Elisabeth Rosenthal, Author at ��ϳԹ�� News

She Owed Her Insurer a Nickel, So It Canceled Her Coverage

Elisabeth Rosenthal — Mon, 30 Mar 2026 09:00:00 +0000

Last summer, Lorena Alvarado Hill received a series of unexpected medical bills.

A teacher’s aide in Melbourne, Florida, Hill is a single mom who works shifts at J.Crew on the weekends to send her daughter to college. Hill and her mother, who lives with her, had been enrolled in an insurance plan through HealthFirst.

Hill paid nothing toward the premiums for the government-subsidized plan, which previously had covered her scans and other appointments.

Then the bills came.

Hill was on the hook for a $2,966.93 MRI, as well as more than half a dozen doctor visits costing about $200 or $300 each. Without that kind of money on hand, Hill said, she put a few of the bills on payment plans and tried to figure out what had gone wrong.

She discovered, to her surprise, that her insurance had been canceled for “non-payment of premiums.”

The Medical Service

A health insurance plan purchased through the Affordable Care Act federal exchange, healthcare.gov.

The Bill

A monthly premium bill for 1 cent, which in the following months increased incrementally to 5 cents.

The Billing Problem: Small Bill, Big Consequences

Premium subsidies for ACA plans are automatically recalculated every time coverage is changed because of a life event, such as marriage, a change of job, or a child turning 26. In June, Hill removed her mother from the family’s group plan because she turned 65 and became eligible for Medicare and Medicaid.

The change triggered a recalculation of Hill’s monthly premium contribution, increasing it from $0 to 1 cent. She said she thought the amount was so small that she couldn’t pay it with her credit card.

Hill acknowledged she had received some bills that noted, “You may lose your health insurance coverage because you did not pay your monthly health insurance premium.”

But she said that her doctors collected the usual copayments during subsequent visits and that her insurance broker told her not to worry, reassuring her that the plan was “active.” Hill figured the 1-cent monthly premium was probably a rounding error that couldn’t result in termination, she said.

On Nov. 22, she got a letter marked “Important: Your health insurance coverage is ending.” It listed the last day of coverage as July 31, nearly four months before.

“I panicked,” Hill said. “I didn’t sleep that night.”

On Nov. 22, 2025, Hill got a letter informing her that her health insurance had been canceled — listing the last day of coverage as July 31. The terminated policy left her on the hook for thousands of dollars in bills. “I didn’t sleep that night,” she said. (Michelle Bruzzese for ��ϳԹ�� News)

She made an appointment the next day with her broker, who called HealthFirst for clarification. The news was even worse: Not only had her insurance been canceled, but the 5-cent bill could be sent to a collection agency.

Hill takes out loans to pay her daughter’s college expenses. “I couldn’t have my credit ruined,” she said.

Others have lost their coverage over owing small amounts, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “This woman’s situation is not so unusual with the enhanced subsidies,” she said.

The American Rescue Plan, passed in 2021, increased the amount of government assistance available to ACA plan holders. Those enhanced subsidies, which Congress let expire at the end of last year, meant enrollees with lower incomes had to pay little or nothing toward their premiums.

The Biden administration found that, in 2023, about 81,000 subsidized ACA insurance policies were terminated because the enrollee owed $5 or less. Nearly 103,000 more were canceled for owing less than $10.

To prevent that kind of coverage loss, most likely hitting people with little income, Biden administration health officials to allow ACA enrollees to retain coverage if they owed less than $10, or less than 95% of premium costs.

Insurers were required to keep insurance active for a 90-day “grace period” to give enrollees time to respond. That’s why Hill’s doctors initially took her copayments and sent no bill, as if nothing had changed.

That Biden administration “flexibility” rule took effect Jan. 15, 2025, though not every insurer opted to offer leniency to those owing small amounts.

The Trump administration removed the rule on Aug. 25, eliminating the protection entirely in the name of combating fraud and abuse.

The Resolution

Alarmed by the cancellation, the thousands of dollars in bills, and the threat of collections over 5 cents, Hill researched insurance law and fought back.

She filed a complaint in December with HealthFirst and the Florida Department of Financial Services asking for a write-off of her 5-cent balance and retroactive restoration of her policy, citing state and federal laws that seemed to apply to her situation.

In particular, she wrote, “creditors are not required to collect, and consumers are not required to pay, credit-card balances of $1.00 or less,” adding that “all major insurers and payment processors in Florida follow a 1-cent write-off policy.”

She noted that HealthFirst’s policy was to respond to complaints in 30 days.

Thirty days came and went, but Hill said she heard nothing in response — and new bills from her canceled policy kept coming.

Despite her frustration, Hill said, all her doctors were contracted with HealthFirst, so she reenrolled for 2026.

Lance Skelly, a spokesperson for HealthFirst, initially said the case “is still in the appeals/grievance process.” In a follow-up email, he said HealthFirst had in canceling Hill’s policy.

“Stepping back from what’s legal, this is just ridiculous,” Corlette said.

Weeks after a reporter’s query to the insurer, Hill said she looked at her billing statements for all the medical services she received in 2025 and was pleasantly surprised that the balances owed had been adjusted to $0.

But she said she would also like HealthFirst to cover what she had paid and still owed toward the bills she’d put on payment plans.

Hill and her mother were enrolled together in a health plan purchased through the federal Affordable Care Act exchange. Hill removed her mother from the plan when she became eligible for Medicare and Medicaid, but the change triggered a recalculation of her monthly premium contribution, increasing it from $0 to 1 cent. She said the amount was so small that she couldn’t figure out how to pay for it with her credit card. (Michelle Bruzzese for ��ϳԹ�� News)

The Takeaway

Even small bills can have major consequences.

With the automation of more health billing decisions, irrational results have become increasingly common.

“One cent?!” Hill said. “No human would do this!”

It can be tempting to dismiss the notice of a tiny debt, but it’s important to take it seriously. Contact the insurer and get a human involved.

And while insurance policies have grace periods allowing coverage to remain in place if you miss a payment, some are not very long. For subsidized ACA marketplace plans, the period is 90 days, but others last just 30 or 45.

Missing one payment can mean losing coverage. So it’s important to keep a close eye on premiums to make sure they’re paid.

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

��ϳԹ�� 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 .

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Even Patients Are Shocked by the Prices Their Insurers Will Pay — And It Costs All of Us

Elisabeth Rosenthal — Tue, 03 Mar 2026 10:00:00 +0000

Samantha Smith of Harrisburg, Pennsylvania, went into the operating room for emergency removal of an ectopic pregnancy. “I’m grateful I didn’t die,” she said, but she was shocked to see that the outpatient surgery was billed to her insurer for about $100,000.

Jamie Estrada of Albuquerque, New Mexico, twice received injections of lidocaine in his upper spine to test if a permanent nerve ablation would treat his chronic neck pain. His pain vanished — until the numbing agent wore off about six hours later. The real zinger: His insurer was billed $28,000 for each 10-minute procedure.

Mark McCullick of Longmont, Colorado, was sent for a whole-body PET scan to find out whether his prostate cancer was back. The two-hour scan showed no evidence of cancer, but the $77,000 bill sent to the company that administered his insurance alarmed him.

Medical inflation has general inflation for years, with bills for many brief, routine procedures reaching tens of thousands of dollars.

These cases highlight the questions that haunt the American health system and the patients caught in its grip: What is a reasonable price for any health care visit or procedure, and how is it determined? How hard do insurers, the purported stewards of the patient’s hard-earned health dollars, fight to lower charges, and how closely do they scrutinize bills for accuracy?

Smith, Estrada, and McCullick’s cases are all “chargemaster” bills, calculated from the master price list that health providers place on services. Patients who have insurance don’t generally pay them. But they matter because they are often the starting point for the negotiated price the insurer agrees is reasonable to pay for the services. Patients are typically responsible for 10% to 20% of the negotiated price, their coinsurance — and when prices are this high, that can be a big number. What’s more, those negotiated rates are difficult for patients to access (until they get the bill) and seemingly arbitrary.

Also, because health insurers can offset high outlays one year by raising premiums and deductibles the next, they have little incentive to bargain hard for good deals for the patients they cover. So patients all pay unknowingly, indirectly.

In the cases of Smith and Estrada, their insurers paid the majority without questions. Penn State’s Hershey Medical Center, which treated Smith, received $61,000, or 62% of what it charged. New Mexico Surgery Center Orthopaedics, which treated Estrada, received $46,000, or 82%.

McCullick’s insurer, on the other hand, said it would pay Intermountain Health just 28% of his $77,000 bill. Then came another curveball: The hospital, which said it had gotten preauthorization, discovered after the fact that his scan was not covered. So it billed McCullick the full chargemaster rate of $77,000 — or, it offered, he could pay the cash rate of $14,259.

In an emailed statement, Chris Bond, a spokesperson for AHIP, the leading trade group for health insurers, blamed hospitals for the trouble, saying that plans are “focused on making benefits and coverage as affordable as possible for their members,” and that: “As the largest single category per premium dollar spent, increases in the cost of hospital-based care have an outsized impact on premiums.”

In a health system in which prices can vary exponentially with little transparency, how can patients afford to get sick?

‘It Makes No Sense’

Americans as a top priority for government in 2026, according to an Associated Press-NORC poll, expressing particular concern about cost, access, and insurance coverage.

The first Trump administration required insurers and hospitals to publish files containing cash, gross, and negotiated prices for various items and services. These raw, machine-readable price lists — often hundreds of pages filled with medical billing codes — to patient-customers.

Five years later, they’ve been ingested, parsed, and enriched by academics and startups, shedding light on the often-shocking disparities in prices and how they’ve come to exist.

“When we look at the data, whether it’s from a chargemaster or what insurers paid, it’s all over the map — it makes no sense,” said Marcus Dorstel, senior vice president of operations at Turquoise Health, a price transparency startup with payers and providers as clients. “The variation is huge, even in a specific area.”

When researchers at the Johns Hopkins Bloomberg School of Public Health looked at the data, they discovered that the price different insurers pay for the same billed charges “can be three or more times different at the same hospital,” said Ge Bai, a professor of health care accounting who was among the researchers.

The prices insurers pay are determined by numerous factors, including what’s in their contracts with health systems. Some health plans, such as Smith’s, automatically pay a percentage of the hospital’s billed charges, incentivizing hospitals to increase their rates. Hershey Medical Center increased its prices for 11 common hospital billing codes by an average of about 30% from 2023 to 2025, Dan Snow, a data scientist at Turquoise Health, calculated for this article. But those prices were not much different than those of other hospitals in Pennsylvania.

In other cases, an insurer might agree to pay a health system a case rate — a standard rate for a type of care, say a colonoscopy or an inpatient stay for pneumonia.

But there’s a lucrative catch, called a “carve-out,” which refers to a particular benefit that’s negotiated and paid separately. If the hospital used expensive drugs or devices, for instance, they can be billed in addition to the bundled case rate, with no limits on hospital markups. That was the case with McCullick’s PET scan; about 80% of the charge was not for the scan, but for a new kind of drug injected before the scan to detect cancer.

Most often the final prices depend on the relative negotiating power of the insurer and the health system: Which side has enough market sway to walk away if the other doesn’t meet its demands?

Such factors “can explain the price variations and patterns that we see,” Dorstel said. “In some markets insurers are price-makers, and in others they are price-takers.”

For Insurers, Paying More Is Profitable

Insurers aren’t incentivized to lower prices, because high prices mean they “get a slice of a bigger pie,” Bai said.

By law, insurers must spend 80% or 85% of premiums on patient care. But when prices rise, they can pass on the increase to customers in the form of higher premium costs and still meet their legal obligation. So higher premiums mean less money for the patient and more profit for the insurer.

For each spinal injection Estrada received, his insurance company’s contracted rate was $23,237.50. Estrada’s coinsurance was $5,166.20. With a high-deductible plan, he was asked to pay all of that more than $5,000 bill.

When he called to challenge the big bill, he said, the surgery center’s administrator told him the charges were the result of a “legacy contract” with the insurer that is “advantageous” and “favorable” to the center.

New Mexico Surgery Center Orthopaedics’ charges are many times those of the hospital where the center’s doctors admit patients, for example; there, Estrada’s insurance company’s contracted rate for the same spinal injection is just $2,058.67. And compared with the roughly $20,000 the insurer paid for each of Estrada’s injections, other insurers pay the center about $700 for the same procedure, Snow found.

The surgery center is part of a national group that owns more than 535 surgical facilities, United Surgical Partners International, which in turn is owned by Tenet Healthcare, a for-profit health conglomerate. That kind of market dominance can lend companies the negotiating power to charge — and get paid — what they want, Bai said.

The surgery center, United Surgical Partners International, and Tenet Healthcare did not reply to multiple requests for comment from ��ϳԹ�� News.

With charges prenegotiated, insurers have little incentive to scrutinize questionable bills. When Smith asked for an itemized bill for her surgery, she discovered that she had been billed for two surgeries: one for the ectopic pregnancy removal and another because the surgeon noticed signs of endometriosis and performed a biopsy. Both were billed at the contracted rate of $37,923.

She was livid at the charges, which to her seemed like double-dipping. “That was one surgery,” she said. “There was one incision.”

A Yale University-trained lawyer, Smith consulted the federal Centers for Medicare & Medicaid Services’ , which note the two billing codes used for her surgery generally can’t be “billed together for the same patient encounter” because one more or less is bundled with the other.

Smith said she reached out to the Penn State hospital, the insurer, and even the state attorney general without resolution. So she expects she will, reluctantly, have to pay the $5,250 coinsurance that the hospital and insurer say she owes.

In response to questions from ��ϳԹ�� News, Scott Gilbert, a spokesperson for the health system, did not respond to the specifics of this case, but wrote: “Penn State Health recognizes that health care billing can be confusing and often overwhelming for patients. The process involves many factors, including the type of care provided, where it’s delivered and the details of a patient’s insurance coverage.”

A ‘Reasonable’ Price?

After a reporter sent multiple inquiries to Intermountain Health, McCullick said an agent asked him what would be “a reasonable amount to resolve the situation.”

Sara Quale, a spokesperson for Good Samaritan Hospital, the Intermountain affiliate where he got the PET scan, wrote: “We sincerely regret the frustration this situation has caused Mr. McCullick,” noting that “we have been in consistent contact with him and will continue to follow up as needed.”

McCullick said he wants to pay his fair share but is still trying to figure out what that is — certainly less than the different self-pay prices he’s been offered, which all top $10,000. “The fluid nature of these numbers is mind blowing,” he wrote in an email.

As for Estrada, he was so angry that he decided not to go ahead with the nerve ablation. While he was being prepped for the procedure, Estrada recalled, the physician said he had “heard he might sue” and chastised him for being a troublemaker. The hospital did not respond to a request for comment on the allegations, and Estrada said he had never threatened legal action.

Estrada got off the table and put his shirt back on. “I’m not going to let this person put a big needle into my back.”

Bill of the Month is a crowdsourced investigation by and that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? !

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He Needs an Expensive Drug. A Copay Card Helped — Until It Didn’t.

Elisabeth Rosenthal — Fri, 27 Feb 2026 10:00:00 +0000

Over the course of 2025, Jayant Mishra of Mission Viejo, California, progressively developed scaly, itchy red patches on his skin. Then came the pain and swelling in the joints of his hands, making it difficult to do his work at a bank.

His primary care doctor referred him to a rheumatologist, who diagnosed psoriatic arthritis. She advised Mishra that while there’s no cure, there were many new medicines that could keep the autoimmune disease in check, and she recommended one, Otezla.

At first, Mishra balked. He knew the medicines were expensive. He worried about side effects. He thought he could manage with over-the-counter drugs.

But by September he was in so much pain that he agreed to try a starter pack provided by Otezla’s manufacturer, Amgen. It worked: The skin lesions disappeared, and the joint pain that kept him up at night dissipated. He was sold.

His rheumatologist got approval for the drug from his insurer, UnitedHealthcare, and signed him up for Amgen’s copayment assistance program. Having enrolled other patients, she told Mishra the copay card, similar to a credit card, should last a year, he said, shielding him from the drug’s high list price: around $5,000 for a 30-day supply, .

He said the doctor explained that, in her patients’ experience, insurers and their pharmacy benefit managers negotiated a deeply discounted price with Amgen — she estimated $1,400 to $2,200 a month. Patients paid a percentage of that amount, their “patient responsibility,” using the copay card.

Mishra said he was approved for a copay card covering $9,450 a year. “I was happy when I got the message,” he said.

He added that the doctor reassured him about the cost. “She said: ‘You shouldn’t have to pay anything out-of-pocket. Your copay card will cover this.’”

He started the medicine and, at first, paid nothing.

Then the bill came.

The Medical Service

Otezla, which comes in a pill, is approved to treat some autoimmune disorders, including psoriatic arthritis.

The Bill

$441.02, for the second month’s fill of the drug — before Mishra chose to ration rather than refill his prescription, because his copay card was empty.

The insurance statement from UnitedHealthcare’s pharmacy benefit manager, Optum Rx — another subsidiary of the same parent company, UnitedHealth Group — showed it did not provide a negotiated discount and covered just $308.34 of the full $5,253.85 charge for a 30-day supply. The charges for the second month depleted the copay card and left Mishra owing the balance.

The Billing Problem: Copay Card ‘Tug-of-War’

Copay assistance programs are part of a “tug-of-war between drug manufacturers and insurers,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies the pharmaceutical industry.

The value of drugmakers’ copay cards has become more unpredictable as insurers try to restrict their use. Many insurance plans, for instance, do not count the money from a copay program .

And patients who use a copay card can wind up paying full or nearly full price rather than the discounted rate negotiated by their insurer’s pharmacy benefit manager.

“When you purchased your medication a Manufacturer Coupon was used,” Mishra’s explanation of benefits statements read, in tiny letters. The amount the copay card covered “was not applied towards your Deductible and Out of Pocket Maximum.”

Caroline Landree, a spokesperson for UnitedHealthcare, said that “the copay card is an arrangement between the patient and the pharmacy. It is used outside of insurance.”

In an emailed statement, Elissa Snook, a spokesperson for Amgen, expressed a different view of who was responsible for Mishra’s dilemma: “Copay assistance programs are designed to help patients start and stay on prescribed therapy, but the value of that assistance can be exhausted more quickly when a health plan requires patients to pay the full list price of a medicine.”

Few patients can afford the list prices that pharmaceutical manufacturers charge in the United States for brand-name drugs.

Insurers insulate themselves and their customers from those higher prices through pharmacy benefit managers’ negotiated discounts. They might, for example, designate certain drugs as preferred medications for plan members in exchange for the manufacturer agreeing to a significant price reduction.

Manufacturers’ copay assistance programs offer another way for patients to avoid paying full price. The assistance is intended to encourage patients to choose an expensive, brand-name drug — not one that “treats the same condition that the insurer has gotten for a cheaper price,” said Fiona Scott Morton, an economist at the Yale School of Management who studies drug pricing.

The assistance also discourages patients from discussing with their doctor whether a cheaper, generic drug would do, drug industry researchers said.

While the Food and Drug Administration first approved a generic version of Otezla in 2021, Amgen has of its generic competitors, ensuring the brand-name drug has patent protection until 2028. Generic versions are available overseas and in Canada, where patients can purchase it in some cases for .

Mishra said one of his children joked he could cover a trip to visit relatives in India simply by purchasing his medicine while he was there.

The Resolution

Mishra has a health plan with a $5,000 deductible and contributes to a tax-free health savings account.

In September, he paid for the first month’s supply of Otezla with the copay card. But paying for October’s supply emptied the card — which he originally expected to last a year — and he said he used his HSA to pay for the roughly $400 that remained.

But wary of what the drug would cost in November and December, Mishra said, he tried to spread out the pills he had left from the starter pack and the first two months’ supply. He skipped some days and took only half of the prescribed dose to stretch the supply for two more months, knowing he would get a new copay card with the new year. Many of his symptoms returned, he said.

In January, he got another copay card, good for $9,450, which again wasn’t sufficient to pay for two months’ supply. He again paid the remaining balance in February from his HSA to count toward his $5,000 annual deductible. This time he owed $550, he said.

Mishra said his symptoms have resolved. With no clue what he’d be charged for March’s supply, he called UnitedHealthcare in late February and was told he would need to pay $4,450 for the month to meet his out-of-pocket maximum, he said.

But he said he pressed the representative further, asking why UnitedHealthcare doesn’t have a negotiated price. It does, they told him. “Actual price is $6,995.36.”

Mishra says his doctor reassured him that a copay card would cover his out-of-pocket costs for an expensive drug to treat psoriatic arthritis. But the assistance ran out much sooner than he’d expected. (Ariana Drehsler for ��ϳԹ�� News)

The Takeaway

Copay cards and drugmaker programs that promise patients “you could pay $0” work in mysterious ways.

On the one hand, they encourage patients to use brand-name or expensive drugs that are off insurers’ formularies, or lists of preferred, covered drugs. On the other, many patients couldn’t afford prescribed medicines without them.

Patients with public insurance, such as Medicare and Medicaid, are not permitted to use the cards, because the government considers them an end run around its attempts to bring down drug spending.

Using a copay card has gotten trickier as insurers push back. First, patients need to understand whether there is an annual dollar or time limit on the card and how it works with their insurance. Otherwise, they risk ending up reliant on a drug they can’t afford.

Less expensive drugs often can suffice. For example, there are a number of medicines to treat psoriatic arthritis, some of which may be cheaper or have better coverage from a particular insurer. Patients should ask their doctors whether cheaper medicines will work.

It also can help patients to consider their prescriptions when they select a health plan. Landree, of UnitedHealthcare, said Mishra could have selected a plan for 2026 that would have covered Otezla for a $100 copay each month, though that would have meant a higher premium.

“Personally I’m not in financial distress — I can afford it,” Mishra said. “But it was sticker shock, and it just doesn’t seem right.”

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Scorpion Peppers Caused Him ‘Crippling’ Pain. Two Years Later, the ER Bill Stung Him Again.

Elisabeth Rosenthal — Fri, 19 Dec 2025 10:00:00 +0000

Maxwell Kruzic said he was in such “crippling” stomach pain on Oct. 5, 2023, that he had to pull off the road twice as he drove himself to the emergency room at Mercy Regional Medical Center in Durango, Colorado. “It was the worst pain of my life,” he said.

Kruzic was seen immediately because hospital staff members were pretty sure he had appendicitis. They inserted an IV, called a surgeon, and sent him off for a scan to confirm the diagnosis.

But the scan showed a perfectly normal appendix and no problems in his abdomen. Doctors racked their brains for other possible diagnoses. Could it be a kidney stone? Gallstones? Here was a 37-year-old man in agony, but nothing really fit.

Then, someone asked what Kruzic had eaten the night before. He said he’d consumed tacos with some hot sauce that he’d made from a kind of scorpion pepper, grown from seeds he ordered from a chile pepper research institute.

The peppers measure over 2 million Scoville heat units on the spiciness scale, he noted, compared with a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.

The peppers are among “the world’s hottest, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and had never had a problem with it, but apparently this was just too much burn for his digestive system.

Kruzic spent much of the night on a gurney in the ER. After about four hours, the pain decreased, and he was sent home with medicine to treat nausea and vomiting.

Then the bill came — about two years later.

The Medical Procedure

Kruzic underwent blood work and a CT scan of his abdomen during his ER visit for acute abdominal pain.

Consuming very spicy foods painful inflammation and irritation of the digestive system. The discomfort typically resolves on its own.

The Final Bill

$8,127.41, including $5,820 for the CT scan. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 — the remainder of the $1,585.26 he owed toward his plan’s deductible and $972.22 he owed in coinsurance.

The Problem: Ghost Bills From Visits Past

This September, Kruzic received a bill for his pepper-induced ER visit in 2023.

Unfortunately for patients, there are no uniform rules for timely billing.

Anticipating a bill, Kruzic repeatedly checked the hospital’s online portal, as well as that of his insurer, UnitedHealthcare. He noted that the insurer said the claim had been processed shortly after his treatment. For about eight months, he kept checking the hospital portal’s billing section, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.

It is unclear what caused the nearly two-year delay. At least part of the problem seems to have involved protracted disagreements between the insurer and the hospital over how much his visit should have cost.

It took two years for Kruzic to get a bill for his October 2023 trip to the ER. There are no uniform rules requiring hospitals and other medical providers to bill patients in a timely manner after care. (Jeremy Wade Shockley for ��ϳԹ�� News)

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to ��ϳԹ�� News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”

Asked why it had taken two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.

But UnitedHealthcare contested that view. “This was paid accurately,” said Caroline Landree, a spokesperson for the insurer.

But those explanations don’t satisfy Kruzic, a geological consultant: “Receiving a bill two years after the service wouldn’t fly in any other industry. We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’”

“How could this be considered anything but surprise billing?” he added.

The federal No Surprises Act doesn’t protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they visit an in-network hospital, or in an emergency.

But in medical billing, what’s legal and what’s reasonable are two very different issues.

“The bill certainly sounds outrageous,” said Maxwell Mehlmen, co-director of the Law-Medicine Center at the Case Western Reserve University School of Law. “The question is whether it’s legal.”

That, he said, “is a matter of state law and the terms of the insurance policy and the agreement between the hospital and the insurer.”

In Colorado, there are extensive regulations about how long health care providers have to file a claim and . For instance, claims for Medicaid patients must be filed from the date of service. For patients with private insurance, the terms may be outlined in their insurers’ contracts with individual providers.

If a hospital and the provider and insurer were working out payment in good faith, then a patient can be billed for their share of the costs years later.

The Resolution

Within hours of ��ϳԹ�� News contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.

Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said that UnitedHealthcare had taken so long to properly pay the bill that the hospital couldn’t collect from the patient. She said that Kruzic’s statement balance “was to be adjusted to zero, but due to a clerical error, a statement was sent to the patient in error.”

UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the physician’s office.”

“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.

“Receiving a bill two years after the service wouldn’t fly in any other industry,” says Kruzic, who works as a geological consultant. “We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’” (Jeremy Wade Shockley for ��ϳԹ�� News)

The Takeaway

��ϳԹ�� News’ “Bill of the Month” series receives complaints every year about ghost bills — bills that arrive long after a service is rendered.

Sometimes it’s because the insurer and hospital are haggling over payment, and the patient’s responsibility — usually a percentage of that number — can’t be calculated . Other times, insurers audit old bills and, determining they overpaid, try to claw back the money, resulting in the patient (or ) being billed for the difference.

For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.

An insurer’s word that a claim has been “processed” doesn’t mean that the insurer has agreed to pay and that the billing is resolved. It could also mean that the insurer balked at the bill or completely denied payment.

As for Kruzic and his affinity for hot peppers? He said he still loves spicy food, but in his cooking, “I will not use scorpion peppers again.”

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

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Will Trump’s Team Slow Supersized Health Mergers?

Elisabeth Rosenthal — Fri, 14 Nov 2025 19:30:00 +0000

Rising health care costs and the impending expiration of expanded Obamacare subsidies fueled the record-setting government shutdown that ended this week.

But there’s another driver of escalating costs and prices playing out in a far broader, more impactful way: the rapid consolidation of insurers, hospital systems, doctors’ groups, and pharmacies into behemoths, effectively giving them monopoly power.

Calling it “mutually enforced monopolization,” Barak Richman, the Alexander Hamilton professor of business law at George Washington University, told me: “It’s not competition. It’s more like collusion. They don’t care about price.”

In our market-based system, the price of each service is determined through a complex set of negotiations between an insurer and a provider. An insurer might agree to pay grossly inflated prices for a hospital system’s labs to gain access to that system’s must-have cancer center – and that cancer center might be in a town halfway across the country, where the insurer has a lot of clients.

The result is high prices: A patient who visits a hospital lab for a simple blood test could be stuck with $1,000 or more in deductibles, copays, and coinsurance.

Studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%.

At first, anti-competitive consolidation was easy for government regulators such as the Federal Trade Commission and the Justice Department to spot, because it involved hospitals acquiring other hospitals or providers in their own market area. But in recent years, new types of deals have been harder to police. Giant hospital systems now acquire providers far away, deals known as trans-market mergers. Insurers acquire doctors’ practices and specialty pharmacies, often called vertical mergers.

President Joe Biden had made oversight of health care mergers a priority, issuing that included these new types of consolidation. His FTC chair, Lina Khan, was vocal in her criticism of the trend.

Her successor under President Donald Trump has signaled a more moderate approach. But in an exclusive interview with ��ϳԹ�� News, Daniel Guarnera, the director of the FTC’s Bureau of Competition, said that the new leadership at the FTC and the Justice Department has endorsed the 2023 guidelines “as a framing device” for companies contemplating a merger.

What this means going forward remains unclear. Khan is now advising New York City Mayor-elect Zohran Mamdani.

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As Health Companies Get Bigger, So Do the Bills. It’s Unclear if Trump’s Team Will Intervene.

Elisabeth Rosenthal — Mon, 10 Nov 2025 10:00:00 +0000

A cancer patient might live in a town with four oncology groups, but only one accepts his insurance — the one owned by his insurer. A young couple could see huge bills after their child is born, because their insurer agreed to the health system’s rates in exchange for a contract with obstetricians across the country. A woman might have to pay a big sum she can’t afford for basic lab tests at a hospital — inflated rates her insurer accepted so its customers have access to the system’s children’s hospital elsewhere in the state.

And even well-insured patients receive unaffordable bills in this era of high-deductible health plans, narrow insurance networks, and 20% cost sharing.

Health systems, doctor groups, and insurers are merging and coalescing into ever-bigger giants. While these mergers are good for business, studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%.

These new deals are “mutually enforced monopolization,” said Barak Richman, the Alexander Hamilton professor of business law at George Washington University. “It’s not competition. It’s more like collusion. They don’t care about price.”

Those market factors contributed to a landscape where a dose of the antiviral Paxlovid given in a hospital ; magnetic resonance imaging ; and joint replacements .

President Donald Trump has talked about the burden of health care costs since his first campaign, but he has signaled that his administration’s regulators are less inclined than his predecessor’s to intervene in health mergers.

This summer, President Joe Biden’s that all federal agencies make sure markets remain competitive, reversing course from Biden’s more expansive interpretation of antitrust law. And in a scathing statement upon taking over the Federal Trade Commission, Trump-appointed chair Andrew Ferguson , implying that she had overstepped the agency’s legal authority, as well as criticizing what he called her “clumsy” and “breathless” rhetoric and her focus on the incursion of private equity into health care.

What this will mean in practice is unclear.

In an interview with ��ϳԹ�� News, Daniel Guarnera, the director of the FTC’s Bureau of Competition, said that the leadership at the FTC and the Justice Department has endorsed guidelines issued by the Biden administration, which he characterized as a “framing device” for companies contemplating a merger.

The expanded , issued in 2023, focused for the first time on a wide variety of new types of anti-competitive practices that had become common in health care, such as hospitals and private equity firms buying doctors’ practices and insurers owning what are known as specialty pharmacies to dispense complicated and often expensive drugs.

Guarnera noted that regulators’ strongest enforcement tool is convincing a judge that mergers violate the Clayton Antitrust Act, a statute that is the foundation of antitrust law. But administrations can interpret this statute differently, and it’s unclear what cases the Trump administration’s FTC will choose to bring.

“The Biden administration tried to be more innovative,” said a professor of health services, policy, and practice at Brown University’s School of Public Health. “The Trump administration has signaled a more traditional approach — that it’s unwilling to push the envelope.”

In the battle for profits between insurers and providers, each side insists it needs to grow bigger to hold sway in the negotiations that determine health care prices. But evidence shows the prices that make sense in industry-level dealmaking have little to do with the actual value of the services involved. Instead, they’re merely a data point in large-scale calculations that, at best, reflect the power balance between opposing parties.

Under Trump, the FTC has already sued to block two mergers of medical-device makers and has continued the Biden administration’s challenges of individual drug patents.

“Helping improve the health care system though ensuring that there is more and better competition are very, very high priorities for us at the FTC,” Guarnera said, noting that health care has “enormous effects on both Americans’ pocketbooks as well as well-being.”

But it is far more difficult to take on the more massive entities, and though the number of new mergers dipped as companies navigated the uncertain effects of tariffs and interest rates, consolidation continues.

A recent identified “28 large health systems growing bigger,” noting, “This is not an exhaustive list.”

For example, in May, Northwell Health of New York Connecticut’s Nuvance to become a 28-hospital behemoth with over 1,000 outpatient clinics. That was a more traditional merger, where hospitals in the same region joined to extend their reach and increase their market power.

Meanwhile, companies are creating powerhouses not previously seen in health care, by racking up smaller purchases that aren’t expensive enough to trigger federal review. They include what are known as vertical mergers, which combine companies that provide different functions in the same industry — most commonly, hospital systems or insurers buying doctors’ practices or specialty pharmacies.

For instance, UnitedHealth Group, the , now owns health insurance plans; physician practices and other providers; data and analytics services; payment processors; a pharmacy benefits manager; and pharmacies themselves. Jonathan Kanter, the competition czar in Biden’s Justice Department, has likened the UnitedHealth amalgamation to Amazon.

Likewise, hospital systems and private companies — often private equity firms — are increasingly expanding their reach to different regions, gobbling up hospitals, medical practices, and surgery centers. This kind of consolidation, known as a , allows companies to accumulate huge collections of doctors — and significant market power — across the country in particular specialties, such as gastroenterology, ophthalmology, pediatrics, or obstetrics.

Research shows a change in ownership means a change in prices. While pediatrics and obstetrics have traditionally been poorly paid specialties, for instance, they represent a land of opportunity to investors because parents are willing to pay more when it comes to care for their kids.

It used to be relatively simple for regulators to discern when a hospital that merged with its nearby competitor gained monopoly power, rendering it anti-competitive and driving up prices. Health researchers say these new, more complicated types of deals, creating a more complex interplay between insurers and medical providers, have made that tipping point to define.

In health care, even more traditional, vertical consolidation can be problematic, Richman said. “Economic theory says it could be innocuous, like a suit manufacturer opening a store, even though studies show in health care it’s dangerous — higher prices, poorer quality, less choice,” he said.

For example, patients who have Cigna health plans and need an array of more expensive, often injectable prescriptions must use Accredo, the specialty pharmacy in 2018, even though a different pharmacy may have a better price.

Economists have developed computer modeling to predict when patients will experience higher prices and less choice because of these new types of consolidation. But judges who could nix the transactions are so far “not convinced,” said Daniel Arnold, a health economist at Brown’s School of Public Health.

Experts such as Fuse Brown say new laws and enforcement tools are needed.

“The old laws,” she said, “are just not calibrated to the complexity and novel types of mergers.”

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Listen: Young Adults Turning 26 Face Health Insurance Cliff

Elisabeth Rosenthal — Fri, 26 Sep 2025 09:00:00 +0000

LISTEN: Obamacare. COBRA. Deductibles. Coinsurance. There’s a lot to figure out when you’re on your own looking for health insurance for the first time. ��ϳԹ�� News senior contributing editor Elisabeth Rosenthal appeared on WAMU’s “Health Hub” series on Sept. 24 to help young adults find a plan that meets their needs.

Many young adults are staring down an “insurance cliff” as they turn 26. That’s the age when many can no longer stay on their parents’ health insurance. If they can’t get coverage through their job, they’ll need to start looking for their own. The search can be nerve-racking and confusing. ��ϳԹ�� News senior contributing editor Elisabeth Rosenthal appeared on WAMU’s “Health Hub” on Sept. 24 to share some tips for finding the right plan.

Read her full article for more help starting your search.

Already have an Affordable Care Act insurance plan? Check out KFF’s to find out how much more you may have to pay next year if enhanced tax credits expire.

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The Price Increases That Should Cause Americans More Alarm

Elisabeth Rosenthal — Fri, 22 Aug 2025 09:00:00 +0000

Wary of inflation, Americans have been watching the prices of everyday items such as eggs and gasoline. A less-noticed expense should cause greater alarm: rising premiums for health insurance. They have been for years and are now rising faster than ever.

Consider that, from 2000 to 2020, fluctuated between just under $1 and about $3 a dozen; they reached $6.23 in March but then fell to $3.78 in June. Average , after seesawing between $2 and $4 a gallon for more than a decade starting in 2005, peaked at $4.93 in 2022 and recently fell back to just over $3.

Meanwhile, since 1999, health insurance premiums for people with employer-provided coverage have . From 2023 to 2024 alone, they rose more than 6% for both individuals and family coverage — and overall inflation.

For many people who have the kind of insurance plans created by the Affordable Care Act (because they work for small companies or insure themselves), rates have probably risen even more drastically. In this market, insurers’ proposed rate increases, but only if they exceed 15%.

And the situation is about to get worse: For 2026, ACA marketplace insurers have proposed : In New York, UnitedHealthcare has proposed a 66.4% rise. HMO Colorado has asked for an average increase of in that state. In Washington, the across all insurers is 21.2%, and in Rhode Island it’s 23.7%.

According to Business Group on Health, a consortium of major employers, “actual health care costs have since 2017.” In a published in 2021, 87% of companies said that in the next five to 10 years, the cost of providing health insurance for their workers would become “unsustainable.”

And insurers in the ACA marketplace are increasing premiums by an average of 20% for next year, according to a . Imagine if tens of millions of Americans’ rent or mortgage payments were to suddenly increase by that amount.

Insurance regulators theoretically that these proposed rates be lowered — and this often happens. But some states are more active than others in this regard. And all are wary that too much regulatory interference could drive insurers from their markets.

Insurers offer many explanations for their calculations, some of which are tied to recent actions by Congress and President Donald Trump. New tariffs on America’s trading partners, for example, are expected to push up the cost of drugs and medical supplies.

Meanwhile, included in the GOP budget bill, along with the expiration of some Biden-era premium subsidies at the end of this year, will cause many people to lose their health insurance. About are expected to become uninsured by 2034, in many cases because keeping insurance will become unaffordable.

Because most of these people are likely to be young and/or healthy, the “risk pool” of those remaining insured will become older and sicker — and therefore .

“Ultimately, we believe the ACA market will likely be smaller and higher acuity-driven next year,” Janey Kiryluik, vice president of corporate communications for Elevance Health (formerly known as Anthem), wrote in an email. She added: “Our position reflects early disciplined action.”

Remember, most insurers in the United States are public, for-profit companies; as such, they tend to act in the interests of their shareholders, not the patients whose health care they cover.

Large employers that manage their own health care plans might be able to negotiate better deals for their workers. But smaller companies, for the most part, will need to accept what’s on offer.

Premiums are not the only part of health insurance that’s getting more expensive. Deductibles — the money that beneficiaries must spend out-of-pocket before insurance kicks in — are also rising. The average deductible for a standard ACA silver plan in 2025 , about double what it was in 2014. (For those with employer-based insurance, the average number is .)

A few states are trying to stem the tide by offering a state-run “public option,” a basic affordable insurance plan that patients can choose. But they because a lower payment rate for workers generally means fewer participating providers and reduced access to care.

If voters paid as much attention to the price of health insurance as they do to the cost of gas and eggs, maybe elected officials would respond with more action.

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Reduced ACA Subsidies May Make It Harder for Young Adults To Afford Coverage

Elisabeth Rosenthal — Fri, 15 Aug 2025 19:30:00 +0000

As they move into adulthood, many young Americans face a unique and daunting challenge: finding their own health insurance by the time they turn 26. The lucky ones are covered through their jobs. But in an age of gig employment, more are falling off the “26 insurance cliff” and landing hard.

For a project produced in partnership with The New York Times, my colleague Hannah Norman and I gathered statistics (where they existed) and asked young people to tell us their stories. And, boy, they did. The article clearly touched a nerve, gathering over 1,600 comments the day after it published.

Many of the young adults we interviewed for the article, like Elizabeth Mathis and Evan Pack, a couple in Salt Lake City, could afford their insurance only because of Biden-era premium subsidies for plans bought through the Affordable Care Act, which created where people can purchase health insurance. Those subsidies expire at the end of this year and, so far, Congress has shown little interest in extending them. If they expire, studies estimate, premiums are expected to rise next year, and roughly would lose coverage.

The cliff was an unintended byproduct of a part of the Affordable Care Act that allowed young adults to stay on their family plan until 26. That number was chosen somewhat arbitrarily, as an age when people should be able to afford standardized plans created by the ACA or go on Medicaid.

In many respects, the law was an immediate win for young adults, or at least an improvement over the prior state of affairs: Kids were commonly kicked off the family plan earlier, at 18 or 21, for example, and thrown into an open market where insurance products could exclude basic health needs, like reproductive care, and insurers could refuse to cover patients with preexisting conditions, like asthma.

Millions of young adults gained insurance who would have otherwise gone without. But in the intervening years, Republicans undercut many of the ACA provisions that helped form this safety net, and, today, 26 is the age at which most Americans are uninsured.

“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration. (Pollitz is also a former ACA expert for KFF, a health information nonprofit that includes ��ϳԹ�� News.) “The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”

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‘Alternative Facts’ Aren’t a Reason To Skip Vaccines

Elisabeth Rosenthal — Thu, 14 Aug 2025 09:00:00 +0000

President Donald Trump’s administrations have been notorious for an array of “alternative facts” — ranging from the relatively minor (the size of inaugural crowds) to threats to U.S. democracy, such as who really won the 2020 election.

And over the past six months, the stakes have been life or death: Trump’s health officials have been endorsing alternative facts in science to impose policies that contradict modern medical knowledge.

It is an undeniable fact — true science — that vaccines have been miraculous in preventing terrible diseases from polio to tetanus to measles. Numerous studies have shown they . That is accepted by the scientific community.

Yet Secretary of Health and Human Services Robert F. Kennedy Jr., who has no medical background or scientific training, doesn’t believe all that. The consequences of such misinformation have .

For decades, the vast majority Americans willingly got their shots — even if a significant slice of parents had misgivings. A 2015 survey found that 25% of parents believed that the measles, mumps, and rubella (MMR) vaccine could cause autism. (A that suggested the connection has been thoroughly discredited.) Despite that concern, just 2% of children entering kindergarten were exempted from vaccinations for religious or philosophical objections. Kids got their shots.

But more recently, poor government science communication and online purveyors of misinformation have tilled the soil for alternative facts to grow like weeds. In the 2024-25 school year, rates of full vaccination for those entering kindergarten dropped to just over 92%. In more than a dozen states, the rate was under 90%, and in Idaho it was under 80%. And now we have a stream of measles cases, more than 1,300 from a disease declared extinct in the U.S. a quarter-century ago.

It’s easy to see how both push and pull factors led to the acceptance of bad science on vaccines.

The number of recommended vaccines this century, overwhelming patients and parents. That is, in large part, because the clinical science of vaccinology has boomed (that’s good). And in part because vaccines, which historically sold for pennies, now often sell for hundreds of dollars, becoming a source of big profits for drugmakers.

In 1986, a typical child was recommended to receive 11 vaccine doses — seven injections and four oral. Today, that number to between 50 and 54 doses by age 18.

The Advisory Committee on Immunization Practices, which renders judgments on vaccines, makes a scientific risk-benefit assessment: that the harm of getting the disease is greater than the risk of side effects. That does not mean that all vaccines are equally effective, and health officials have done a lackluster job of fostering public understanding of that fact.

Older vaccines — think polio and measles — are essentially 100% effective; diseases that parents dreaded were wiped off the map. Many newer vaccines, though recommended and useful (and often heavily advertised), don’t carry the same emotional or medical punch.

Parents of the current generation haven’t experienced how sick a child could be with measles or whooping cough, also called pertussis. Mothers didn’t really worry about hepatitis B, a virus generally transmitted through sex or intravenous drug use, infecting their child.

That lack of understanding spawned skeptics. For example, since 2010, the vaccine for influenza, which had been around for decades, has been recommended annually for at least 6 months old. In the 2024-25 season, the rate of flu vaccination was only between ; in other years, it has been lower than that. “I got the flu vaccine, and I still got the flu” has been a common refrain of skeptics.

“Pre-covid, there were people who took everything but flu,” said , an associate professor at Johns Hopkins University’s Bloomberg School of Public Health, who studies vaccine demand and acceptance. “Then it became everything but covid. Now it’s everything — including MMR and polio.”

Even as the first Trump administration’s Operation Warp Speed helped develop covid vaccines, conservative media outlets that the shots were needed: doubts that mRNA technology had been sufficiently tested; doubts that covid-19 was bad enough to merit a shot; concerns that the vaccines could cause infertility or autism.

Trump these dangerous misperceptions and got when he said that he’d been vaccinated. Once vaccine mandates came into play, Trump strongly opposed them, reframing belief in the vaccine as a question of personal liberty. And if the government couldn’t mandate the covid shot for school, it followed that officials shouldn’t — couldn’t — mandate others.

Thus 100 years of research proving the virtues of vaccination got dropped into a stew of alternative facts. You were either pro- or anti-vaccine, and that signaled your politics. Suddenly, the anti-vax crowd was not a small fringe of liberal parents, but a much larger group of conservative stalwarts who believed that being forced to vaccinate their kids to enter school violated their individual rights.

Even within the Trump administration, there have been some who (at least partly) decried the trend. While Marty Makary, the Food and Drug Administration commissioner, to roll back the recommendation that all Americans get annual covid boosters — saying the benefits were unproven — he noted it should not be a signal to stop taking other shots.

As “public trust in vaccination in general has declined,” he wrote, the reluctance to vaccinate had harmed “vital immunization programs such as that for measles–mumps–rubella (MMR) vaccination, which has been clearly established as safe and highly effective.”

Nonetheless, Makary’s boss, Kennedy, continued to about vaccines broadly, even as he sometimes grudgingly acknowledged their utility in cases like a measles outbreak. He has funded new research on the already disproven link between MMR shots and autism. He has halted in grants for developing vaccines using mRNA technology, the novel production method used for the first covid vaccines and a technique scientists believe holds great promise for preventing deaths from other infectious diseases.

In my 10 years practicing as a physician, I never saw a case of measles. Now there are . More than 150 people have been hospitalized, and three, all unvaccinated, have died.

Alternative facts have formed what David Scales, a physician and sociologist at Weill Cornell Medical College who studies misinformation, calls “an unhealthy information system.” It is an alternative scientific universe in which too many Americans live. And some die.

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