, who note that drugmaker prices continue to rise and that enrollees could fall ill with a condition like cancer or multiple sclerosis for which they need a very high-priced drug.

“It’s important to think not just in context of those groups who hit the cap every year, but also people are paying more in premiums to protect their future selves as well,” said Casey Schwarz, the senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

The new prescription drug cap and other changes apply to both the stand-alone Part D drug plans and Medicare Advantage plans. But those Medicare Advantage plans are not expected to increase the drug portion of their premiums, partly because the private sector plans are paid more per member than what it costs taxpayers for the traditional program.

That means Advantage plans have far more money to add benefits, such as vision and dental coverage, which traditional Medicare does not include, or to use them to cushion the impact of rising spending on drug costs, thus limiting premium increases.

Those additional benefits are advertised to attract customers to Medicare Advantage, which also sometimes offers plans with minimal or no monthly premium costs. There are other differences between traditional Medicare and private sector plans. For example, Advantage members must stick to doctors and hospitals in the plan’s networks, and they may face more prior authorization or other hurdles than in the traditional program.

The growing difference between premiums — fueled by the extra rebates flowing to the private sector plans — “is increasingly tilting coverage toward Medicare Advantage and making traditional Medicare plus a stand-alone PDP [prescription drug plan] unaffordable for many enrollees,” said Juliette Cubanski, deputy director of the program on Medicare policy at KFF, a health information nonprofit that includes KFF Health News.

3. Trump Administration Reduced Funding Meant To Slow Premium Growth

The final factor in the premium increase equation is a program set up to slow the rise of premiums in stand-alone Part D plans.

It began under the Biden administration to offset premium increases tied to changes in the Inflation Reduction Act by temporarily injecting additional federal dollars to help insurers adjust to the new rules.

That plan sent just over $6 billion this year to Part D insurers.

And it had an effect.

The average monthly premium for a stand-alone Part D drug plan dropped 9%, from $43 last year to $39 this year, according to KFF, even when factoring in that some plans raised prices by up to $35 a month, the maximum increase allowed under the stabilization plan for this year.

In a memo released in late July, the Trump administration said it would continue the program for next year, while shaving about 40% of the funding. A government official told The Wall Street Journal that the administration felt that keeping the full funding would have mainly benefited the insurers and cost taxpayers an “enormous, excess amount.”

The stabilization effort next year will send $10 a month per enrollee to Part D insurers to help keep premiums in check, down from $15 this year. Among other changes, it allows insurers to raise premiums by as much as $50 a month, up from the $35 allowed this year.

That would be a substantial increase, Cubanski noted, although it is not clear just how many insurers would pursue the full amount.

“We did see some plans this year were taking premium increases of that $35 amount in 2025, and I fully expect we will see some plans with increases up to $50 a month” next year, she said.

Another reason to take a close look at all the options once open enrollment begins.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, covid-era ACA tax subsidies to expire at the end of December.

“The out-of-pocket change for individuals will be immense, and many won’t actually be able to make ends meet and pay premiums, so they will go uninsured,” said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University.

Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Donald Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won’t occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions.

“I am hearing on both sides — more from Republicans, but from both the House and Senate” — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups.

In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, according to an analysis for the Peterson-KFF Health System Tracker covering 19 states and the District of Columbia. KFF is a national health information nonprofit that includes KFF Health News.

That’s up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%.

Health insurers “are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes,” wrote Chris Bond, a spokesperson for AHIP, the industry’s lobbying group. The emailed response also called on lawmakers “to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026.”

Neither the White House nor the Department of Health and Human Services responded to requests for comment.

These are initial numbers and insurance commissioners in some states may alter requests before approval.

Still, “it’s the biggest increase we’ve seen in over five years,” said analysis co-author Cynthia Cox, a KFF vice president and director of its Program on the ACA.

Premiums will vary based on where consumers live, the type of plan they choose, and their insurer.

For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, according to an analysis of a smaller set of insurers by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA’s enhanced tax credits are extended.

Most insurers are asking for 10% to 20% increases, the KFF report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed.

But rising premiums are just part of the picture.

A bigger potential change for consumers’ pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden’s term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022.

Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to chip in 8.5% of their household income toward the premiums.

Across the board, but especially among lower-income policyholders, bigger subsidies helped fuel record enrollment in ACA plans.

But they’re also costly.

A permanent extension could cost $335 billion over the next decade, according to the Congressional Budget Office.

Such an extension was left out of the policy law Trump signed on July 4 that he called the “One Big Beautiful Bill.” Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels.

That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds four times the federal poverty level — $84,600 for a couple or $128,600 for a family of four this year — won’t get any subsidies at all.

If the subsidies expire, policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%. In some states, ACA premiums could double.

“There will be sticker shock,” said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses.

And enrollment could fall sharply. The Wakely Consulting Group estimates that the combination of expiring tax credits, the Trump law’s new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%.

According to KFF, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members.

Some conservative think tanks, such as the Paragon Health Institute, say the more generous subsides led people to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization.

But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. In 2024, 56% of ACA enrollees lived in Republican congressional districts, and 76% were in states won by Trump.

Allowing the enhanced subsidies to expire could also reshape the market.

Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Trump’s new tax law allows people enrolled in either “bronze” or “catastrophic”-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs.

“Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options,” Brooker said.

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The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges.

Many of those states fear that the additional red tape — especially requirements that would end automatic reenrollment — would have an outsize impact on their policyholders. That’s because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal healthcare.gov marketplace.

“The federal marketplace always had a message of, ‘Come back in and shop,’ while the state-based markets, on average, have a message of, ‘Hey, here’s what you’re going to have next year, here’s what it will cost; if you like it, you don’t have to do anything,’” said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director with the Manatt Health consulting group.

Millions — perhaps up to half of enrollees in some states — may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule from the Trump administration and the likely expiration at year’s end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year. That’s starting to happen already, based on some early state rate requests for next year, which are hitting double digits.

“We estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,” said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees this year, a record.

Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the “One Big Beautiful Bill,” could undo inroads made in the nation’s uninsured rate, which dropped by about half from the time most of the ACA’s provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data.

Premiums would rise along with the uninsured rate, because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage — and are thus less expensive — would not.

After a dramatic all-night session, House Republicans passed the bill, meeting the president’s July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration.

The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round.

In addition, automatic reenrollment, used by more than 10 million people for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently.

That’s a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era’s “lax verification requirements.”

He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers’ being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers.

In testimony to Congress on June 25, Blase wrote that “this simple step will close a massive loophole and significantly reduce improper enrollment and spending.”

States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal healthcare.gov.

The state-run marketplaces credit their additional security measures and tighter control over broker access than healthcare.gov for the relative lack of problems.

“If you look at California and the other states that have expanded their Medicaid programs, you don’t see that kind of fraud problem,” said Jessica Altman, executive director of Covered California, the state’s Obamacare marketplace. “I don’t have a single case of a consumer calling Covered California saying, ‘I was enrolled without consent.’”

Such rollovers are common with other forms of health insurance, such as job-based coverage.

“By requiring everyone to come back in and provide additional information, and the fact that they can’t get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,” said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

Federal data shows about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF.

States do check income and other eligibility information for all enrollees — including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they’ve experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period.

“We have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,” Altman said.

If flagged for mismatched data, applicants are asked for additional information. Under current law, “we have 90 days for them to have a tax credit while they submit paperwork,” Altman said.

That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information.

A white paper written for Capital Policy Analytics, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes.

While “tighter verification can curb improper enrollments,” the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, “would push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,” wrote free market economists Ike Brannon and Anthony LoSasso.

“Insurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,” they wrote.

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El proyecto de ley, aprobado por el Senado el martes 1 de julio, revertiría muchos de los avances en cobertura médica de las administraciones Biden y Obama, cuyas políticas facilitaron el acceso a la atención médica a millones de personas y redujeron la tasa de personas sin seguro en el país a mínimos históricos.

El plan del Senado para recortar drásticamente la financiación de Medicaid y los mercados de ACA podría hacer que unas 12 millones de personas más no tuvieran seguro para 2034, según estima la CBO.

Esto, a su vez, perjudicaría las finanzas de hospitales, residencias de adultos mayores y centros de salud comunitarios —que tendrían que absorber una mayor parte del costo del tratamiento de las personas sin cobertura— y podría obligarlos a reducir servicios y personal, hasta a cerrar instalaciones.

La legislación está en el escritorio de Trump a la espera de su firma, aunque primero el Senado y la Cámara de Representantes deben aprobar la misma versión. La Cámara de Representantes aprobó su propia versión en mayo y se espera que considere la versión del Senado hoy (2 de julio), según Tom Emmer, líder de la mayoría en la Cámara.

A continuación, se presentan cinco maneras en que los planes del Partido Republicano podrían afectar el acceso a la atención médica.

¿Necesita Medicaid? Entonces consigue un trabajo

Los recortes más profundos al gasto en atención médica provienen de la propuesta de un requisito de trabajo para Medicaid, que cortaría la cobertura a millones de afiliados que no cumplen con estos nuevos estándares.

En 40 estados y Washington, D.C., que han ampliado Medicaid bajo ACA, algunos beneficiarios de Medicaid tendrían que presentar regularmente documentación que demuestre que trabajan, hacen voluntariado o asisten a la escuela al menos 80 horas al mes, o que califican para una exención, como por ejemplos el cuidado de un niño pequeño.

El requisito del proyecto de ley no se aplicaría a las personas en los 10 estados, mayoritariamente republicanos, que no han ampliado Medicaid.

Investigadores de salud afirman que la política tendría poco impacto en el empleo. Según KFF, la mayoría de los beneficiarios de Medicaid en edad laboral que no reciben prestaciones por discapacidad ya trabajan o buscan trabajo, o no pueden hacerlo porque tienen una discapacidad, asisten a la escuela o cuidan a un familiar.

Los experimentos estatales con requisitos de trabajo se han visto plagados de problemas administrativos, como la pérdida de cobertura de los beneficiarios elegibles por problemas con el papeleo, y más gasto.

El requisito de trabajo de Georgia, que se implementó oficialmente en julio de 2023, ha costado más de $90 millones, de los cuales solo 26 millones se han destinado a prestaciones de salud, según el  Georgia Budget & Policy Institute, una organización de investigación no partidista.

“Los costos ocultos son astronómicos”, afirmó Chima Ndumele, profesor de la Escuela de Salud Pública de Yale.

Menos dinero significa menos atención en las comunidades rurales

Las medidas de ajuste que se aplicarían a los estados podrían traducirse en una disminución de los servicios de salud, profesionales médicos e incluso hospitales, especialmente en las comunidades rurales.

El plan del Partido Republicano reduciría una práctica conocida como impuestos a los proveedores, que casi todos los estados han utilizado durante décadas para aumentar los pagos de Medicaid a hospitales, residencias de adultos mayores y otros proveedores, así como a empresas privadas de atención médica administrada.

Los estados suelen utilizar el dinero federal generado a través de los impuestos para pagar a las instituciones más de lo que Medicaid pagaría de otra manera. (Medicaid generalmente paga las tarifas más bajas por la atención médica, en comparación con Medicare, el programa para personas mayores de 65 años y algunas personas con discapacidad, y los seguros privados).

Los hospitales y residencias de adultos mayores afirman que utilizan estos fondos adicionales de Medicaid para ampliar o añadir nuevos servicios y mejorar la atención para todos los pacientes.

Los hospitales rurales suelen operar con márgenes de ganancia reducidos y dependen de los pagos de impuestos de Medicaid para sostenerlos. Investigadores del Cecil G. Sheps Center for Health Services Research que examinaron el proyecto de ley de la Cámara concluyeron que este obligaría a más de 300 hospitales rurales, muchos de ellos en Kentucky, Louisiana, California y Oklahoma, a reducir sus servicios o cerrar.

Los senadores republicanos agregaron un fondo de $50 mil millones a su versión del proyecto de ley para amortiguar el impacto en los hospitales rurales.

Más dificultad para obtener, y mantener, la cobertura de ACA

Para quienes tienen cobertura del mercado de seguros de salud de ACA, el plan republicano dificultaría la inscripción y el conservar los planes.

Los asegurados del mercado de seguros estarían obligados a actualizar sus ingresos, estatus migratorio y otra información cada año, en lugar de reinscribirse automáticamente, algo que más de 10 millones de personas hicieron este año.

También tendrían menos tiempo para inscribirse; el proyecto de ley acorta el período anual de inscripción abierta en aproximadamente un mes.

Las personas que soliciten cobertura fuera de ese período —por ejemplo, porque pierden su trabajo u otro seguro, o necesitan agregar a un recién nacido o cónyuge a una póliza existente— tendrían que esperar a que se procesen todos sus documentos antes de recibir subsidios del gobierno para ayudar a pagar sus primas mensuales. Actualmente, reciben hasta 90 días de ayuda con las primas durante el proceso de solicitud, que puede tardar semanas.

Los legisladores republicanos y algunos centros de estudios de políticas conservadoras, incluido el Paragon Health Institute, afirman que los cambios son necesarios para reducir las inscripciones fraudulentas, mientras que los opositores afirman que son el último intento de desmantelar el Obamacare.

La legislación tampoco contempla una extensión de los subsidios mejorados implementados durante la pandemia de covid-19. Si el Congreso no actúa, estos subsidios expirarán a finales de año, lo que resultará en un aumento promedio del 75% en las primas el próximo año, según KFF.

¿Tienes Medicaid? Se pagará más por las consultas médicas

Muchos beneficiarios de Medicaid podrían tener que pagar más de su bolsillo por las citas.

El proyecto de ley exigiría a los estados que han ampliado Medicaid cobrar a los beneficiarios hasta $35 por algunos servicios si sus ingresos se encuentran entre el nivel federal de pobreza (este año, $15.650 por persona) y el 138% de esa cantidad ($21.597).

Los beneficiarios de Medicaid generalmente no pagan nada cuando buscan servicios médicos, ya que estudios han demostrado que cobrar incluso copagos pequeños lleva a las personas de bajos ingresos a renunciar a atención necesaria. En los últimos años, algunos estados han agregado cargos inferiores a $10 por algunos servicios.

Esta política no se aplicaría a las personas que buscan atención primaria, atención de salud mental o tratamiento de adicciones.

Recortes para inmigrantes con residencia legal

El plan republicano podría provocar que al menos cientos de miles de inmigrantes con residencia legal —incluyendo solicitantes de asilo, víctimas de tráfico humano y refugiados— pierdan su cobertura del mercado de seguros al eliminar los subsidios que hacen que las primas sean asequibles. La restricción no se aplicaría a los titulares de tarjetas de residencia permanente (Green Card o tarjeta verde).

Dado que los inmigrantes que perderían subsidios bajo este plan tienden a ser más jóvenes que la población general, su salida dejaría una población de afiliados de mayor edad, con mayor riesgo de enfermedad y costos más elevados, lo que incrementaría aún más las primas del mercado, según directores de los mercados de seguros de salud en California, Maryland y Massachusetts, y analistas de salud.

Quitar el acceso a la atención médica a los inmigrantes que viven legalmente en el país “causará un daño irreparable a las personas que hemos prometido proteger e impondrá costos innecesarios a los sistemas locales que ya están sobrecargados”, declaró John Slocum, director ejecutivo del Refugee Council USA, un grupo de defensa, en un comunicado.

Tanto la versión de la Cámara de Representantes como la del Senado del proyecto de ley reflejan el enfoque restrictivo de la administración Trump hacia la inmigración.

Sin embargo, debido a que contravenía las normas del Senado, la legislación no incluirá una propuesta que habría reducido los pagos federales de Medicaid a estados como California, que utilizan sus propios fondos para cubrir a inmigrantes sin papeles.

La corresponsal principal de KFF Health News en Washington, Julie Rovner, contribuyó con este artículo.

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The bill, passed in both the House and the Senate without a single Democratic vote, is expected to reverse many of the health coverage gains of the Biden and Obama administrations. Their policies made it easier for millions of people to access health care and reduced the U.S. uninsured rate to record lows, though Republicans say the trade-off was far higher costs borne by taxpayers and increased fraud.

Under the legislation Trump’s expected to sign on Friday, Independence Day, reductions in federal support for Medicaid and Affordable Care Act marketplaces will cause nearly 12 million more people to be without insurance by 2034, the Congressional Budget Office estimates. That in turn is expected to undermine the finances of hospitals, nursing homes, and community health centers — which will have to absorb more of the cost of treating uninsured people. Some may reduce services and employees or close altogether.

Here are five ways the GOP’s plans may affect health care access.

Need Medicaid? Then Get a Job

The deepest cuts to health care spending come from a proposed Medicaid work requirement, which is expected to end coverage for millions of enrollees who do not meet new employment or reporting standards.

In 40 states and Washington, D.C., all of which have expanded Medicaid under the Affordable Care Act, some Medicaid enrollees will have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption, such as caring for a young child. The new requirement will start as early as January 2027.

The bill’s requirement doesn’t apply to people in the 10 largely GOP-led states that have not expanded Medicaid to nondisabled adults.

Health researchers say the policy will have little impact on employment. Most working-age Medicaid enrollees who don’t receive disability benefits already work or are looking for work, or are unable to do so because they have a disability, attend school, or care for a family member, according to KFF, a health information nonprofit that includes KFF Health News.

State experiments with work requirements have been plagued with administrative issues, such as eligible enrollees’ losing coverage over paperwork problems, and budget overruns. Georgia’s work requirement, which officially launched in July 2023, has cost more than $90 million, with only $26 million of that spent on health benefits, according to the Georgia Budget & Policy Institute, a nonpartisan research organization.

“The hidden costs are astronomical,” said Chima Ndumele, a professor at the Yale School of Public Health.

Less Cash Means Less Care in Rural Communities

Belt-tightening that targets states could translate into fewer health services, medical professionals, and even hospitals, especially in rural communities.

The GOP’s plan curtails a practice, known as provider taxes, that nearly every state has used for decades to increase Medicaid payments to hospitals, nursing homes, and other providers and to private managed-care companies.

States often use the federal money generated through the taxes to pay the institutions more than Medicaid would otherwise pay. Medicaid generally pays lower fees for care than Medicare, the program for people over 65 and some with disabilities, and private insurance. But thanks to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Hospitals and nursing homes say they use these extra Medicaid dollars to expand or add new services and improve care for all patients.

Rural hospitals typically operate on thin profit margins and rely on payments from Medicaid taxes to sustain them. Researchers from the Cecil G. Sheps Center for Health Services Research who examined the original House version of the bill concluded it would push more than 300 rural hospitals — many of them in Kentucky, Louisiana, California, and Oklahoma — toward service reductions or closure.

Republicans in the Senate tacked a $50 billion fund onto the legislation to cushion the blow to rural hospitals. The money will be distributed starting in 2027 and continue for five years.

Harder To Get, and Keep, ACA Coverage

For those with Obamacare plans, the new legislation will make it harder to enroll and to retain their coverage.

ACA marketplace policyholders will be required to update their income, immigration status, and other information each year, rather than be allowed to automatically reenroll — something more than 10 million people did this year. They’ll also have less time to enroll; the bill shortens the annual open enrollment period by about a month.

People applying for coverage outside that period — for instance because they lose a job or other insurance or need to add a newborn or spouse to an existing policy — will have to wait for all their documents to be processed before receiving government subsidies to help pay their monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take weeks.

Republican lawmakers and some conservative policy think tanks, including the Paragon Health Institute, say the changes are needed to reduce fraudulent enrollments, while opponents say they represent Trump’s best effort to undo Obamacare.

The legislation also does not call for an extension of more generous premium subsidies put in place during the covid pandemic. If Congress doesn’t act, those enhanced subsidies will expire at year’s end, resulting in premiums rising by an average of 75% next year, according to KFF.

On Medicaid? Pay More To See Doctors

Many Medicaid enrollees can expect to pay more out-of-pocket for appointments.

Trump’s legislation requires states that have expanded Medicaid to charge enrollees up to $35 for some services if their incomes are between the federal poverty level (this year, $15,650 for an individual) and 138% of that amount ($21,597).

Medicaid enrollees often don’t pay anything when seeking medical services because studies have shown charging even small copayments prompts low-income people to forgo needed care. In recent years, some states have added charges under $10 for certain services.

The policy won’t apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees who seek emergency room care for nonemergencies. But if Medicaid patients fail to pay, hospitals and other providers could be left to foot the bill.

Cuts for Lawfully Present Immigrants

The GOP plan could cause at least hundreds of thousands of immigrants who are lawfully present — including asylum-seekers, victims of trafficking, and refugees — to lose their ACA marketplace coverage by cutting off the subsidies that make premiums affordable. The restriction won’t apply to green-card holders.

Because the immigrants who will lose subsidies under the legislation tend to be younger than the overall U.S. population, their exit would leave an older, sicker, and costlier population of marketplace enrollees, further pushing up marketplace premiums, according to marketplace directors in California, Maryland, and Massachusetts and health analysts.

Taking health care access away from immigrants living in the country legally “will do irreparable harm to individuals we have promised to protect and impose unnecessary costs on local systems already under strain,” John Slocum, executive director of Refugee Council USA, an advocacy group, said in a statement.

The bill reflects the Trump administration’s restrictive approach to immigration. But because it ran afoul of Senate rules, the legislation doesn’t include a proposal that would have reduced federal Medicaid payments to states such as California that use their own money to cover immigrants without legal status.

KFF Health News chief Washington correspondent Julie Rovner contributed reporting.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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So, in mid-March, he took his family to a primary care clinic at the University of Texas Medical Branch in Galveston.

By the end of the visit, his son, Anh Hoang, had received one shot protecting against four illnesses — measles, mumps, rubella, and chickenpox. He also received a second shot against tetanus, diphtheria, and whooping cough, as well as a flu shot. His twin daughters, who had already had their measles vaccinations, got other immunizations.

Nguyen, who is a UTMB postdoctoral fellow in public health and infectious disease, said he asked clinic staff whether his family’s insurance would cover the checkups and immunizations. He said he was assured that it would.

Then the bills came.

The Medical Procedure

The first measles vaccine was licensed in 1963 and became part of the combination measles, mumps, and rubella, or MMR, vaccine in 1971. Today the vaccine against chickenpox, or varicella, is sometimes combined into what is known as the MMRV vaccine.

A first dose of the measles vaccine is usually given between 12 and 15 months, with a second between ages 4 and 6. Experts may recommend vaccinating children at younger ages during an outbreak — like the ongoing U.S. measles outbreak, which has led to more than 1,200 cases, 750 of them in Texas. According to the Centers for Disease Control and Prevention, 95% of the cases have occurred in unvaccinated people or those whose vaccine status is unknown.

Recommendations affecting administration and insurance coverage are made by the Advisory Committee on Immunization Practices. In mid-June, Health and Human Services Secretary Robert F. Kennedy Jr. replaced the committee, adding vaccine skeptics. The new panel, which met last week, is expected to scrutinize past recommendations, including for the MMR vaccine.

The Final Bill

UTMB billed $2,532 for the boy’s office visit and three shots. The MMRV shot alone was billed at $1,422, plus $161 for administering it.

The Billing Problem: Coverage Gaps and Provider ‘Errors’

There are guardrails in the U.S. health system intended to prevent recommended vaccines from being prohibitively expensive. They did not help the Nguyen family.

Their health plan, purchased from insurance broker TaiAn for Nguyen’s wife and children and administered by the International Medical Group, does not cover immunizations. And, initially, the family was not offered assistance under the Vaccines for Children Program, a federally funded effort, created after a measles outbreak more than 30 years ago, that provides free immunizations for uninsured and underinsured children.

So the family was exposed to the sticker shock of U.S. medical care without insurance, with providers setting prices. In this case, UTMB’s price for the child’s MMRV shot was about $1,400, more than five times what the CDC says it costs in the private sector.

Nguyen was surprised when their insurer did not pay anything, leaving bills for his three children’s checkups that, combined, were close to $5,000.

He said the family’s income, from his job in UTMB’s labs, is less than $57,000 a year. Nguyen’s job provides him health insurance, but he balked at the $615 a month it would cost to cover his family, too, and instead purchased the one-year policy from TaiAn, which totaled $1,841. The policy covers certain types of office visits, emergency room care, hospitalization, and chemotherapy, but not immunizations or checkups.

Nguyen and his wife, who are from Vietnam, are living in the country on temporary visas while he completes his studies. In Vietnam, Nguyen said, the total cost of the preventive care his family received at the clinic would probably be no more than $300.

He was concerned about the high prices set by the clinic for the vaccines, particularly during a measles outbreak.

“It’s insane,” he said.

Carly Kessler, a spokesperson for International Medical Group, confirmed in an email to KFF Health News that the family’s plan does not cover preventive care, including immunizations.

After UTMB was contacted by KFF Health News, its vice president of clinical contracting strategies, Kent Pickering, looked into the matter. “This situation should not have happened” but did so because of “a series of errors,” he said in an interview.

Most insurance offered in the U.S. must cover, without copays, a variety of preventive care services — including the measles vaccine — under rules in the Affordable Care Act. But some plans are exempt from those rules, including short-term plans or travel insurance. International students on temporary visas do not have to buy an ACA-compliant plan during their first five years in the country.

But what about the cost of the vaccines?

Hospitals and other providers may set their own prices for services, creating price lists called chargemasters. Insurers negotiate discounts for services they agree to cover. People with no insurance coverage are generally on the hook for the full amount.

“One of the most frustrating parts of our health care system is that people who don’t have health insurance coverage have to pay far more than even a health insurance company would pay,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.

While prices can vary, the CDC’s Vaccines for Children Program price list shows the MMRV vaccine — also known by the brand name ProQuad — costs about $278 in the private sector. Consumer prices for ProQuad at Galveston-area pharmacies range from about $285 to $326, according to the prescription cost-tracking website GoodRx.

UTMB’s Pickering told KFF Health News that, initially, the Nguyen family’s insurance was entered incorrectly by the clinic staff, so they did not pick up that his plan didn’t cover vaccines. If they had, UTMB likely would have checked whether the Texas Vaccines for Children Program would cover the cost of the shots, charging only the program’s small administration fee.

A second error was uncovered when Pickering looked into the bill. He said UTMB’s chargemaster had been updated a few months earlier and the vaccine prices for those who do not receive shots through the children’s vaccine program were listed at incorrectly high amounts, resulting in the price Nguyen’s son was charged.

Pickering said the prices had been corrected, though he declined to cite exact figures.

The Resolution

In addition to contacting the insurer, Nguyen reached out to the financial offices at UTMB, asking for a reduction or waiver of the fees.

In mid-May, UTMB sent Nguyen a revised bill for his son’s office visit. It applied a 50% self-pay discount, which its website says is offered to those who are uninsured. His revised total was $1,266, $711 of which was for the MMRV vaccination.

“I expected them to waive the vaccination cost for my children or at least reduce it more, especially for MMRV vaccine,” said Nguyen, noting that his family would still be strapped trying to pay their bills.

After Pickering spoke with KFF Health News, a customer service representative reached out to Nguyen, waiving the cost of the vaccines. His new bill was $202.75 for his son’s office visit, as well as similarly smaller amounts for his daughters’ medical care.

The Takeaway

More Bill of the Month

• A Medicaid Patient Had a Heart Attack While Traveling. He Owed Almost $78,000. May 29, 2025
• The Patient Expected a Free Checkup. The Bill Was $1,430. Apr 30, 2025
• He Had Short-Term Health Insurance. His Colonoscopy Bill: $7,000. Mar 28, 2025

Medical billing experts say it’s always a good idea to check with your insurer before elective treatments like checkups or vaccinations to find out what is covered and how much you might owe.

International students and others who purchase non-ACA-compliant plans, such as short-term coverage, should carefully review their benefits, because there are often limitations.

For some services, including vaccinations, there may be lower-cost options.

Constance Almendarez, the immunization manager for the Galveston County Health District, said in an email that many public health departments, including Galveston’s, offer free vaccinations through the children’s vaccine program to those 18 and under who are eligible, including people without insurance or whose insurance does not cover vaccines.

But those programs are potentially threatened as the Trump administration institutes layoffs of federal workers and moves to cancel grants to health departments.

Finally, you can ask for a discount. Medical providers may offer self-pay discounts for patients who are uninsured or underinsured, or charity care policies to those who meet specified income requirements.

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

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This story can be republished for free (details).