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Dan: Hey there, you don’t need me to tell you. 2025 has been a lot. 

I mean, just with health care: As I record this, the US government has been shut down for more than a month over whether to extend health insurance subsidies that more than 20 million people rely on. 

I mean, if Congress resolves this tomorrow– and I’m not holding my breath–it’s still gonna be a huge mess.

And I could definitely go on. But I’m not gonna do that.

Instead, I’ve been spending my time these last few weeks looking at what’s happened this year that didn’t suck and what we can learn from that. 

And it turns out, at the state level, there’s a lot to look at. 

All over the country, state governments took action this year to make things suck a little less — on things like medical debt and health insurance and the price of drugs.

And it happened dozens of times this year in a lot of states.

Nebraska Newscaster: New tonight, new Nebraska legislation will make it easier for patients to access healthcare.

Maine Newscaster: We’re on your side tonight as a new law aimed at protecting Maine consumers from the impacts of medical debt goes into effect.

Virginia newscaster: Virginians are only one medical crisis away from bankruptcy according to advocates. That’s why the General Assembly passed a bill to create some protections for people facing medical debt.

Dan: And I’ve been talking with people who helped get new non-sucky laws passed this year.  In red states, blue states, purple states. 

And I cannot wait to start introducing you to some of these folks and to share what I’ve learned about what they got done — and maybe most important: how they did it…’cause we need more non-sucky laws passed in as many places as possible.

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 on this show 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.

Here. Let me introduce you to somebody.

Eliot Bostar: My name is Eliot Bostar and I am a legislator in Nebraska. I represent Legislative District 29, which covers essentially South Lincoln, our capital city.

Dan: I thought Nebraska was interesting. One ’cause it’s a state we don’t hear from as often. It’s not a blue coastal state. 

Eliot Bostar: Whatever the opposite of that is, that’s what we are. Yes.

Dan: And Eliot Bostar sponsored and passed legislation this year imposing new rules on prior authorization. 

That’s where your doctor or your provider tells you you need something, a drug, a test, a procedure, and the insurance company comes back and says, yeah, not so fast. Your provider has to show us why that’s necessary.

And look, just to zoom out: 

There’s an argument here that not everything that gets prescribed or ordered is actually necessary or even appropriate. But in practice, prior authorization can result in treatment getting delayed or denied in ways that seem arbitrary and unreasonable and that have big consequences. 

In a recent survey from the American Medical Association, almost 30% of doctors said problems with prior authorization had led to a patient getting hospitalized or becoming permanently disabled, or sustaining other permanent damage, or almost dying, or actually dying. 

Amy Killelea is a professor with Georgetown University’s Center on Health Insurance Reforms.

They’re part of a research team tracking prior authorization, and whenever they give a talk to college students, to policy nerds, to groups of patients with conditions like diabetes, they’ll say this.

Amy Killelea: Raise your hand if you’ve ever had a problem or um, an emotional reaction to prior authorization, and every hand in the room goes up. It’s so ubiquitous. It’s something that everybody can relate to on like a fundamental, visceral level. 

Dan: Amy Killelea says this kind of anger is starting to show results. The Georgetown Center tracks state laws on prior authorization.

In 2024 they know of 10 that passed.

In 2025, so far, they have logged 20.

And looking over their list, a couple of things stand out. One is these are 20 politically diverse states. Alaska, Rhode Island, Arkansas, California, Montana.

You get the idea. The other thing that stands out is these things they’re regulating generally make you go, wait. There was no law against that before? 

I mean, Nebraska’s new law regulating prior authorizations is about as aggressive as anything I’m seeing on this list. And the results are just, like, common sense.

Like for one big example: if an insurance company denies your prior authorization request, or an appeal, that denial now has to come from a licensed clinician with relevant experience.

And when I talked with Eliot Bostar, I was like, wait, like this wasn’t required before?

Eliot Bostar: You’d be surprised. So, I’ll give you an example. A neurosurgeon was attempting to get approval for fusing of a cervical disc in the spine, right? There was a person that was at risk of honestly paralysis and got an initial denial, appealed, and got another denial. And that denial came from a pediatrician. 

Dan: Like a general… 

Eliot Bostar: General practice pediatrician.

Dan: How old was the patient?

Eliot Bostar: An adult.

Dan: Okay. Not, not, not, not a candidate for pediatric care. All right.

Eliot Bostar: Or, a request is put in for a medication by a prescribing physician and a denial comes back from a dentist.

Dan: Yeah. None of that was illegal under Nebraska law, until now. 

And not just Nebraska. Four other states passed similar rules just this year 

And there are more what I’ll call, “wait, what?” kind of provisions in Nebraska’s new law.

Like it sets a deadline for how long your insurance can make you wait for a yes or no on prior authorization, or like, they can’t make you wait for prior authorization to approve an ambulance ride to the ER. 

And Nebraska’s law also features a technical provision that I don’t think anybody would’ve imagined a few years ago.

It outlaws the use of AI as the sole basis for denying coverage. 

And Eliot Bostar says insurance companies don’t say they’re doing that, but he’s seen examples that look a lot like it. 

Eliot Bostar: Physicians putting in a request through a digital platform, um, putting in all the information, hitting submit, and then instantly getting a denial. There’s not a lot of ways that can happen, right? It’s not that there was a human who sat there and read it all and was thoughtful, analyzed the case, and made a determination of denial within half a second. So something else happened in that time, and so that should not happen anymore.

Dan: Two other states, Maryland and Texas restricted the use of AI this year, according to that cheat sheet I got from Georgetown. 

So, Elliot Bostar and his colleagues got a big win. He says the state medical society, Nebraska’s chapter of the American Medical Association and the state hospital association were big allies. 

But health insurance companies are powerful opponents. Eliot says, in earlier years, he and his allies had tried taking smaller swings at prior authorization– and gotten swatted away. This time, they went big.

Eliot Bostar: The decision was made that we were gonna, we were gonna really go after all of it. We’re gonna go after all of it.

Dan: He says a lot of that decision came down to sheer frustration and a little bit of political calculation. A big swing can rally people to you and give the other side good reason to take you seriously.

Eliot Bostar: I think it’s important to make clear that we’re not going to put up with a system that’s this broken, any longer. You can be really direct. So you can tell the insurance companies, we’re gonna do something. And you can either kind of work with us on how to do that or, or not.

Dan: And then he set out to divide and conquer.

Eliot Bostar: If insurance companies themselves don’t necessarily agree with each other, or they’re not fully aligned on a bill or on a policy, that can effectively neutralize the industry.

Dan: I asked him:, how’d you figure out who you might be able to pick off? 

Eliot Bostar: So Blue Cross Blue Shield in Nebraska is just a Nebraska company, right? They’re part of the larger Blue Cross, you know, network, but they are just a Nebraska company versus United is not.

Dan: He said by the time the bill came up for a hearing, he’d been negotiating with insurance companies for months and he didn’t get everything he wanted. But you know, it passed.

Eliot Bostar: I don’t think anyone voted against it. 

Dan: Eliot Bostar says his strategy got a boost from some specifics of Nebraska’s legislative structure.

Like there’s just one house, a Senate. 49 members smallest in the country, and elections are nonpartisan. So things work differently than they do in most places.

Eliot Bostar: There’s no majority leader. There’s no whip, there’s no any of that.

Dan: He says that setup allowed him to hand sell this proposal to one colleague at a time. 

So some lessons here: 

One, go big. Why the heck not? 

Two: Figure out who you can pick off in the opposition. 

Three: However the political structure works in your state, work it.

Because, you know, lawmakers in 20 states made new rules on prior authorization this year. They don’t all work like Nebraska. 

One caveat here, states don’t have all the power. With health insurance, that’s especially true. 

You know, we’ve talked about this before. If you get your health insurance from work– especially if you work for a good sized company– your health plan is probably set up in a way where state insurance regulations don’t apply.

But Eliot Bostar says he gives local employers a two-part pitch to offer their workers similar protections. 

One, they can save money because delaying care now can mean more-expensive care later. 

Two, because new state protections raise everybody’s expectations. 

Eliot Bostar: And how much of a unfortunate shame would be if their employees didn’t receive the same benefits that perhaps their neighbors are.

Dan: In other words, you want to piss off your workers? He says sometimes it works. 

Just ahead: In Virginia, a new law bans wage garnishment for medical debts — and caps interest at just three percent. Democrats passed it. The Republican governor signed it. How’d they pull it off? 

That’s next.

This episode of An Arm and a Leg is produced in partnership with ���ϳԹ��� News. That’s a nonprofit newsroom covering healthcare in America. These folks are amazing journalists. Their reporting wins all kinds of awards every year. We are honored to work with them.

Ok, let’s meet a couple folks from Virginia.

Amanda Gago Silcox: I am Amanda Gago Silcox. I am the education and resource manager here at Virginia Poverty Law Center.

Jay Speer: I’m Jay Speer. I’m the Executive director and consumer rights attorney at the Virginia Poverty Law Center.

Dan: Their organization, VLPC, for short, does a bunch of stuff. 

Among other things, they operate toll free helplines for folks struggling to pay utility bills. They coordinate with local legal aid offices across the state and. They lobby in the state capital. 

Medical debt is a big issue for them, and this year they helped pass a law that will limit how far Virginians can get chased for medical debt specifically, it caps interest on medical debt at 3%.

Amanda Gago Silcox: And then the bill also bans garnishing the wages of anyone qualifying for financial assistance.

Dan: …which seems like common sense.  like if you qualify for financial assistance from a hospital, you should be getting your bill reduced or canceled, not getting money grabbed from your paycheck. Or having your home foreclosed on to pay a hospital bill, which has also happened, and which the new law will also ban. Along with … getting arrested over a hospital bill. Yeah.

And there’s another provision that VPLC really pushed for in this bill. It’s gonna sound technical, but this is big.

Amanda Gago Silcox: It prohibits, the sale of medical debt to a debt buyer unless they follow basically the same requirements as are required of medical creditors.

Dan: Here’s why that’s big. There are two kinds of collection agencies. There’s the kind that work for a hospital or whoever and get paid basically on commission and then — as Jay explains– there debt buyers. Those are different. 

Jay Speer: They’re the ones that pay anywhere from one to 5% of what’s owed and then sue you for the whole amount. Debt buyers deal in volume. They get, they buy thousands and thousands of debts and they sue everybody.

Dan:Yeah, Jay says VPLC has analyzed data from across the whole state court system-  and saw just how many lawsuits debt buyers were actually filing.

Jay Speer: In Virginia last year, they filed 45% of the lawsuits in Virginia. Um, so it’s a huge amount.

Dan: 45% all lawsuits, like..?

Jay Speer: …of all lawsuits were filed by debt buyers.

Dan: The new law aims to put the brakes on that, at least from medical debts. 

Jay Speer: It says if you sell the debt to a debt buyer, you have to have an agreement with that debt buyer that they will follow these rules.

Dan: That is, they won’t charge more than 3% interest. No garnishing wages, no foreclosing on homes, no arrests. Jay thinks requiring these kinds of agreements could basically mean providers just won’t be able to sell to debt buyers. ‘Cause he’s been studying how that whole side of medical debt actually works.

Jay Speer: I’ll tell you right now, there is no such thing as these agreements between providers and debt buyers.

Dan: Hmm.

Jay Speer: All debt buyers buy is a spreadsheet with names and numbers on it. They’re not gonna enter into these agreements. Maybe I’m wrong. I mean, they could change their whole practice, but I would be surprised.

Dan: That’s the kind of insight VPLC brought to the push for this law. But Amanda admits that push wasn’t part of some master plan. 

Amanda Gago Silcox: And you know, I wish that we had planned many, many days and months, to work on this bill, but it kind of fell in our laps.

Dan: She says late last year, she heard from an advocate with a national group called Blood Cancer United–  they advocate for cancer patients, not cancer–with a pitch for the idea.

Amanda Gago Silcox: I’ll be quite honest, I was like, wow, this is really aggressive. I don’t know about this.

Dan: Jay was skeptical too. Getting a bill like this passed would be one thing, even with Democrats holding majorities in both legislative houses, but then Republican Governor Glenn Youngkin would need to sign it.

Jay Speer: And the governor also has a history of vetoing tons and tons and tons of bills, five times more than any other governor’s ever vetoed. And so that’s hanging over the whole thing.

Dan: But Amanda says The folks at Blood Cancer United were very gung-ho. They promised to bring patients with powerful stories to tell

… and they thought VPLC’s technical expertise, including their research on debt buyers, would add a lot.

And they’d already lined up a sponsor: Delegate Carrie Delaney, who had just succeeded in passing a bill to keep medical debts off of credit reports.

Jay Speer: So we knew she was serious about it. I mean, that’s always a consideration when you’re thinking about legislation is, who’s your patron? Are they really serious about it?

Dan: VPLC decided to join up. Amanda took point on their lobbying, she says. It wasn’t easy.

Amanda Gago Silcox: I remember there being a day where it just felt like we were giving up little pieces here and there, and I was like, I just don’t know if what we’re gonna get out of this is worth it. We’ve given up everything. This doesn’t even do anything anymore. 

Dan: Specifically, she says the cap on interest looked like it was gone. 

Amanda Gago Silcox: Yeah. I thought we were gonna have to give that up.

Dan: Somehow the interest cap came back in. Amanda got her faith back. 

And she says there were also moments that gave her confidence, like just making the rounds of legislators offices to drop off information and sign up for a time to meet with the lawmakers.

Amanda Gago Silcox: When we were talking to their administrative assistants and we mentioned that we were there to talk about medical debt and many, many of the administrative assistants mentioned, oh yeah, like my husband had cancer and we had X, Y, Z, Or I had a friend who had breast cancer and she had this happen to her. So it really resonated with, with legislators’ staff, with the folks that they’re surrounded with. So I think that really helped us continue pushing.

Dan: And they won. Both houses. Now It was the governor’s move. 

Jay Speer: So Virginia has a weird process. Where they send the bills to the governor. The governor either signs the bills, vetoes the bills, or makes a quote recommendation. In this case, he made a recommendation.

Dan: He wanted to weaken the bill, so that sends it back to the legislature.

Jay Speer: And they either accept his recommendation, which puts the bill in, into law, or they reject it. Then it goes back to the governor. And the governor then has two choices. He could veto it or sign it. So it’s a risky business to reject his recommendation because you’re almost taunting him to veto it.

Dan: So when legislators DID reject the governor’s recommendation, Jay and Amanda say they were shocked.

Amanda Gago Silcox: We were shocked when it went back to the governor and he did in fact sign it. I mean, I thought we were, it was gonna be vetoed. 

Jay Speer: I was sure he was gonna veto it. I mean, like I said, he is vetoed like God five times more bills than any other governor. 

Jay Speer: I think the only explanation is he’s nervous about this and it makes him look bad to not help people out with medical debt.

Dan: They didn’t get everything they wanted. 

The law doesn’t take effect till July, 2026,, and it exempts credit cards, including medical credit products like CareCredit, which issues a plastic card–  and charges 33% interest after a promotional period.

Amanda Gago Silcox: So this is definitely an area where there’s some work to be done.

Dan: Yeah, like me, these folks are never gonna run outta material. Meanwhile, they won a victory this year. They really didn’t think they’d get. And talk about having a lot of material. I reported a whole story about how Maine passed a law to keep medical debts off of credit reports. State Senator Donna Bailey sponsored that bill, which passed unanimously, and a similar bill had failed before, but this time she says: 

Donna Bailey: I don’t remember a lot of heavy pushback, which was pleasantly surprising to me, quite honestly.

Dan: We’ll get to that one.

By the way, five other states did the same thing this year, total of 15 since 2023, and a bunch of states passed new regulations on pharmacy benefit managers. The most aggressive was probably Arkansas. So yeah, there is more news that didn’t suck coming.

And speaking of things that don’t suck as we bring you this episode, it’s November, which means I get to test something I’ve been saying to my colleagues for a long time. Reaching more people with An Arm and a Leg is both our mission imperative, ’cause we wanna be of the most use to the most people. And it’s our business model ’cause the way we’ve gotten this far is by asking you listeners, will you help us keep doing this? And a certain fraction of people have always said yes. And I’ve said, if we can reach more people, well that’s more people to say yes. And that will allow us to do more and keep growing. And this year I get to test that because Seattle’s Public Radio Station, KUOW, became our distributor this year, and they’re helping us reach a lot more people than we did a year ago, like twice as many.

And so I get to test this theory and under really favorable conditions because. November is the beginning of a project called News Match from the Institute for Nonprofit News. Now news match matches individual gifts of up to a thousand dollars. And this month through a special gift from the Jonathan Logan Family Foundation, especially for an arm and a leg news match is double matching your gifts.

So if you’ve been listening, if you have found this show entertaining and empowering and useful, if you think it’s cool to hear what states are doing to make things suck less and how they’re doing it, if you found it useful when we ran down ways to save money on prescription drugs. If you think it is awesome that Arm and a Leg listeners have been coming together to build tools to help other folks stay out of medical debt, then this is your chance to make a lot more of that happen. ’cause every dollar you give us this month is matched two for one. You give us 50 bucks, it turns into $150. You give us a hundred, bam it’s 300. 

And you know, we have so much work to do. All you have to do is go to armandaleg show.com/support.

That’s armandaleg show.com/support and News Match will make your gift count for triple Your support becomes super support. 

I mean, let’s do this, Armand leg show.com/support. 

Thank you so much. We’ll be back before Thanksgiving with our next episode. Till then. Take care of yourself.

(Psst: Arm and a leg show dot com, slash, support. Thanks!)

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. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with ���ϳԹ��� 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.

 Zach Dyer is senior audio producer at ���ϳԹ��� News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.