Open enrollment for health plans under the Affordable Care Act began Nov. 1, yet it remains unclear how much the estimated 24 million Americans who purchase from the ACA marketplaces will be expected to pay in premiums starting in January. Unless Congress acts to extend tax credits added to the program in 2021, most consumers will be expected to contribute much more out-of-pocket; in some cases, double or triple what they are paying in 2025. 

The politics of this year’s ACA fight are also complicated. Democrats are using the only leverage they have — a government shutdown — to try to force Republicans to negotiate over the expiring ACA tax credits. Yet many, if not most, of the people who will face much higher premiums in 2026 are from GOP-dominated states such as Texas and Florida, and belong to professions that tend to be more Republican than Democratic, such as farmers and ranchers, or small-business owners. 

In this special episode of “What the Health?” from KFF Health News and WAMU, host Julie Rovner talks to Cynthia Cox, a vice president at KFF and the director of its Program on the ACA. Cox explains what the nation’s health system looked like before the passage of the health law, how it has contributed to lower health spending and better insurance coverage, and the peculiar politics of the current fight.

Guest

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. 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. 

Usually, I’m joined by some of the best and smartest health reporters in Washington, but today we have a special episode. We’re taping this week on Monday, Nov. 3, at 10 a.m. As always, and especially this week, news happens fast, and things might’ve changed by the time you hear this. So here we go. 

Today, we’re going to explore the state of the Affordable Care Act with one of my favorite experts, KFF’s Cynthia Cox, who’s a vice president and director of the program on the ACA. Open enrollment for 2026 health plans began on Saturday, Nov. 1, and there is so much confusion. I thought it would be helpful to see where we’ve been and, possibly, where we’re going. 

Cynthia, thank you so much for joining us. 

Cynthia Cox: Yeah, thanks for having me, Julie. 

Rovner: I want to start by reminding everyone how the Affordable Care Act changed the health care system, what problems the law tried to solve, what problems were left for another day. I feel like people have either forgotten or never knew what things were like pre-the ACA. 

Cox: It has been quite awhile, so let’s, I guess, rewind 15 years or so. 

There were a couple of big problems that the ACA was trying to address in the U.S. health care system. One was that there were a lot of people who were uninsured. And that was partly because of cost reasons and partly because of the second big problem that the ACA was trying to solve, which was that people who have preexisting conditions were often denied access to health insurance. 

And to explain that a bit more, what that looked like, was if you had a serious illness like cancer or diabetes or some other illness that might require expensive treatments, and if you had any gap in your coverage — say, you left your job and then needed to find some other health insurance after a period of time — then the insurer would often just deny your application and say they wouldn’t insure you. And if you had a less severe condition, maybe even something like acne where you needed Accutane treatment or something, then they would still give you insurance, but they could charge you more. They would charge a surcharge for covering that preexisting condition. 

And then still another issue with preexisting conditions was that insurers didn’t have to cover your treatment for a condition, too. So, you might get a health insurance coverage for certain treatments but, say, it might exclude mental health treatment or even pregnancy care or prescription drugs or other things that didn’t need to … There was no minimum standard for what needed to be included in these health insurance plans that were sold to individuals. 

Usually, insurance that was sold to larger businesses or that larger companies offered was pretty comprehensive. The ACA did make some changes to those plans, too, like setting out-of-pocket limits and prohibiting lifetime caps. But most of the changes were in what was called the individual market, where people would buy their own health insurance on their own, usually when they were between jobs, or between school, or maybe a stay-at-home parent, or that sort of thing. 

Rovner: Or even a self-employed individual, which was …  

Cox: Yes. Exactly. 

Rovner: … growing in the early parts of this century. 

Cox: Yeah. 

Rovner: I think people don’t remember how much of a wild West the individual market really was at that point. The Congress had regulated the employer market in 1996 with HIPAA [Health Insurance Portability and Accountability Act], which was about a lot more than confidentiality. But that’s for another day. But the individual market was so crazy that you could get insurance — it wasn’t really insurance — or you could get charged more just for being a woman, right? 

Cox: Exactly. You could even be charged based on what your job was. People who had risky professions might’ve been excluded from health insurance, too. There were very few rules or standards in this market, it was … 

One insurer might have insured you, and another insurer wouldn’t have. And there was no way to really know what was going to be available to you without having to maybe apply to multiple companies and go through a lengthy underwriting process, too. 

Rovner: How did the ACA change that? 

Cox: The ACA created a lot of standards, and the way that it did that was to say: Here are the only ways that you can vary premiums. Rather than having rules about every single little thing that could have been covered, the ACA was basically like, OK, here are the only ways that insurers can change things. 

The only ways that insurers can change premiums are based on how old you are, where you live, and if you smoke cigarettes or used tobacco, and then also, just how many people are signing up for the coverage. So basically, if your whole family is signing up, then obviously that’s going to be more than if just you is signing up. 

And then it basically prohibits all those other things, like you can’t rescind coverage based on preexisting conditions or exclude coverage based on preexisting conditions, or … It basically is saying: If you have a preexisting health condition, that is not a reason for an insurance company to charge you more or deny you coverage or carve out certain benefits. So now the health insurance that is sold to individuals — which now we’ve started calling these the ACA marketplaces or Obamacare markets or that sort of thing — so that coverage that’s sold there looks a lot more like the coverage that had been available to people with large employer coverage before the ACA. 

Basically, it was trying to bring the standards for individual insurance coverage up to what already had been the standards for employer coverage. And, in doing so, it made health insurance more expensive in the individual market because when health insurers have to pay out claims for people who are sick, then that brings up their average costs, which they have to spread out, meaning higher average premiums that they’re charging. 

Those premiums today are no more expensive than the premiums that employer plans have. They cover similar benefits. It costs about the same, but when you get coverage through work, your work is paying for a large part of that premium. And when you pay your premium, it’s usually with some sort of tax benefit, too. So I think a lot of us who have employer coverage just don’t realize how expensive employer coverage is. And the ACA … 

Rovner: We also don’t realize how much we’re getting subsidized by the government because that’s … 

Cox: That, too. Yes. 

Rovner: … one of the big fights. It’s like: Why are we giving these people subsidies? It’s like: You’re getting a subsidy, too, if you have employer coverage. 

Cox: Yeah, exactly. Yeah, it’s a tax benefit. 

And so basically, in the individual market or Obamacare markets, the premiums — the raw total gross, whatever word you want to say, how much the insurance company is charging — is about the same as in the employer market, and it covers about the same services. It’s very similar coverage, and that’s why it’s expensive. But that’s also why there are tax credits that are available to help individuals afford coverage. Because if you’re low-income, there’s no way you’re going to be able to afford full-price health insurance. 

Rovner: And the tax credits have been a big boon to this market, right? Including … 

Cox: That’s right. 

Rovner: … the expanded tax credits from 2021. 

Cox: Yeah. The ACA included premium tax credits to begin with. But the enhanced tax credits — which is what Congress is debating right now — those were passed in 2021, and those basically just boosted the amount of financial assistance that people were getting. 

When the ACA was first passed in 2010, there was a lot of talk about, well, how do we make health insurance affordable, but also how do we define what affordable is? There was not really a standard against which to say, OK, this is what a low-income person can afford to pay. This is what a higher-income person can afford to pay. 

And so there was a table basically in the law that said, at the time, that a low-income person would pay 2% of their income for a premium, and a higher-income person would get no financial help, but a middle-income person would pay 10% or so of their income. And it turned out that that definitely helped people afford coverage.  

But a couple of issues that existed in the early ACA were that those higher-income or even middle-income people were priced out of health insurance if they didn’t get a tax credit. And those were often small-business owners, or entrepreneurs, or self-employed people who were a pretty vocal group about how they were being harmed by higher premiums and not getting any financial help to pay for their costs. This was a group that got a lot of media attention and was really part of why we were even talking about repealing or replacing the ACA. It was that group of people who did not get any financial help but had higher premiums that were really, arguably, harmed by the ACA, especially if they had been healthy and had been able to get insurance before the ACA. That was one issue. 

And then the other issue was just that take-up was not as high as what expectations had been, and I think a lot of that was even for lower-income or people who were getting a tax credit, maybe they just weren’t getting enough financial assistance to make that coverage affordable or attractive. 

Rovner: And we should talk about the mandate, because that was the big fight over the ACA … the idea was if you were going to let all these sick people into the individual market, we needed to get more healthy people into the individual market. And maybe the tax credits wouldn’t be enough, so we’re going to require people to either pay a tax penalty or buy insurance. And that was so controversial that it got repealed. 

Cox: Yeah. The idea here was, well, if you’re going to allow people with preexisting health conditions to come in and buy health insurance, what’s to stop them from waiting until they get sick to get that coverage? And if they do that, then there was this word that suddenly everyone became a health economist back in 2010 and heard about adverse selection or death spirals. 

And so the concern was that if you wait until you’re sick to get health insurance — if everyone waits until they’re sick to get health insurance and only sicker people are buying health insurance — then basically that makes premiums astronomically high. No insurance company is going to want to even participate in a market like that because it could lead to what’s called a death spiral — meaning the premiums just get higher and higher and higher and higher until no one can afford to purchase that coverage. 

And so the individual mandate, sorry, was one way in which people were basically compelled to purchase insurance and not wait until they were sick. Basically, there were carrots and sticks in the ACA. The sticks were the individual mandate and also this short open enrollment window. So if you didn’t sign up during open enrollment and you found out you had some serious illness after open enrollment ended, you would have to wait until the next open enrollment to sign up. And then the carrot was the tax credit, basically making coverage affordable. 

So when the individual mandate penalty was reduced to $0 — effectively getting rid of the individual mandate — there was a lot of concern that that was going to lead to a death spiral or adverse selection at least. It didn’t really play out that way, I think, because what really mattered was the carrots. The open enrollment window is still there as a stick, but I think people want health insurance. It just needs to be affordable enough for them to get it. And so the tax credits are really key there to making the coverage affordable and attractive for someone to buy it even if they are not sick. 

Rovner: And the enhanced credit just made the carrot that much bigger, right? 

Cox: Yeah. It basically supersized the carrot. 

That’s when you see when these enhanced tax credits rolled out, people started buying this coverage a lot more. The markets doubled in size. It went from about 11 million people signed up to over 24 million people signed up just within a few years of these enhanced tax credits being available. 

Rovner: So there were also some things in the ACA that were supposed to help dampen, if you will, the acceleration of health care spending. The consensus is those didn’t work quite as well, but they were there, right? It’s not that [the] law just ignored the cost of health care. 

Cox: Yeah. The law did not ignore the cost of health care. But I will say, I think the primary emphasis was on making health insurance affordable for individuals rather than making it affordable for our society. There were some measures put in place to slow the growth of health care. And actually, another thing that President [Donald] Trump did in his first term was use authority from the ACA to implement price transparency rules for hospitals to try to get at hospital prices. And there were, of course, other efforts, too, but I would say nothing that really made a huge impact on total health care spending as a nation. 

We have seen health care spending has slowed. It’s not growing as quickly as it was before the ACA in general. I don’t know if you can attribute all of that to the ACA, though, but we still are, as a nation, spending about 20% of our GDP [gross domestic product] on health care. Whereas other countries that are large and wealthy, like the United States, spend closer to 10, 11, 12% of their GDP, and that’s regardless of whether they’re a single-payer nation or not. Even countries that have multiple payers will still spend significantly less on health care than the United States does. 

Rovner: But the Republican talking point that this is all, that health care spending has gotten out of control because of the ACA isn’t true. 

Cox: Yeah, no. In fact, I think health care spending growth has slowed since the ACA. 

When you look at the individual market, which is where so much of the emphasis has been in changing how preexisting conditions are covered and that sort of thing, yes, premiums are higher today in the individual market than they were in the pre-ACA individual market. But individual market premiums today are really similar to employer premiums today, where the ACA, really, barely touched those plans. 

I think the issue is that health insurance is just really expensive in this country, and it’s really expensive because we spend a lot on … we pay high prices for doctor’s visits, hospital stays, prescription drugs. And the ACA did do some things to try to address those underlying reasons why health care is so expensive in the U.S., but it wasn’t really the main focus. I think the main focus of the ACA was to subsidize coverage and make it affordable for individuals. But that still means that it’s expensive for society. 

Rovner: So who are the individuals in the ACA individual market, if you will? There’s — what? — 24 million of them? 

Cox: Yeah. There’s 24 million of them, and about half of them are either small-business employees, or owners, or self-employed people, and that’s because a lot of us get coverage through work. 

But we work at bigger companies where that company offers a benefit as part of your total compensation package. You get your salary, and you also get your health insurance. Smaller companies often do not offer health insurance. They’re not required to, especially very tiny companies like mom-and-pop shops or that sort of thing. Also, even people who are not affiliated with a small business are still usually working or in a working household. They might just be working part-time, or they might be a stay-at-home parent where their spouse works, and they just don’t get health insurance for themselves. 

And so generally speaking — because you have to have an income of at least the poverty level to be getting a subsidy in this market — these are working individuals or working families. Also, a lot of farmers and ranchers rely on the ACA marketplace because, again, that’s a field where they don’t necessarily get health insurance through work. So that’s a big part of it. 

The other thing that’s pretty common is pre-retirees or early retirees. So basically, people who are not quite old enough to be on Medicare — since you have to be 65 to get on Medicare — you see a lot of 64-year-olds buying ACA marketplace coverage. 

Rovner: I think the thing that confuses most people, at least the most people that I talk to, is that we keep hearing that ACA premiums are going up an average of 17% next year, or 30%, or more than 100%. And all of those numbers are actually correct because they’re referring to different things. So what’s the difference between premiums the insurers charge and the premiums consumers have to pay? 

Cox: Yeah, there are too many percentages out there for a normal person to keep track of, so I will do my best to explain it. 

Basically, there’s two ways to think about premiums in the individual market. There’s how much the insurance company is charging for their premiums. That’s the revenue that the insurance company is bringing in. But a lot of that is not paid by individuals. The federal government is paying a large share of that in the form of a tax credit. 

So then the other way that people think about premiums in this market is how much individuals are paying out of their own pockets for their premiums. And if you’re just a regular person shopping on healthcare.gov, that’s what you see as your premium payment is how much you have to contribute as an individual. 

The amount that the insurance companies are charging, we have a couple of different numbers on that. We have what they requested to state regulators was an 18% increase on average. Four percentage points of that, they were saying, was this extra premium increase that they weren’t otherwise going to charge. But they were saying, we think that when these enhanced tax credits expire, that healthier people are going to drop their coverage, meaning we’re going to be left with a sicker group of enrollees, so we’re going to have to charge even higher premiums than we otherwise would have. Either way, even if the enhanced premium tax credits had been extended, insurers in this market still would’ve been raising premiums by double digits. 

That’s the steepest increase that we’ve seen in many years in this market. But we’re also, I think, looking at double-digit premium increases for employer plans, too. It’s just an expensive year coming up. That’s how much … 

And then we have newer data that just looks at silver plans. This is super wonky. But basically, a certain plan that is the benchmark against which subsidies are calculated. The insurers are actually charging 26% more on average for that plan. So I think that these requested rates might’ve understated how much insurers are actually charging. And so these are really significant premium increases. But … 

Rovner: I would say a really important piece of this is that if the tax credits weren’t changing, people wouldn’t be paying these increases. Right? They would be absorbed … 

Cox: Exactly. 

Rovner: … by the tax credit. 

Cox: Yeah. Nine out of 10 people in this market get a tax credit right now. And if the tax credits were extended, people would pay the same next year that they do this year. Their out-of-pocket premium payment would be held relatively flat. They would not be paying these increases that insurance companies are charging. 

Looking into next year, there are people who will lose the tax credit altogether if the enhanced tax credits expire. These are the middle-income, small-business owners who we were talking about before. They will lose the tax credit. So they will get less financial help or no financial help, and then they will also have to pay this double-digit premium increase that insurers are charging. So that’s this double-whammy effect for that group of people. 

But even the people who continue to get a tax credit, they’ll just get a smaller tax credit next year. They’re still also going to see their premium payments go up, not because of what the insurance company is charging, but because of Congress not extending the enhanced premium tax credits. So that means that they have to pay a larger share of their income. So a low-income person, instead of paying nothing each month, will have to start paying 2% to 4% of their income. A middle-income person, instead of paying maybe 6% to 8% of their income, might pay 8% to 10% of their income. 

Again, for most people, this is not a function of what the insurance company is charging. It’s actually a function of what Congress sets the law to be and how much of a tax credit they get. 

Rovner: If the tax credits do expire, as currently scheduled, is there any way for people to offset that increase, like buying a less generous bronze plan instead of a silver plan? And what would that mean for their out-of-pocket spending on health care? It’s a trade-off, right? 

Cox: Yeah. Our analysis shows that if people stay in the same plan, they would see a premium increase of 114% on average. But for many people, it could be an option to switch to a lower level of coverage. So maybe instead of buying a silver plan, they buy a bronze plan. 

But the issue there is, a lot of the people who are buying ACA marketplace coverage right now are so low-income that they’re getting really generous financial help for their deductibles, too. It’s not just their premiums. So instead of a silver premium having a deductible of a few thousand dollars for that person, their deductible might be less than a hundred dollars now. And so if they were to switch from a silver plan to a bronze plan, they might still be able to keep a zero premium payment, or near-zero premium payment, but their deductible would be $7,000 more than it is today. Either way, they’re going to see their costs go up. It’s just, do they see them go up when they go to the doctor, or have an emergency, or have a hospitalization, or fill a prescription drug? Or do they see their monthly costs go up for each month that they’re paying their premium? 

If you’re young and healthy, it might make sense to take the risk and get the bronze plan. But if you’re pretty sure you’re going to use some health care next year, then it makes sense to just pay the higher premium so that you can keep that low deductible. 

Rovner: Yeah. One of the main Republican talking points is all these people who have insurance but don’t file claims every year, which they say is evidence of widespread fraud. But isn’t it also possible that some of those people don’t use their insurance because they literally can’t afford these four- and five-figure deductibles? 

Cox: Yeah. It’s also … There’s a lot of reasons why someone might not use their health insurance. We certainly know whether you’re getting your coverage through work or through the ACA marketplaces. If you have a high deductible, then that can be a significant cost barrier. Also, lower-income people face other non-cost-related access barriers, like getting time off of work, or just the ability to find an appointment. 

But also the market has gotten younger. And with enhanced premium tax credits attracting more people to buy coverage, this was part of the whole idea was that you get younger, healthier people to sign up for coverage and not wait until they’re sick. And so that also can make it look like there’s less utilization of care. But if you’re just young and healthy, then you might not be going to the doctor either way. 

And also just … 

Rovner: It’s the opposite of the death spiral, right? 

Cox: Right. A health spiral is what some people have called it. 

But I think there’s also just some issues with the data source that was used to do that. I won’t go into all those details, but I think … there’s something there. There is fraud. There’s no question that there’s fraud in this market. And it’s being committed mostly by agents and brokers who are signing people up either without their knowledge, or switching their plan, or switching the name of the broker so they can get the commission. But I think the scale of the fraud has been exaggerated. 

Rovner: Something else I think has gotten pretty lost in the fight over extending these additional tax credits is that it’s not the only change coming to the Affordable Care Act for 2026. Republicans made some major alterations to the law in their big budget bill that they passed last summer. Let’s start with the changes to how much people might have to repay if they estimate their income incorrectly. What’s that change? 

Cox: I think this is probably one of the biggest changes aside from the expiration of the enhanced premium tax credit, and it hasn’t gotten a lot of attention. So I’m worried that people who are buying their own coverage might not know about this. 

Congress has basically repealed any limits on how much you would have to repay when you file your taxes the following year after you enroll in ACA marketplace coverage. The idea is that when you sign up for ACA coverage, you have to project what you think your income will be by the end of the next calendar year. That can be really hard for someone who, say, gets their income from driving Uber or working shifts at a restaurant, or so on and so forth. Or even a small-business owner might have a hard time projecting exactly how much their income will be next year. And so, if you guess wrong — in other words, if you say, now I think I’m going to make $50,000 next year, but you end up making $60,000 next year — then you might have to repay a significant amount of the tax credit.  

The other simultaneous thing is that with the enhanced premium tax credits going away next year — if that actually does come to be — then this subsidy cliff will come back, meaning that if you make just a dollar too much, meaning just over 400% of the poverty level, then you’ll have to repay the entire tax credit, which could be thousands, if not tens of thousands, of dollars. And so people who are right around that cutoff will need to be really careful about if they have control over their income. For some people, it might make sense to make sure that your income is below four times the poverty level. Or you can also adjust your tax credit midyear or decide to wait and get the tax credit at the time you file your taxes instead of getting it up front. 

Rovner: Yeah, I think this is a big deal. And also there’s going to be less help available for people to actually sign up for coverage, even though there’s all these big changes happening. 

Cox: Yeah. When the ACA was first passed, there was this idea that it was going to be like going online and booking your own hotel, or airplane, or whatever, and that’s just not how it has panned out. Most people need help signing up for health insurance. It still is a complicated process. And so they turned to agents, brokers, and what are called navigators, who are nonprofit organizations that have helped people buy insurance. But the Trump administration has cut funding for the navigator program really significantly, and so there’s going to be fewer of those folks to help. 

Also, I think this is just going to be probably one of the busiest and most chaotic ACA open enrollment periods ever, probably, and so many … 

Rovner: 2013 wasn’t great but … 

Cox: Yeah. But there weren’t so many buying it back then. 

Rovner: … where the website didn’t work. 

Cox: Yeah, yeah. 

I remember that well, but also, there were not that many people shopping. Now, there’s three times as many people shopping for coverage. 

Rovner: True. 

Cox: I don’t know if there are more agents or brokers than there were back then, but I suspect not. But there’s just going to be busy people. And so if you need to make an appointment with an agent or broker, then go ahead and do that as soon as you can. 

Rovner: Yeah. This is the trade-off here. On the one hand, people want to wait and see if Congress maybe comes to some deal on these expanded subsidies. On the other hand, it’s going to be really hard to sign up at the last minute. 

Cox: Yeah, yeah. So if it were me — and I obviously would feel more comfortable signing up on my own without the help of someone — but I would personally prefer to wait and see what happens. I wouldn’t wait too long, but I might wait till Thanksgiving or early December and wait to make a decision about my plan until then. But you can’t advise everyone to do that because if you need an agent or broker to help you, maybe get that appointment as soon as you can. But maybe also just keep an eye out on things and decide before Dec. 15 if you want to change your plan. 

Rovner: So it’s not just the expanded tax credits. There’s also [a] new restriction on who’s eligible. There are a lot of people who are immigrants — who were here legally — who have been eligible for tax credits who no longer will be, right? 

Cox: Yeah. There has been a lot of talk about undocumented immigrants getting this coverage. And just to be clear, the ACA marketplaces are not where undocumented people come to get health insurance. You can’t even buy this coverage without a subsidy if you’re undocumented. 

Now, there had been an exception for DACA [Deferred Action for Childhood Arrivals] recipients. That is no longer going to be an option for folks. And then also even some folks who are here legally but just have not been in the country for long enough to qualify for Medicaid. So you have to be in the country for five years before you can qualify for Medicaid. And it had been that if you were, say, here for two years and still waiting to get Medicaid eligibility, you could get subsidized coverage on the ACA marketplace. And so some of those folks will no longer be able to this year, and then all of those folks will no longer be able to in the coming year. 

Rovner: I know the Trump administration tried to make even more changes in its annual regulation governing the marketplace, although some of those have been blocked by the courts. What are some of those changes that aren’t happening this year but that people may have heard about and that may, depending on what the courts do, come into play next year? 

Cox: I think one of the most important ones was this idea that they were going to change how auto re-enrollment works. So a lot of people in the ACA marketplaces get a zero premium plan. And like all other health insurances out there, whether it’s your homeowner’s insurance or your car insurance, you just get automatically re-enrolled from one year to the next. And that’s true for these ACA marketplaces, too. 

So the Trump administration had a rule that said: Well, if you were going to be auto-re-enrolled into a zero-premium plan, we want to make sure that you still want that plan. Because if you’re not paying anything each month, you might be just getting automatically re-enrolled without your knowledge. And so the idea was that you would get charged $5 a month until you actively re-enroll. That was one of a few things that was … 

There was a stay in a court decision basically saying: We need to hear more about this before the court could make a final decision. But long story short, that’s not going into effect this year. But there will be other changes to auto re-enrollment in the coming years, basically due to the summer reconciliation package where auto re-enrollment would effectively end. And so that’s an even bigger deal, but that’s not going into effect yet. That will be in the coming year. 

Rovner: Yes. So more people will have to actually go in and do something with their policy, but there are fewer people to help them. Do I have that right? 

Cox: That’s right. Yeah. So there’s going to be a lot of activity this year. This year and in coming years. Yeah. 

Rovner: So what’s the bottom line here for people who now have Affordable Care Act coverage or who plan or hope to have it for next year? 

Cox: I think, first of all, watch this closely and don’t make any decision about dropping your coverage or even dropping down to a lower level of coverage until probably early December is probably the right time to really make a final decision on this. You can still start making all of your plans and getting all your paperwork together and talk to an agent or broker, but just keep watching this until there’s some sort of clear resolution about what’s going to happen in Congress. Because if the enhanced premium tax credits do get extended, you’re probably better off keeping the same level of coverage that you have now. Or for newer people, they’re probably better off in a silver plan than a bronze plan in many cases. So you don’t want to make a significant change to your coverage just yet until you know what’s going to happen next year. 

But it’s a difficult situation for people to be in. They have to, at a certain point, just make a judgment call. And I think that can lead to people picking a plan that’s not necessarily the best one for them, or even going without insurance because they just don’t feel like they can afford it anymore. 

Rovner: This is a conundrum. It’s obviously a conundrum for the Democrats because they’re keeping the government closed — which they normally don’t want to do — demanding that these tax credits be extended. Ironically, a lot of the people who will be helped if the tax credits do get extended are Republicans in Republican states. They’re small-business people. There are people in a lot of these very red states where we saw enrollment skyrocket. Why don’t the Republicans want to do that? It’s their voters who would be helped. 

Cox: Yeah. That’s right. 

I think from the Republican perspective, this would be new government spending, because if Congress does nothing, these enhanced premium tax credits expire. So from the Republicans’ perspective, it would cost $35 billion a year in new government spending to extend these enhanced premium tax credits. That’s a lot of money, and that’s coming at a time when Republicans have already shown willingness earlier in the year to make significant cuts to existing health programs like Medicaid work requirements. 

I think it is a complicated issue for Republicans and that I think many of them would just rather these enhanced premium tax credits expire. But I think you’re seeing some Republicans, especially in parts of the country where premium increases would be very steep, or where maybe they’re in a swing district where they’re looking at this and saying, oh, actually most of the growth in the ACA marketplaces has been in Southern red states. Most of the people benefiting from these enhanced tax credits live in a state that was won by President Trump or in a congressional district that was won by a Republican. So it’s a complicated issue for Republicans. 

Rovner: Well, we will keep track of what’s happening. Cynthia Cox, thank you so much. 

Cox: Thank you. 

Rovner: Thanks this week to our fill-in editor, Stephanie Stapleton, and our fill-in producer-engineer, Taylor Cook. A reminder: “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, at kffhealthnews.org. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me on X @jrovner or on Bluesky @julierovner. Cynthia, are you hanging on social media these days? 

Cox: Yes. @cynthiaccox on both X and Bluesky. 

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

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He hasn’t forgotten the pile of hospital bills that awaited him after he had a seizure while tending to customers in his Austin, Texas, barbershop four years ago. Once doctors hurriedly removed the dangerous tumor growing on his brain, a weeklong hospital stay, months of therapy, and nearly $250,000 worth of medical expenses followed.

The coverage he has purchased for years through the Affordable Care Act marketplace covered most of those bills.

“That saved my ass,” said Cleveland, who owns three barbershops across the city.

Even with Cleveland’s monthly premiums expected to soar next year — from $560 to about $682 — he will still sign up for a plan that requires him to shell out $70 if he sees a doctor and 50% of the cost for any emergency room visits. Still, Cleveland is most worried about some of his employees, who might risk going without insurance once they see the high prices.

Small-business owners are among those who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the covid-19 pandemic lapse. The looming change threatens not only their own coverage but also that of their employees, who often depend on marketplace coverage.

Whether to extend the enhanced ACA subsidies that cost taxpayers billions of dollars yearly poses a serious political conundrum for Republicans. After years of unified opposition to Obamacare, the party now faces pressure from one of its most loyal constituencies, small-business owners, who will bear the brunt of rising premiums if the subsidies disappear.

Most of the roughly 20 employees who work on Justin Miller’s 113-year-old family fruit farm in rural Northern California purchase coverage through the Obamacare marketplace.

He’s agonizing over what it could mean if health insurance through the marketplace becomes unaffordable for his employees. He fears they might consider leaving his farm for a job that comes with health coverage.

“Being a small-business owner, especially in a field like ours, where it is tough work and we really understand how hard everybody works, we have to look everybody in the eyes every day,” Miller said. “Knowing that they’re going to have to pay $4,000 or $5,000 more a year to stay on their insurance is a tough pill to swallow.”

Miller says he already pays a minimum wage of $22.50 and provides sick leave, vacation, retirement, and employee housing benefits.

Adding health insurance for his employees, he said, would be too costly to keep his farm in business.

GOP Pollsters Issue ACA Caution

About half of the 24 million people enrolled in Obamacare coverage are, or are employed by, small-business owners — a group that is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election. Farmers, dentists, real estate agents, and chiropractors are among the professions most represented among enrollees.

Even Trump’s own pollsters have found deep support for the Obamacare subsidies, warning that failing to extend them could cost Republicans in next year’s midterms.

A poll conducted last month by Republican pollster John McLaughlin found that a majority of independent voters would be less likely to vote for politicians who voted to let the enhanced tax credits expire.

Given that “approximately 4 million” people would lose coverage and premiums would “skyrocket by an average of 75%,” the poll also concluded that: “A candidate for congress who let the healthcare tax cuts expire would also be vulnerable to more pointed messages.”

Red States Benefited From the Subsidies

Some red states have seen Obamacare enrollment balloon since the federal government began offering extra help paying premiums in the form of more generous subsidies.

Texas and Florida have added 2.8 million enrollees each since 2020, far outpacing growth in most other states. Together, the two states now account for more than a third of marketplace enrollment nationally.

A small chorus of Republican lawmakers — up for reelection next year, mostly in competitive races — have proposed an extension of the subsidies, urging Democrats to vote to reopen the government while simultaneously pleading with House Speaker Mike Johnson to work out a bipartisan deal that doesn’t allow them to simply lapse.

At Cleveland’s barbershops in Austin, about a third of his 18 employees rely on Obamacare coverage. He’s talked to them about their health insurance options for next year but said many hadn’t started thinking about open enrollment, which began Nov. 1.

He’s worried they’ll be baffled once they see the new prices, which currently reflect what customers will pay next year without an extension of the extra subsidies.

“There’s a couple of my barbers that are going to go without, because they’re healthy and young, but I thought I was too when everything happened to me,” said Cleveland, now 47.

Republicans, meanwhile, remain wary of voting to extend the additional Obamacare subsidies, said Rodney Whitlock, a vice president at the McDermott+ consultancy who was a longtime congressional staffer and advises on health care policy.

No Republican voted for the extra subsidies when they were introduced in 2021 or continued in 2022. Approving them now, he said, is viewed by many as a band-aid that would temporarily help a program GOP leaders have long lambasted as problematic and too costly.

But, Whitlock noted, many in the party are coming to terms with how the subsidies might affect their changing constituencies. Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district.

“Republicans are slowly starting to grasp that the lower third of income earners are their voters,” he said. “For the first time, I think they’re getting there. That battleship turns slowly.”

Rep. Marjorie Taylor Greene, a Georgia Republican who has firmly backed Trump, broke with her party last month, calling on the GOP to extend the subsidies. Greene said in an interview that rising health care costs are the “No. 1 issue” she hears about from people living in her district.

“I know a lot of small-business owners, like a family of four, and they’re paying $2,000 a month,” Greene said during the television interview, adding that rising deductibles make the insurance hardly functional for anything other than catastrophes.

She warned in another TV interview that “ignoring” the issue could be “very bad for midterms” next year.

Miller, the farmer who lives in a conservative district in Northern California, expects monthly health insurance premiums for himself, his wife, and two of his children to jump from $264 to $600. His deductibles and copayments are going up, too. He expects all these new expenses will still be on his mind when he goes to vote in the midterm elections next year, he said. Describing himself as an independent, Miller said he is frustrated that few American politicians talk about the type of universal health care coverage that’s available in other countries.

“I’m definitely voting for those that will protect the working American, regardless of party,” he said.

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

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She has developed a strategy for addressing high insurance premiums — one that’s based on giving patients reliable information about how much they, and their insurer, would have to pay for care. The system is already working in Massachusetts. Could it be a model for the rest of the country?

Ho explains to Dan Weissmann, host of “An Arm and a Leg,” why she thinks this approach could help curb high prices and how listeners can help prove it by sharing their medical bills.

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Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

Vivian Ho is a health economist at Rice University and the Baylor College of Medicine in Houston. And since early 2024, she’s been giving talks at… HR conferences. Which is not a typical gig for an economist.

Vivian Ho: Um, yes. Economists don’t usually do that. We love to go talk at our own conferences.

Dan: But she’s been eager to spread a pretty big message.

Vivian Ho: There’s a potential to save workers, um, you know, and employees a lot of money.

Dan: And a few weeks ago, she sent me an email asking for help with what she’s trying to do: 

She’s wants folks to send her hospital bills for a study she thinks could be part of saving people a lot of moneys. She wondered if I’d encourage people to pitch in.

And honestly, I wanted to say yes before I even really knew anything specific about the study.

I should say: Vivian Ho has been a donor to this show. That’s actually how I met her and learned about her work. And became kind of a fan. 

Over the last few years, she’s been digging up and publishing evidence we need, to push back against the way health care keeps getting more and more expensive.

This is stuff a lot of us suspected, to say the least — stuff reporters have documented examples of — but she’s demonstrated they’re actual trends, not one-offs. 

For instance: When nonprofit hospitals make big profits — and they often do – they call them surpluses– they don’t generally use that money to help patients, by giving more charity care to reduce people’s bills. 

In one study, she compared hospital finances in the early 2010s and near the end of the decade. As the decade was ending, she found nonprofit hospitals were a LOT more profitable than they’d been before. 

And they’d gotten a lot richer, with like seventy percent more cash in the bank than they’d had earlier.  

But they were actually giving out less charity care.  

 She told me she ran that down after she got help understanding a big set of data that helped her see what hospitals actually do with their money– and started to poke around in it.

Vivian Ho: I say, well, I’m just gonna go have a look at, you know, one of the local hospitals and see what it says and then I pull it up and I go, oh wow.

Dan: She took a peek at one hospital’s “fund balance” — that’s non-profit speak for an institution’s savings, like for a rainy day. 

Vivian Ho: The fund balance for one of the hospitals across the street from Rice University is five and a half billion dollars. And so, you know, then it’s like, well, I need to take a closer look at this.

Dan: Here’s a couple things she found: That fund balance — the “rainy day fund” — was enough to run the hospital for more than two years. And it runs a healthy profit margin. 

And her study showed when she zoomed out: This is not a one-off. Among hospitals that do well, it’s the norm.

And this kind of data — this kind of EVIDENCE of how things work, of who benefits, and how much, from the totally unfair and unaffordable prices we’re all up against — it’s ammunition. 

Vivian Ho is looking for people to share their hospital bills with her, in order to build up her arsenal of information . 

She’s got a strategy in mind for how to deploy that information to save a lot of people a ton of money. It’s interesting.

And: I have no idea if this specific strategy will pay off.

But here’s what I do think: ?If we’re going to fight against the greed and exploitation that make our health care system so unhealthy — so deadly — we’re gonna need all the fighting power we can get.

So, I’ve sent Vivian Ho a hospital bill. And at the end of this episode I’ll encourage you to do the same. 

This is An Arm and a Leg — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you a show that’s entertaining, empowering and useful.

Dan: Vivian Ho has been a health economist for like 40 years. And you could say she has mixed feelings.

Vivian Ho: Health economists, they work on so many different things and they are all important and interesting. But I do think the issue of the cost of healthcare and the cost of health insurance premiums is the biggest problem putting a burden on the average American citizen. And I don’t think as a profession that we spend enough time on that basic issue. I feel kind of – well, it does make me quite sad because here I am, I’ve worked in this career for this entire time, and things aren’t getting better. They’re actually getting much worse.

Dan: And that, she says, is why she does things like go to HR conferences these days. She’s got the motivation and she’s got the freedom to do it. 

Vivian Ho: So I’m super lucky. I’ve got tenure at Rice and you know, I’m a member of National Academy of Medicine. I’ve sort of achieved everything that I wanted to achieve, and now it’s, it’s all about, well, what can we do?

Dan: She’s decided to go after what she now sees as the biggest problem. Not the ONLY problem, but the biggest driver in prices that only seem to go up more every year.

Hospital systems are consolidating — gobbling each other up. So they get more bargaining power with insurers. They get higher prices without necessarily delivering more value.

Which isn’t what economists always expect. Bigger can mean better, more efficient. That’s what Vivian Ho used to expect.

Vivian Ho: I started this whole research agenda sort of 10-15 years ago, and I thought bigger was going to be better. I thought because of economies of scale and that if you allowed hospitals to acquire physician practices, there would be less duplication of services, you’d save money. But then the problem is there’s no mechanism that forces a provider to pass any savings onto the consumer. So there may be economies of scale, it’s just you and I as consumers aren’t able to enjoy any of those benefits.

Dan: That’s something we’ve talked about on this show. Like a lot. But what Vivian Ho has been able to demonstrate is: At this point, the average profit margins for hospitals — including “non-profit” hospitals — are actually higher than average profit margins for insurance companies.

Vivian Ho: There’s plenty of rural hospitals and smaller hospitals that lose money, but net, when you average on just how much profits the consolidated systems are making and you add them up all over the country, it’s much higher than what you get for the total profits of insurers.

Dan: Which isn’t to say that insurance companies don’t have a BIG role to play in our suffering. 

Vivian Ho: Insurers are, in many ways, not doing what they should be for customers. Certainly the show demonstrates that in many ways and that they are earning high profits. I’ve just looked at the data and concluded that the hospitals are earning much higher profits than the insurers are, and that’s where we’ve gotta focus our attention. 

Dan: I mean, there’s so much to unpack there, right? One is, wow, the hospitals are earning higher profits than insurance companies, and the insurance companies, by and large, are publicly traded entities that answer to shareholders. And the majority of hospitals in the United States are, as far as the IRS is concerned not-for-profit entities.

Vivian Ho: Exactly. We’ve been doing research lately that unfortunately shows that our not-for-profit hospitals behave a lot like for-profit companies.

Dan: So, okay, how do we get at that? 

Vivian Ho: Oh, uh, how do we change the behavior of what’s going on? 

Dan: Yeah.

Vivian Ho: Yeah. So…

Dan: Here’s Vivian Ho’s game plan. It’s complicated, and I’m not in a position to say, “this’ll totally work” — but there’s a lot that’s worth knowing here.

Especially this:

When Vivian Ho talks to business executives or HR managers, she brings out another set of data. And this is data that’s only become available in the last few years. 

Insurers now have to show what they pay hospitals. Not the sticker price, the negotiated price.

So, Vivian Ho’s talk includes a slide showing some details from three Houston hospitals. Blue Cross pays one of them about 22 thousand dollars for spinal fusion surgery. Another one gets 66 thousand — three times as much.. 

And the slide shows: That math is similar for other procedures. 

Vivian Ho: Employers didn’t realize how different the prices could be at their local hospitals. They thought, you know, anyone would think, oh, the prices couldn’t be that different. And now that some of the data is starting to make it out there, it’s becoming clear you really could save a lot of money.

Dan: I mean, you MAYBE could — if you could give your workers a good reason to go to the hospital that charges less.

Vivian Ho has a model for how that could work. It’s — based in part on a story I call Once Upon a Time in Massachusetts. 

That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. They’re a nonprofit newsroom covering health issues in America. Their reporters do amazing work. They win all kinds of awards every year. We’re honored to work with them. 

So, here’s our story — Once Upon a Time in Massachusetts — straight from the story’s author.

Elena Prager: I am Elena Prager. I’m an assistant professor of economics at the Simon Business School at the University of Rochester.

Dan: And while doing her dissertation, she came across a very unusual set of data. 

Elena Prager: I was like, wow, goldmine.

Dan: Here’s the story: Massachusetts has an agency that basically runs employee health benefits for all state employees, and a lot of local-government workers too.

And once upon a time — starting in 2010– they tried something unusual. 

Elena Prager: Possibly because they were lucky, possibly because they were smart, they designed their health insurance plans – at least when it came to hospital care – based everything on copays. And what that means is that you are given a dollar number. Let’s say $250 or $500 and like that’s it. That’s the number. If you go to hospital A, you pay 250, you go to hospital B, you pay 500. The end.

Dan: Which is totally different from how we’re used to looking at hospitals, right? I mean, regular insurance plans typically say, “You’ll pay like 10 percent, or 20 percent or 30 percent of whatever the total bill turns out to be.” 

Elena Prager: And the patient is left scratching their head being like, well, how do I know what the total bill is gonna be? Even if the hospital tells me something. Like, what if something goes wrong with the anesthesia? They have to call in an extra specialist. There’s a complication. More stuff gets done. Like it’s very, very hard to, for a patient and even really a provider, to predict in advance what’s gonna be done to them and therefore what the price is going to be.

Dan: So there’s no way for me to take price into account if I need to go to the hospital.

But Once Upon a Time in Massachusetts, there was. It was a co-pay. Whatever insurance plan you were on, it worked the same way:

Go to hospital A — where prices are generally higher — your copay might be five hundred dollars.

Go to hospital B — that charges the insurance plan less for stuff — you’d pay two-fifty.

And Elena Prager found the data that showed what happened next.

Long story short, she found that over three years, patients started using lower-priced hospitals more often. Patients saved money, and so did the health plan. 

And actually, Massachusetts still runs its health plans this way, but– 

 Vivian Ho doesn’t think other employers can just get their insurance companies to adopt this same model. 

VIVIAN HO: It’s actually a fair amount of work.

DAN:  Work for the insurance company. Doing the math to figure out which tier is which, and what the copays would be.

Vivian Ho: and of course it gets the hospitals really upset.

Dan:  The folks in Massachusetts had a ton of leverage that most employers don’t have:  

Elena Prager says they represented a huge chunk of the insurance market like a twelfth of it. Enough business that it was worth insurance companies’ while to put in the work.

But now, Vivian Ho has her eye on a couple of new services that are promising to do something similar.

One is actually a subsidiary of everybody’s favorite insurance company: United Healthcare. They make an app called Surest.

Surest Ad: It’s easy to shop for a vacation rental or your next flight, but when it comes to something like healthcare, not so easy. That’s why Surest is a health plan, designed to be simple with clear upfront costs.

Dan: Here’s how Vivian Ho describes the mechanics of this kind of app.

Vivian Ho: Doctor tells you you need to go get an MRI, you punch an MRI, the app knows where you live, and it says, here’s a list of providers where you can go get an MRI. And then if you go to this particular place, there’s no copay and there’s actually no deductible, and then if you go to this MRI place, well, you know, there’s gonna be a $25 copay or a $50 copay. Yeah. Isn’t that kind of mind blowing?

Dan: I tell her: That sounds like I would want that if I trusted that the place that costs my employer less is, you know, gonna take good care of me.

Vivian Ho: Right. Well that’s why I’m trying to get funding to do an analysis to look at the spending and quality implications of using one of these apps.

Dan: That is: Do people using these apps end up choosing lower-cost providers? AND: Do they get good care when they do?

Vivian Ho wants to study that. But first she needs to study something else. 

Vivian Ho: All of these apps and price shopping applications, they all depend on having the correct data. Now, the insurers are required to disclose this information by federal rules. It is slowly coming out. It’s not all there yet, but no one’s actually looked to see whether it’s accurate.

Dan: Oh.

Vivian Ho: So there’s been a lot of focus on, is the price there or is it not there, but not is it the price that the patient is actually getting billed.

Dan: And this is why Vivian Ho wants our hospital bills. 

Because: Whether or not one particular strategy is gonna pan out, the data itself contains ammunition. One hospital gets paid twice as much as the ones across the street? 

I mean, that’s information I want out in the open, and getting put to use. 

But that information can  only be useful if we know the data is accurate. And right now, there’s no way to know. 

Insurers are publishing big data sets, but how  do we *know* somebody at the insurance company didn’t just go to Chat GPT and say, “Make me a giant spreadsheet with these fields on it?”

Vivian Ho says if she has enough ACTUAL bills — a thousand would be good, three thousand would be great — she can check. 

Actually, even better: She wants your itemized bill and, if she can get it, the paperwork you get from your insurance company about what they paid. The thing that says “This is not a bill.” It’s an “explanation of benefits” — or EOB for short.

And, she recognizes, this isn’t a TINY ask.

Vivian Ho: I realize it’s time consuming. It does, you know, because you gotta sit down. It’s like, what’s my password and log in, and then you’ve gotta, you know, find one of these EOBs.

Dan: Oh, and you’ve gotta cover up all your personally identifying information.

Vivian Ho: We don’t wanna see your your name and address and so, you know, it takes time to you, you can sort of print these out and use a Sharpie and cross them out.

Dan: It does sound like a huge drag, but I’m here to tell you: I did it. And it took me maybe five minutes.

I don’t know how Vivian Ho’s specific strategy will play out, and honestly, neither does she.

Vivian Ho: You know, I am going at this at sort of like many different angles.

Dan: Yeah.

Vivian Ho: So just trying to raise people’s awareness of there are huge price differences. This is, this is what it takes to address the issue. 

Dan: If you’ve gotten a hospital bill in the last year or so, and you’ve got five minutes — maybe set a note on your calendar for when you DO have five minutes? — I’d love it if you gave this a shot. 

Grab a sharpie, fire up your printer, dig up your login. Print out a bill and an EOB, scratch out your identifying information, take a picture on your phone — wow, this is sounding long, but honestly, it took me five minutes — so do those things, and send the images to pricecheck@rice.edu. 

Vivian Ho’s got researchers standing by.

Coming up on this show: We’re gonna take some time as the year ends, to look at some things that DIDN’T suck in 2025. 

Which basically means: Places where state governments stepped in to protect us from ripoff prices. Which, it turns out, happened! 

News archive 1: Oregonians burdened by medical bills may soon get a break on their credit scores.

News archive 2: New law aimed at protecting Maine consumers from the impacts of medical debt goes into effect.

News archive 3: Tonight Indiana governor Mike Braun signs 10 health care-related bills into law.

Dan: Happened enough that it’ll take more than just one episode to give you a good sample.

That’s next time on An Arm and a Leg.

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

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Aunque la temporada de inscripciones ya está en marcha, el futuro de los subsidios ampliados —que hacen más accesible el seguro para el 92% de las personas inscritas— sigue siendo incierto, con la posibilidad de que las primas aumenten significativamente.

Aun así, hay medidas que puedes tomar para asegurarte de elegir correctamente tu plan para el próximo año.

1. Entender cómo llegamos hasta aquí

En 2021, como parte de un paquete de ayuda por covid, se ampliaron los subsidios de ACA para reducir los costos de las personas que ya calificaban y extender la elegibilidad a quienes tenían ingresos superiores al 400% del nivel federal de pobreza (unos $63.000 para una sola persona en 2025).

Estas ampliaciones, que fueron renovadas en 2022, vencerán al finalizar 2025, a menos que el Congreso actúe.

El debate sobre si renovar los subsidios ha sido el centro de una lucha política entre republicanos y demócratas en el Congreso, conflicto que contribuyó al cierre del gobierno federal que ya lleva más de un mes.

Las implicaciones económicas para muchas personas inscritas en los mercados son enormes.

Según KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News, se proyecta que los pagos de bolsillo de las primas (lo que pagas cada mes por tu cobertura) para los inscritos subirán más del doble si expiran los subsidios ampliados.

“Cuanto más tiempo dure esto, mayor será el daño”, dijo Cynthia Cox, vicepresidenta y directora del Programa sobre ACA en KFF. “Si alguien entra al sitio web el 1 de noviembre y ve que su prima se duplicó, es posible que se vaya”.

Eso sería un error, según las personas expertas en los mercados. Lo que sí está claro es que quienes buscan seguro deben estar informados y tener precaución.

2. Seguir las noticias

Puede resultar frustrante seguir el día a día las peleas en el Capitolio, pero puede ser la mejor manera de mantenerse al tanto.

El Congreso podría llegar a un acuerdo para renovar los subsidios en cualquier momento durante los próximos meses, o no. En cualquier caso, eso puede afectar tu decisión de inscripción. Así que, mantente atento.

No cuentes con que el mercado o tu aseguradora te informen sobre lo que podrías llegar a pagar. “Muchos mercados estatales han retrasado” el envío de notificaciones a los consumidores con las primas netas (que ya tienen en cuenta los subsidios), dijo Sabrina Corlette, codirectora del Centro sobre Reformas del Seguro de Salud de la Universidad Georgetown.

El gobierno federal no envía notificaciones a las personas inscritas sobre las primas para el próximo año en los 28 mercados administrados a nivel federal. Para 2026, también ha indicado que los planes de salud pueden optar por no hacerlo.

3. Actualizar la información de tu cuenta

Ingresa a tu cuenta del mercado de seguros y actualiza tus ingresos, el tamaño de tu hogar y cualquier otro dato que haya cambiado.

Este año, es particularmente importante proporcionar una estimación precisa de tus ingresos pronosticados para 2026.

Una disposición en la ley HR 1, a veces llamada One Big Beautiful Bill Act, eliminó los límites sobre lo que muchas personas debían devolver si subestimaban sus ingresos y recibían más ayuda de la que les correspondía.

El próximo año, tendrán que reembolsar la totalidad del monto recibido de más.

Dada la incertidumbre sobre las primas, este probablemente no sea un buen año para permitir que el mercado te reinscriba automáticamente en tu plan actual o en uno similar, según especialistas.

Esto es especialmente importante para quienes, si no hay un nuevo acuerdo, ya no calificarán para subsidios el próximo año, específicamente quienes tengan ingresos superiores al 400% del nivel federal de pobreza.

4. Elegir el plan según el precio publicado

Si el Congreso no llega a un acuerdo para extender los subsidios ampliados, muchas personas se sorprenderán al ver el costo proyectado de sus primas.

Según KFF, se espera que las primas de los seguros de salud en los mercados aumenten, en promedio, un 26% el próximo año. Es el mayor incremento desde 2018.

Hasta ahora, las personas han estado protegidas en gran medida de estos aumentos gracias a los subsidios ampliados, que casi todas reciben. Así funciona: la mayoría de las personas con planes de ACA pagan una parte de su prima según una escala progresiva basada en sus ingresos, y el gobierno cubre el resto.

Según un análisis de KFF, si no se renuevan los subsidios ampliados, una familia de cuatro con ingresos de $75.000 tendrá que pagar $5.865 anuales por un plan de referencia de nivel plata en 2026: más del doble de los $2.498 que pagaría si se renuevan.

Al evaluar un plan, concéntrate en el precio publicado. Si no es accesible sin los subsidios ampliados, no es una buena opción.

“Las personas deben tomar decisiones basadas en lo que tienen delante”, señaló Cox.

Si no puedes pagar ese precio sin los subsidios ampliados, considera inscribirte en un plan menos generoso con una prima más baja pero un deducible más alto, dijo Cox. Los planes de nivel bronce deben ofrecer cobertura integral, incluyendo atención preventiva gratuita, y pueden cubrir algunas visitas médicas antes de que se alcance el deducible (lo que tú debes pagar antes de que la aseguradora se haga cargo del gasto).

“En la mayoría de los casos, tiene más sentido tener un plan bronce que no tener seguro”, explicó.

La administración Trump ha estado promoviendo los planes catastróficos como una opción más accesible para quienes enfrentan dificultades económicas, incluyendo a las personas que no califican para subsidios porque sus ingresos están por debajo del 100% o por encima del 400% del nivel federal de pobreza.

Al igual que los planes bronce, los planes catastróficos cubren un conjunto de beneficios esenciales, ofrecen atención preventiva gratuita y deben cubrir al menos tres visitas al médico antes de alcanzar el deducible. Pero estos planes tienen los deducibles más altos de todos los planes del mercado: $10.600 para individuos y $21.200 para familias en 2026.

“Son caros en relación con lo que cubren”, señaló Jennifer Sullivan, directora de acceso a la cobertura médica en el Centro de Prioridades Presupuestarias y Políticas (CBPP), quien advirtió que las primas pueden costar varios cientos de dólares.

5. Revisar más de una vez

Si te desanimas al ver los precios de las primas en tu primera visita, “no apagues la computadora ni llegues a la conclusión de que no hay opciones para ti”, dijo Sullivan. “El Congreso aún podría actuar y las cosas podrían cambiar drásticamente”.

Los legisladores podrían restaurar los subsidios ampliados hasta fin de año que viene, o incluso después.

En la mayoría de los estados, incluyendo los 28 que usan el mercado federal centralizado, el período de inscripción abierta dura hasta el 15 de enero. También hay otras fechas clave que debes tener en cuenta.

En la mayoría de los estados, las personas deben inscribirse antes del 15 de diciembre para tener cobertura a partir del 1 de enero, y antes del 15 de enero para comenzar la cobertura el 1 de febrero, aunque algunos estados tienen plazos más extensos.

6. Esperar para pagar la prima

Generalmente, las primas deben pagarse antes de que entre en vigencia el plan, aunque los mercados y las aseguradoras tienen la flexibilidad de extender los plazos, explicó Corlette.

Podrían, por ejemplo, permitir más tiempo para hacer el primer pago. “Ya hemos visto eso en el pasado. Funcionarios estatales y aseguradoras han procurado por todos los medios mantener a las personas con cobertura”, dijo.

Pero si se llega a un acuerdo de último minuto y alguien ya pagó su prima para la cobertura de enero y recibió un subsidio menor al que correspondería con el nuevo acuerdo, aún debería poder recibir el subsidio más alto.

“Existen maneras de compensar a las personas”, aseguró Corlette, aunque no está claro cómo sucederá eso en este periodo de inscripción.

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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Even with sign-up season underway, the fate of the enhanced premium tax credits that make coverage more affordable for 92% of enrollees remains up in the air, with the prospect of significantly higher premiums looming.

But there are steps marketplace shoppers can take to ensure they make the right choices for the upcoming plan year.

1. Understand How We Got Here

In 2021, as part of a covid-era relief package, the ACA premium tax credits were enhanced to lower costs for previously eligible people and expand eligibility to people with incomes over 400% of the federal poverty level (which amounts to about $63,000 for one person in 2025). But those enhancements, which were extended in 2022, will expire at the end of 2025 unless Congress acts.

The debate over whether to extend them again has been at the center of a political battle of wills between Republicans and Democrats in Congress, a fight at the heart of the now month-old government shutdown.

The financial implications for many marketplace enrollees are huge. Average out-of-pocket premium payments for subsidized enrollees are projected to more than double if the enhanced tax credits expire, according to KFF, a health information nonprofit that includes KFF Health News.

“The longer this goes on, the more damage is done,” said Cynthia Cox, a vice president and the director of the Program on the ACA at KFF. “If someone logs on Nov. 1 and sees their premium doubling, they might just walk away.”

That would be a mistake, marketplace experts agree. What is clear, though, is that buyers need to beware and be informed.

2. Follow the News

It can be frustrating to track day-to-day Capitol Hill machinations. But that may be your best source for up-to-date information. Congress could make a deal to extend the enhanced subsidies anytime during the next few days, weeks, or months — or not. Either way, it could affect your enrollment decision. So, pay attention.

Don’t count on the marketplace or your insurer to notify you about what you should expect to pay. “Many state marketplaces have hit delay” on sending consumers notices of net premiums, which take premium tax credits into account, said Sabrina Corlette, a co-director of Georgetown University’s Center on Health Insurance Reforms.

The federal government doesn’t send enrollees notices about plan premiums for the coming year for the 28 federally facilitated marketplaces. For 2026, it has said that health plans can also opt not to.

3. Update Your Account Information

Log in to your marketplace account and update your income, household size, and any other details that have changed.

This year, it’s particularly important to provide an accurate estimate of your anticipated income for 2026.

A provision in HR 1, sometimes called the One Big Beautiful Bill Act, eliminated the caps on what many people were required to repay if they underestimated their projected income and received more premium assistance than they should have. Next year, people will have to repay the entire excess amount.

In the past few years, it’s been possible to put your ACA insurance “on autopilot,” with automatic reenrollment in your current or a similar plan. Given the uncertainty around premiums, this is not a good year to do that, enrollment specialists say.

This is especially true for people who, without a deal in Congress, will no longer qualify for subsidies next year, specifically those whose incomes are over 400% of the federal poverty level.

4. Shop Based on Sticker Prices

When people see their projected premiums, assuming Congress hasn’t reached a deal to extend the enhanced credits, many will be shocked.

Health insurance premiums on the marketplaces are expected to increase, on average, 26% next year, according to KFF. That’s the largest rate increase since 2018.

Until now, people have largely been shielded from those increases by the enhanced premium tax subsidies that nearly all enrollees receive. Here’s how it works: Most people with ACA marketplace plans are responsible for paying a portion of their premium based on a sliding income scale, and the government pays the rest.

According to an analysis by KFF, if the enhanced credits are not renewed, a family of four with $75,000 in income, for example, will be responsible for paying $5,865 in annual premiums for a benchmark silver plan in 2026 — more than double the $2,498 it’ll pay if they are renewed.

When evaluating a plan, focus on the listed price. If it’s not affordable without the enhanced tax credits, it’s not a good buy.

“People need to make a decision based on what is in front of them,” Cox said.

If you can’t afford the sticker price without the enhanced credits, consider enrolling in a less generous plan with a lower premium but a higher deductible, Cox said. Bronze plans must provide comprehensive coverage, including covering preventive care at no cost, and may cover some doctor visits before the deductible.

“In most cases, it makes more sense to have a bronze plan than to be uninsured,” she said.

The Trump administration has been promoting catastrophic plans as a more affordable option for people who face financial hardship, including those who don’t qualify for subsidies because their incomes are either less than 100% or more than 400% of the federal poverty level.

Similar to bronze plans, catastrophic plans cover a set of essential health benefits, provide free preventive care, and must cover at least three doctor visits before people reach their deductible. But catastrophic plan deductibles are the highest of any type of marketplace plan: $10,600 for individuals and $21,200 for families in 2026.

“They are expensive relative to what they cover,” said Jennifer Sullivan, director of health coverage access at the Center on Budget and Policy Priorities, noting premiums can cost several hundred dollars.

5. Come Back, Check, and Recheck

If you’re dismayed at premium prices on your first pass, “don’t slam the computer shut and decide that there are no options for you,” Sullivan said. “Congress might still act and things might change radically.”

Lawmakers could restore the enhanced premium tax credits right up to the end of the year, or later.

In a majority of states, including the 28 that use the federal government’s centralized marketplace, open enrollment lasts until Jan. 15. There are also other key dates to remember.

In most states, people must enroll by Dec. 15 for coverage starting Jan. 1, and by Jan. 15 for coverage starting Feb. 1, though some states have later deadlines.

6. Wait To Pay Your Premium

Premium payments are generally due before the plan takes effect, although marketplaces and insurers have flexibility to extend deadlines, Corlette said.

They might allow people extra time to make a first payment, for example. “We’ve seen that in the past. State officials and insurance companies have gotten creative to try and keep people in coverage,” she said.

But if there is a last-minute deal and someone has already paid their premium for January coverage and received a lower tax credit than the deal provides, they should still be able to receive the higher credit.

“There are ways to make people whole,” Corlette said, although how that might happen this enrollment period is unclear.

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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MU Health Care, donde practican la mayoría de los médicos que utiliza su familia, estaba inmerso en una disputa contractual con Anthem, la aseguradora de salud de Wingler. El contrato vigente estaba a punto de expirar.

Entonces, el 31 de marzo, la mujer recibió un correo electrónico alertándola de que al día siguiente el hospital ya no estaría en la red de Anthem.

La noticia la dejó atónita.

“Sé que negocian contratos todo el tiempo… pero parecía un simple trámite burocrático que no nos afectaría. Nunca antes me habían excluido de la red de una aseguradora de esa manera”, comentó. El momento no pudo ser menos oportuno.

La consulta: Cuando la aseguradora de salud de una madre de Missouri no pudo llegar a un acuerdo con su hospital, la mayoría de sus médicos quedaron repentinamente fuera de la red. Se preguntaba cómo conseguiría que se cubriera la atención médica de sus hijos o cómo encontraría nuevos médicos. “Para una familia de cinco… ¿por dónde empezamos?” — Amber Wingler, 42 años, de Columbia, Missouri

La hija de Wingler, Cora, de 8 años, había estado teniendo problemas intestinales sin razón aparente. Las listas de espera para ver a varios especialistas pediátricos y tener un diagnóstico, desde gastroenterología hasta terapia ocupacional, eran largas: iban de semanas hasta más de un año.

(En un comunicado, el vocero de MU Health Care, Eric Maze, afirmó que el sistema de salud trabaja para garantizar que los niños con las necesidades más urgentes sean atendidos lo antes posible).

De repente, las consultas con los especialistas para Cora estaban fuera de la red de su seguro. A varios cientos de dólares cada una, el costo se habría disparado rápidamente. Los únicos otros especialistas pediátricos dentro de la red que Wingler encontró estaban en St. Louis y Kansas City, ambos a más de 120 millas de distancia.

Así que Wingler pospuso las citas médicas de su hija durante meses mientras intentaba decidir qué hacer.

En todo el país, las disputas contractuales son comunes, con más de 650 hospitales involucrados en conflictos públicos con aseguradoras desde 2021.

Y podrían volverse aún más frecuentes a medida que los hospitales se preparan para recortes de aproximadamente $1.000 millones en el gasto federal en salud, según lo estipulado por la ley insignia del presidente Donald Trump, promulgada en julio.

Los pacientes atrapados en una disputa contractual tienen pocas opciones viables.

“Existe un antiguo proverbio africano que dice: cuando dos elefantes pelean, la hierba se aplasta. Y, lamentablemente, en estas situaciones, a menudo los pacientes son la hierba”, afirmó Caitlin Donovan, directora de la Patient Advocate Foundation, una organización sin fines de lucro que ayuda a personas con dificultades para acceder a la atención médica.

Si te sientes aplastado bajo una disputa contractual entre un hospital y tu aseguradora, esto es lo que necesitas saber para protegerte financieramente:

1. “Fuera de la red” significa que probablemente pagarás más.

Las aseguradoras negocian contratos con hospitales y otros proveedores médicos para establecer las tarifas que pagarán por distintos servicios. Cuando llegan a un acuerdo, el hospital y la mayoría de los proveedores que trabajan allí pasan a formar parte de la red de la aseguradora.

La mayoría de los pacientes prefieren consultar con proveedores “dentro de la red” porque su seguro cubre parte, la mayor parte o incluso la totalidad de la factura, que podría ascender a cientos o miles de dólares. Si consultas con un proveedor fuera de la red, podrías tener que pagar la factura completa.

Si decides seguir con tus médicos habituales aunque estén fuera de la red, puedes consultar sobre la posibilidad de obtener un descuento por pago en efectivo y sobre el programa de asistencia financiera del hospital.

2. Las disputas entre hospitales y aseguradoras suelen resolverse.

Jason Buxbaum, investigador de políticas de salud de la Universidad Brown, examinó 3.714 hospitales no federales en Estados Unidos y halló que, entre junio de 2021 y mayo de 2025, un 18% de ellos tuvo una disputa pública con una compañía de seguros de salud.

Cerca de la mitad de esos hospitales finalmente se retiraron de la red de la aseguradora, según los datos preliminares de Buxbaum. Sin embargo, la mayoría de estas rupturas se resuelven en uno o dos meses, agregó. Por lo tanto, es muy probable que tus médicos vuelvan a formar parte de la red, incluso después de una separación.

3. Podrías calificar para una extensión que te permita reducir costos.

Ciertos pacientes con afecciones graves o complejas podrían calificar para una extensión de la cobertura dentro de la red, lo que se llama continuidad de la atención.

Puedes pedir esta extensión llamando a tu aseguradora, pero el proceso puede ser largo. Algunos hospitales han habilitado recursos para ayudar a los pacientes a solicitarla.

Wingler pasó por todo ese calvario por su hija: horas al teléfono, llenando formularios y enviando faxes.

Pero dijo que no tenía el tiempo ni la energía para hacerlo para todos los miembros de su familia.

“Mi hijo estaba en fisioterapia”, dijo. “Pero lo siento mucho, hijo, tú sigue con los ejercicios que tienes que hacer. No voy a pelearme para que tú también tengas cobertura, cuando ya estoy peleando por tu hermana”, se dijo.

También es importante tener en cuenta si se trata de una emergencia médica: en la mayoría de los servicios de urgencias, los hospitales no pueden cobrar a los pacientes más de las tarifas de su red.

4. Puede que tengas que esperar para cambiar de aseguradora.

Quizás estés pensando en cambiarte a una aseguradora que cubra a tus médicos favoritos. Pero ten en cuenta que muchas personas que eligen sus planes de salud durante el período anual de inscripción abierta quedan atadas a su plan durante un año. Los contratos entre las aseguradoras y los hospitales no necesariamente coinciden con el año de tu plan.

Ciertos acontecimientos de vida, como casarse, tener un hijo o perder el trabajo, pueden permitirte cambiar de seguro fuera del período anual de inscripción abierta, pero que tus médicos dejen de pertenecer a la red de tu seguro no se considera un acontecimiento de vida que te permita hacerlo.

5. Buscar un nuevo médico puede llevar mucho tiempo.

Si la ruptura entre tu aseguradora y el hospital parece definitiva, podrías considerar buscar una nueva lista de médicos y otros proveedores que estén dentro de la red de tu plan. ¿Por dónde empezar? Tu plan probablemente tenga una herramienta en línea para buscar proveedores dentro de la red cerca de donde vives.

Pero ten en cuenta que cambiar de médico podría significar esperar para establecerte como paciente de uno nuevo y, en algunos casos, tener que ir más lejos.

6. Vale la pena guardar los recibos.

Incluso si tu seguro y el hospital no llegan a un acuerdo antes de que expire su contrato, existe la probabilidad de que lleguen a un nuevo acuerdo.

Algunos pacientes deciden posponer sus citas mientras esperan. Otros mantienen sus citas y pagan de su propio bolsillo. Si es tu caso, guarda los recibos. Cuando las aseguradoras y los hospitales llegan a un acuerdo, este suele aplicarse retroactivamente, por lo que las citas que pagaste de tu bolsillo podrían estar cubiertas después de todo.

Fin de un suplicio

Tres meses después de que expirara el contrato entre la aseguradora de Wingler y el hospital, ambas partes anunciaron un nuevo acuerdo. Wingler se unió a la multitud de pacientes que programaron las citas que habían pospuesto durante la crisis.

En un comunicado, Jim Turner, vocero de Elevance Health, la empresa matriz de Anthem, escribió: “Abordamos las negociaciones enfocados en la equidad, la transparencia y el respeto por todos los afectados”.

Maze, de MU Health Care, dijo: “Comprendemos la importancia del acceso puntual a la atención pediátrica especializada para las familias y lamentamos profundamente la frustración que algunos padres han experimentado al intentar programar citas tras la resolución de las negociaciones de nuestro contrato con Anthem”.

Wingler se alegró de que su familia pudiera volver a ver a sus médicos, pero su alivio se vio atenuado por la determinación de no volver a encontrarse en la misma situación.

“Creo que seremos un poco más precavidos cuando llegue el período de inscripción abierta”, dijo Wingler. “Nunca nos habíamos preocupado por revisar nuestra cobertura de gastos de bolsillo porque no la necesitábamos”.

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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Hasta ahora, cinco estados informaron que ya han recibido, en total, más de 170.000 nombres, una medida del gobierno federal sin precedentes, que significa involucrar al programa de salud estatal-federal en la campaña del presidente contra la inmigración.

Defensores de los derechos de los inmigrantes advierten que esta decisión impone una carga adicional a los estados al tener que duplicar las verificaciones y podría llevar a que algunas personas pierdan su cobertura médica simplemente por no haber entregado a tiempo la documentación.

Sin embargo, el doctor Mehmet Oz, administrador de los Centros de Servicios de Medicare y Medicaid (CMS), afirmó en una publicación en la plataforma social X el 31 de octubre que se estaban gastando más de $1.000 millones “de los contribuyentes [que pagan impuestos federales] en financiar Medicaid para inmigrantes ilegales” en cinco estados y Washington D.C.

El gasto total de Medicaid superó los $900 mil millones en el año fiscal 2024.

Ni la declaración de Oz ni un video adjunto aclararon el período durante el cual se realizaron estos gastos, y los voceros de los CMS no respondieron de inmediato a las preguntas solicitadas.

Las normas federales limitan la elegibilidad para Medicaid y para el Programa de Seguro de Salud Infantil (CHIP) a los ciudadanos estadounidenses y a algunos inmigrantes que residen legalmente en el país.

Las personas sin estatus migratorio legal no pueden recibir ninguna cobertura de salud financiada por el gobierno federal, incluidos Medicaid, Medicare y los planes adquiridos en los mercados de seguros creados por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Varios estados dijeron estar en desacuerdo con las declaraciones de Oz.

“Nuestros pagos para la cobertura de personas indocumentadas cumplen con las leyes estatales y federales”, declaró Marc Williams, vocero del Departamento de Política y Financiamiento de la Atención Médica de Colorado, que administra el programa estatal de Medicaid. “La cifra de $1.5 millones a la que hicieron referencia hoy los líderes federales se basa en un hallazgo preliminar inexacto y ha sido refutada por datos de expertos de nuestro departamento”.

Agregó: “Resulta decepcionante que la administración anuncie esta cifra como definitiva cuando es claramente exagerada y las conversaciones aún se encuentran en la fase de información y debate”.

Funcionarios del Medicaid de Illinois criticaron duramente los comentarios del jefe de los CMS.

“Una vez más, el gobierno de Trump está difundiendo información errónea sobre el uso habitual de los fondos de Medicaid”, declaró Melissa Kula, vocera del Medicaid de Illinois.

“Esto no es un reality show, y no existe ninguna conspiración para eludir la ley federal y brindar cobertura de Medicaid a personas que no cumplen con los requisitos. El Dr. Oz debería dejar de promover teorías conspirativas y concentrarse en mejorar la atención médica para los estadounidenses”, dijo Kula.

La Autoridad de Atención Médica del Estado de Washington, que administra el programa estatal de Medicaid, también fue contundente. “Las cifras que el Dr. Oz publicó en redes sociales son inexactas”, afirmó la portavoz Rachelle Alongi. “Nos sorprendió mucho ver la publicación del Dr. Oz, especialmente considerando que seguimos colaborando de buena fe con los Centros de Servicios de Medicare y Medicaid (CMS) para responder a sus preguntas y aclarar cualquier confusión”.

En agosto, los CMS comenzaron a enviar a los estados los nombres de personas inscritas en Medicaid que la agencia sospechaba que podrían no ser elegibles, exigiendo a las agencias estatales del programa que verificaran su estatus migratorio.

En octubre, KFF Health News contactó a 10 agencias estatales de Medicaid. Cinco de ellas proporcionaron cifras aproximadas de los nombres que habían recibido de la administración Trump hasta la fecha, pero suponen que llegarán más: Utah recibió 8.000 nombres; Colorado, 45.000; Pennsylvania, 34.000; Ohio, 61.000; y Texas, 28.000.

Actualmente, más de 70 millones de personas están inscritas en Medicaid.

La mayoría de esos estados no aceptaron hacer más comentarios. Otros cinco —California, Nueva York, Georgia, Florida y Carolina del Sur— se negaron a revelar cuántos nombres se les pidió que revisaran, o directamente no respondieron.

Oz afirmó en su publicación de X que California había malgastado $1.300 millones en atención médica para personas no elegibles para Medicaid, mientras que Illinois gastó $30 millones, Oregon $5.4 millones, el estado de Washington $2.4 millones, Washington D.C. $2.1 millones y Colorado $1.5 millones.

“Notificamos a los estados y muchos ya han comenzado a reembolsar el dinero”, dijo. “Pero, ¿qué habría pasado si nunca hubiéramos preguntado?”.

La directora de Medicaid de Washington D.C., Melisa Byrd, declaró que los CMS habían identificado gastos administrativos del programa del distrito, que cubre a personas independientemente de su estatus migratorio, que no debieron haberse facturado al gobierno federal, y que su agencia ya ha corregido algunos de esos errores.

“Administramos un programa grande y muy complejo, y cuando ocurren errores, los corregimos”, afirmó. El programa planea reembolsar $654.014 a los CMS para mediados de noviembre.

Los cinco estados, más Washington D.C., están gobernados por demócratas, y el presidente Donald Trump no ganó en ninguno de ellos en las elecciones de 2024.

En los últimos días, el subsecretario de Salud y Servicios Humanos, Jim O’Neill, comenzó a publicar en la plataforma social X fotos de personas que, según él, son delincuentes convictos que viven en Estados Unidos sin autorización y que han recibido beneficios de Medicaid.

No se pudo contactar a O’Neill para obtener declaraciones.

“Estamos muy preocupados porque esto, francamente, parece un desperdicio de recursos estatales y refuerza la agenda antiinmigrante de la administración”, dijo Ben D’Avanzo, estratega senior de políticas de salud en el National Immigration Law Center, una organización de defensa de los derechos de los inmigrantes. “Esto duplica lo que los estados ya hacen”, añadió.

Como parte de la ofensiva contra las personas sin estatus legal, el presidente ordenó en febrero a las agencias federales que se aseguraran de que quienes no tienen la residencia en regla no obtuvieran beneficios que violaran la ley federal.

En junio, el secretario de Salud y Servicios Humanos (HHS) Robert F. Kennedy le ordenó a los CMS que compartieran con el Departamento de Seguridad Nacional (DHS) la información sobre las personas inscritas en Medicaid. Esto provocó una demanda por parte de varios estados preocupados de que esa información se utilizara para campañas de deportación.

En agosto, un juez federal ordenó al HHS que dejara de compartir esa información con las autoridades migratorias.

Las agencias estatales de Medicaid normalmente utilizan bases de datos administradas por la Seguridad Social, el Departamento de Seguridad Nacional y otras agencias gubernamentales para verificar el estatus migratorio de los solicitantes.

Si los estados tienen que volver a contactar a las personas inscritas para verificar nuevamente su estatus migratorio o ciudadanía, algunas podrían perder su cobertura injustificadamente, por ejemplo, si no ven la carta donde se les solicitan documentos o no responden a tiempo.

“No estoy segura de que haya evidencia suficiente que justifique esta verificación adicional”, dijo Marian Jarlenski, profesora de políticas de salud en la Escuela de Salud Pública de la Universidad de Pittsburgh.

Oz dejó en claro que la administración Trump no está de acuerdo.

En el comunicado de agosto, los CMS explicaron que estaban pidiendo a los estados que verificaran la elegibilidad de las personas cuyo estatus migratorio no pudo ser confirmado mediante bases de datos federales. “Esperamos que los estados actúen con rapidez y supervisaremos los progresos mes a mes”, dijo la agencia.

Leonardo Cuello, profesor investigador del Georgetown University Center for Children and Families, calificó la orden de los CMS a los estados como “algo sin precedentes” en los 60 años de historia del programa Medicaid.

Dijo que es posible que el gobierno federal no haya podido verificar el estatus migratorio de algunas personas porque sus nombres estaban mal escritos o desactualizados, como cuando una beneficiaria aparece con el apellido de soltera en lugar del de casada.

Los listados también pueden incluir a personas que recibieron ayuda a través de Medicaid de Emergencia, un programa que cubre los gastos de servicios de emergencia en hospitales, incluidos el parto y la atención de trabajo de parto, sin importar el estatus migratorio.

“Los CMS están haciendo revisiones inútiles del estatus migratorio de personas cuyos gastos hospitalarios fueron cubiertos por el Medicaid de Emergencia”, explicó Cuello.

Oz señaló en su publicación que la ley federal “permite a los estados usar fondos de Medicaid para tratamientos de emergencia, independientemente de la ciudadanía o el estatus migratorio de los pacientes”, y que los estados pueden “crear legalmente programas de Medicaid para inmigrantes indocumentados usando sus propios impuestos estatales, siempre y cuando no se utilicen fondos federales”.

Todos los estados que mencionó Oz administran sus propios programas de este tipo.

Estas revisiones representan una carga adicional para las agencias estatales de Medicaid, que ya están ocupadas con los preparativos para implementar la ley tributaria y de gasto público que Trump firmó en julio.

Esta ley, que los republicanos han llamado la “One Big and Beautiful Bill”, establece numerosos cambios en Medicaid, incluyendo la imposición de requisitos laborales en la mayoría de los estados a partir de 2027. También les exige que revisen la elegibilidad de las personas inscritas al menos dos veces al año.

“Temo que los estados realicen verificaciones innecesarias que impongan una carga a ciertos beneficiarios, que perderán la cobertura médica cuando no deberían”, explicó Cuello. “Esto será mucho trabajo para los CMS y los estados, con muy pocos resultados reales”.

Dado que la nueva política permite a la agencia divulgar públicamente los datos, Cuello opinó que el esfuerzo tiene más valor político que práctico.

Brandon Cwalina, vocero del Departamento de Servicios Sociales de Pennsylvania —que administra Medicaid—, dijo que el estado ya exige que toda persona solicitante demuestre su ciudadanía o, cuando corresponde, su estatus migratorio.

“Sin embargo, la lista de nombres y las instrucciones emitidas por los CMS el mes pasado constituyen un nuevo procedimiento, y el departamento está revisando cuidadosamente esa lista para encarar las acciones correspondientes”, explicó.

En su publicación, Oz no mencionó a Pennsylvania, estado que Trump ganó en 2024.

Cuando un residente legal no tiene número de Seguro Social, el estado verifica su estatus usando una base de datos del Departamento de Seguridad Nacional, además de revisar los documentos migratorios específicos, agregó.

Otras agencias estatales de Medicaid dijeron que todavía no han comenzado a contactar a las personas inscritas.

“Estamos elaborando un procedimiento para realizar estas revisiones”, dijo Jennifer Stroehecker, directora de Medicaid en Utah, durante una reunión en agosto con una junta asesora estatal.

Renuka Rayasam y Rae Ellen Bichell colaboraron con este artículo.

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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Advocates say the push burdens states with duplicative verification checks and could lead people to lose coverage just for missing paperwork deadlines. But the administrator of the Centers for Medicare & Medicaid Services, Mehmet Oz, said in a post on the social platform X on Oct. 31 that more than $1 billion “of federal taxpayer dollars were being spent on funding Medicaid for illegal immigrants” in five states and Washington, D.C.

Medicaid’s overall spending topped $900 billion in fiscal year 2024.

It wasn’t clear from Oz’s statement or an accompanying video over what period the spending happened, and CMS spokespeople did not immediately respond to questions, either for an earlier version of this article or after Oz’s statement was posted.

Only U.S. citizens and some lawfully present immigrants are eligible for Medicaid, which covers low-income and disabled people, and the closely related Children’s Health Insurance Program. Those without legal status are ineligible for federally funded health coverage, including Medicaid, Medicare, and plans through the Affordable Care Act marketplaces.

Several states disputed Oz’s comments.

“Our payments for coverage of undocumented individuals are in accordance with state and federal laws,” said Marc Williams, a spokesperson for Colorado’s Department of Health Care Policy & Financing, which administers the state’s Medicaid program. “The $1.5 million number referenced by federal leaders today is based on an incorrect preliminary finding, and has been refuted with supporting data by our Department experts.”

He added: “It is disappointing that the administration is announcing this number as final when it is clearly overstated and the conversations are very much in the education and discussion phase.”

Illinois Medicaid officials blasted Oz’s comments.

“Once again, the Trump administration is spreading misinformation about standard uses of Medicaid dollars,” said Illinois Medicaid spokesperson Melissa Kula. “This is not a reality show, and there is no conspiracy to circumvent federal law and provide ineligible individuals with Medicaid coverage. Dr. Oz should stop pushing conspiracy theories and focus on improving health care for the American people.”

The Washington State Health Care Authority, which runs the state’s Medicaid program, was also blunt.

“The numbers Dr. Oz posted on social media today are inaccurate,” said spokesperson Rachelle Alongi. “We were very surprised to see Dr. Oz’s post, especially considering we continue to work with CMS in good faith to answer their questions and clear up any confusion.”

In August, CMS began sending states the names of people enrolled in Medicaid that the agency suspected might not be eligible, demanding state Medicaid agencies check their immigration status.

KFF Health News in October reached out to Medicaid agencies in 10 states. Five provided the approximate number of names they had received from the Trump administration, with expectations of more to come: Colorado had been given about 45,000 names, Ohio 61,000, Pennsylvania 34,000, Texas 28,000, and Utah 8,000. More than 70 million people are enrolled in Medicaid.

Most of those states declined to comment further. Medicaid agencies in California, Florida, Georgia, New York, and South Carolina refused to say how many names they were ordered to review or did not respond.

Oz said in his X post that California had misspent $1.3 billion on care for people not eligible for Medicaid, while Illinois spent $30 million, Oregon $5.4 million, Washington state $2.4 million, Washington, D.C., $2.1 million, and Colorado $1.5 million.

“We notified the states, and many have begun refunding the money,” he said. “But what if we had never asked?”

Washington, D.C.’s Medicaid director, Melisa Byrd, said CMS had identified administrative expenses for the district program that covers people regardless of immigration status that should not have been billed to the federal government and her agency has already fixed some of those areas. “We run a big program that is very complex and when mistakes or errors happen, we fix them,” she said.

The program plans to pay $654,014 back to CMS by mid-November.

All five states, plus Washington, D.C., are led by Democrats, and President Donald Trump didn’t win any of them in the 2024 election.

In recent days, Deputy Health and Human Services Secretary Jim O’Neill began posting pictures on X of people he said are convicted criminals living in the U.S. without authorization who had received Medicaid benefits.

O’Neill could not be reached for comment.

“We are very concerned because this seems, frankly, to be a waste of state resources and furthers the administration’s anti-immigrant agenda,” said Ben D’Avanzo, senior health advocacy strategist with the National Immigration Law Center, an advocacy group. “This duplicates what states already do,” he said.

As part of the administration’s crackdown on people in the U.S. without authorization, President Donald Trump in February directed federal agencies to take action to ensure they are not obtaining benefits in violation of federal law.

In June, advisers to Health and Human Services Secretary Robert F. Kennedy Jr. ordered CMS to share information about Medicaid enrollees with the Department of Homeland Security, drawing a lawsuit by some states alarmed that the administration would use the information for its deportation campaign against unauthorized residents.

In August, a federal judge ordered HHS to stop sharing the information with immigration authorities.

State Medicaid agencies use databases maintained by the Social Security Administration and Department of Homeland Security to verify enrollees’ immigration status.

If states need to go back to individuals to reverify their citizenship or immigration status, it could lead some to fall off the rolls unnecessarily — for example, if they don’t see a letter requesting paperwork or fail to meet a deadline to respond.

“I am not sure that evidence suggests there really is a need for this” extra verification, said Marian Jarlenski, a health policy professor at the University of Pittsburgh School of Public Health.

Oz made clear that the Trump administration disagrees.

“Whether willful or not, the states’ conduct highlights a terrifying reality: American taxpayers have been footing the bill for illegal immigrants’ Medicaid coverage, despite many Democrats and the media insisting otherwise,” Oz said in his X post.

In an August press release, CMS said it would ask states to verify eligibility for enrollees whose immigration status could not be confirmed via federal databases. “We expect states to take quick action and will monitor progress on a monthly basis,” the agency said.

Leonardo Cuello, a research professor at Georgetown University’s Center for Children and Families, called the CMS order to states “unprecedented” in the Medicaid program’s 60-year history.

He said the federal government may have been unable to verify certain individuals’ immigration status because names were misspelled or outdated, such as when a beneficiary is identified by their maiden instead of married name. The names may also include people helped by Emergency Medicaid, a program that covers the cost of hospital emergency services, including labor and delivery, for people regardless of immigration status.

“CMS is conducting pointless immigration status reviews for people whose hospital bills were paid by Emergency Medicaid,” Cuello said.

Oz noted in his post that federal law “does permit states to use Medicaid dollars for emergency treatment, regardless of patients’ citizenship or immigration status,” and that states can “legally build Medicaid programs for illegal immigrants using their own state tax dollars, so long as no federal tax dollars are used.”

The states Oz mentioned all run their own such programs.

The verification checks create an added burden for state Medicaid agencies that are already busy preparing to implement the tax and policy law Trump signed in July. The measure, which Republicans call the One Big Beautiful Bill Act, makes many changes to Medicaid, including adding a work requirement in most states starting by 2027. The law also requires most states to more frequently check the eligibility of many adult Medicaid enrollees — at least twice a year.

“I fear states may do unnecessary checks that create a burden for some enrollees who will lose health coverage who should not,” Cuello said. “It’s going to be a whole lot of work for CMS and states for very little pay dirt.”

Cuello said the effort may have “greater political value than actual value.”

Brandon Cwalina, a spokesperson for the Pennsylvania Department of Human Services, which runs Medicaid in the state, said the state already requires every Medicaid applicant to verify their citizenship or, where applicable, their eligible immigration status.

However, he said, the directive issued by CMS “constitutes a new process, and DHS is carefully reviewing the list in order to take appropriate actions.”

Oz did not name Pennsylvania, which Trump won in 2024, in his post.

If a lawful resident does not have a Social Security number, the state confirms their legal status by checking a database from Homeland Security, as well as verifying specific immigration documents, he said.

Other state Medicaid agencies said they also needed to regroup before reaching out to enrollees.

“Our teams just received this notice and are working through a process by which we will perform these reviews,” Jennifer Strohecker, then Utah’s Medicaid director, told a state advisory board in August.

Renuka Rayasam and Rae Ellen Bichell 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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• Click here to watch Seitz on “Hello Houston.”
• Read Seitz and Julie Appleby’s “A Ticking Clock: How States Are Preparing for a Last-Minute Obamacare Deal.”

KFF Health News senior correspondent Phil Galewitz discussed the federal government shutdown on FOX 5’s “On The Hill” on Oct. 26.

• Click here to watch Galewitz on “On The Hill.”

KFF Health News contributor Patricia Kime discussed potential cancer clusters on nuclear missile bases on NBC Montana on Oct. 22.

• Click here to watch Kime on NBC Montana.
• Read Kime’s “Nuclear Missile Workers Are Contracting Cancer. They Blame the Bases.”

KFF Health News senior contributing editor Elisabeth Rosenthal discussed why the U.S. health care system is so complicated and what you need to know about ACA open enrollment on CNN’s “Chasing Life with Dr. Sanjay Gupta” on Oct. 17 and Oct. 21, respectively.

• Listen to Rosenthal discuss the U.S. health care system on “Chasing Life with Dr. Sanjay Gupta.”
• Listen to Rosenthal discuss ACA open enrollment on “Chasing Life with Dr. Sanjay Gupta.”

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Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that about 3 million people will lose food assistance as a result of several provisions in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to put more people to work, and to improve health.

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration ended an annual report that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law extends those requirements to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

Starting Nov. 1, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a three-year period.

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to a December Urban Institute survey.

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to a report by the Georgetown Center on Poverty and Inequality.

A KFF Health News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly two dozen Democratic governors wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, 12 states have received approval to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to a 2007 USDA report. In 2018, the first Trump administration rejected an effort from Maine to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, according to the USDA. Research shows that encouraging healthy food choices is more effective than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food are more likely to have a mental disorder. Similarly, food insecurity is linked to lower math and reading skills.

Working-age people with food insecurity are more likely to experience chronic disease. That long list includes high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP spend on average $1,400 more a year on health care than those who are.

About 47 million people lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, according to the USDA.

A report by associations representing convenience stores, grocers, and the food industry estimated it could cost grocers $1.6 billion to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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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