[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 ºÚÁϳԹÏÍø News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with ºÚÁϳԹÏÍø News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly â€” in the words of longtime Congress watcher  â€” a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year â€” but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when â€¦ we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers â€” which are actually stronger than many predicted, with fewer people actually dropping coverage â€” reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But â€¦ I think what Julie said is it’s â€¦ the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time â€¦ 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more â€” the out-of-pocket cost of insurance for millions of Americans, 20-ish million â€” but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but â€¦ I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high â€” in economically â€” zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not â€¦ it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers â€” and I’ll post a link to them â€” you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside â€” they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why â€” because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right â€” you know, again, including senators like Cassidy, but also these activist groups â€” they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication â€¦ I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

¸é´Ç±¹²Ô±ð°ù:ÌýSo, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

OK, we’re going to take a quick break. We will be right back. 

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there â€¦ who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs â€¦  

Rovner: Puberty blockers! 

Edney: â€¦ they’re taking â€” exactly â€” and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now â€” most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat â€¦ the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer â€¦ they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion â€” that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over â€” I’m not exactly sure how many years â€” 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes â€” some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health â€” that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just â€¦ like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people â€” and to Alice’s point about how this hasn’t saved money â€” more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just â€¦ a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 â€¦ now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away â€” you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell â€” he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t â€¦ you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer â€” if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians â€” how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who â€” like, I don’t know how all of you watch it â€” but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS â€” or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

[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 ºÚÁϳԹÏÍø News and WAMU Public Radio in Washington, D.C. Welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø 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 â€” say, you left your job and then needed to find some other health insurance after a period of time â€” 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 â€” it wasn’t really insurance â€” 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 â€” which now we’ve started calling these the ACA marketplaces or Obamacare markets or that sort of thing â€” 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 â€” the raw total gross, whatever word you want to say, how much the insurance company is charging â€” 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 â€” which is what Congress is debating right now â€” 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 â€¦ 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 â€” if everyone waits until they’re sick to get health insurance and only sicker people are buying health insurance â€” 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 â€” 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 â€” effectively getting rid of the individual mandate â€” 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 â€” 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 â€” because you have to have an income of at least the poverty level to be getting a subsidy in this market â€” 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 â€” since you have to be 65 to get on Medicare â€” 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 , 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 â€” 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 â€” 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 â€” if that actually does come to be â€” 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 â€” and I obviously would feel more comfortable signing up on my own without the help of someone â€” 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 â€” who were here legally â€” 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 â€” which they normally don’t want to do â€” 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  or on Bluesky . Cynthia, are you hanging on social media these days? 

Cox: Yes. @cynthiaccox on both  and . 

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

[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 ºÚÁϳԹÏÍø News and, starting this week, from WAMU public radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again. 

Winfield Cunningham: Hi, Julie. It’s great to be back. 

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving. 

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either. 

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America. 

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that. 

Rovner: Well, of course, and SNAP isn’t an HHS program. 

Goldman: Exactly. Exactly. 

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find? 

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan — which, of course, is what, we know … that’s what the subsidies are pegged to — is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it. 

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand. 

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …  

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks. 

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain. 

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely — because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced … and now they have no cap. 

Rovner: I think 8.5% of their income, actually, under the enhanced premiums. 

Winfield Cunningham: Under the enhanced. OK. 

Rovner: It’s going to go back to 10%. 

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%. 

Rovner: 400%. 

Winfield Cunningham: Right. Yeah. Yeah. 

Rovner: That’s right. 

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it. 

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies. 

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue. 

Winfield Cunningham: This is very true. 

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something. 

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So … 

Rovner: Yeah. Although it is … 

Goldman: Obviously, that’s a lot of what ifs, but … 

Rovner: … only the death spiral that goes back to prior to covid, which — it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA. 

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers — will be subject to the full force of the premium increases because they won’t have any subsidies. 

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.  

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further — this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought — yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget — states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought? 

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that — I don’t know what health systems have said about this particular move, to be honest — but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is. 

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant. 

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC? 

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this. 

Rovner: Yeah. I’ve seen numbers as low as 60,000. 

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels. 

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years. 

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics. 

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades — focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that. 

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic. 

Ollstein: Exactly. 

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My ºÚÁϳԹÏÍø News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes? 

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects. 

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head. 

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary. 

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division — that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo — to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way — even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.? 

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data. 

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the … give credence to this idea that — I see you nodding, Maya — that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain. 

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch. 

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So … 

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications. 

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do. 

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line. 

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, . Is contraception going to become the next health care service that’s only available in blue states, Alice? 

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services. 

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two. 

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something? 

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate. 

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods? 

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want. 

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but … 

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight. 

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week? 

Goldman: Sure. So this story is from ºÚÁϳԹÏÍø News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked. 

Rovner: Yeah, it is a public health issue, an interesting one. Alice? 

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah. 

Rovner: Yeah. A combination of a lot of different factors in that story. 

Ollstein: Definitely. 

Rovner: Paige? 

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague. 

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my ºÚÁϳԹÏÍø News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.  

OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, , or on Bluesky, . Where are you folks hanging these days? Maya? 

Goldman: I am on X as and I’m also on . 

Rovner: Alice? 

Ollstein: on Bluesky and on X.  

Rovner: Paige? 

Winfield Cunningham: I am still on X. 

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

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–

Over the summer, our pals at ºÚÁϳԹÏÍø News published a story with the headline: “Insurers and customers brace for double whammy to Obamacare premiums.”

Basically– whammy number one — insurers are planning to raise premiums for 2026 —

And whammy number two: federal subsidies for Obamacare policies are scheduled to get a lot less generous. 

Together, these whammies mean millions of people will be looking at paying a LOT more every month — like hundreds of dollars more. 

Folks are going to need as much advance warning as possible, to figure out how to prepare for a hit like that.

Meaning: This is our kind of story. 

And this one hits a little close to home. Because one of those folks is An Arm and a Leg’s senior producer, Emily Pisacreta.

Emily: Yeah, it’s a wild time. I’ve never had to do this before. Cuz I’ve always had health insurance through work. I’ve totally shaped my life around that because I have diabetes, and without health insurance, I can’t afford what I need.

Dan: But that health insurance has never come from An Arm and a Leg. When Emily started working here as an intern, she was the first person besides me to work more than a few hours a week. We didn’t have an employee health plan because we didn’t have employees.

And we’re still so tiny, so tiny. Apart from summer interns, there’s still only ever been one other person working more than a few hours a week besides the two of us. I’m still the only full-time person, and we still don’t have an employee health plan.

Emily: And until recently, that worked for me– I had another part-time job, and it had health benefits.

Except my contract with that job just ended. 

So for the first time, like more than 20 million other people, I’m looking at open enrollment. And I gotta say, it’s one hell of a year to do that. 

Dan: You’re a double-whammy case study. 

And to get a broader perspective, the two of us talked with Julie Appleby, the reporter who wrote that “double-whammy” story, and since then you’ve continued to do more homework. 

Emily: It’s been pretty intense!  

Dan: For real. And I’m a little bit of a case study too:

Suddenly I’m finding out what our country’s “system” — where health insurance gets tied to jobs — looks like … from the employer side. It’s a whole new adventure. 

We don’t know exactly what we’re going to do. Honestly, I don’t think anybody does.

But we’ve learned a ton. About what we’re up against — along with millions of other people — and our options.

And by tackling this right now — six weeks before open enrollment starts — I hope we can help a lot of other people start planning early with solid information. Let’s go.

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 picked 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.

So, we started by checking in with the person whose reporting first got us looking at this story.

Julie Appleby: It’s recording. It looks like it says 10, 11,

Dan in interview: perfect.

Julie Appleby: I have notes and I’ll try not to rattle the papers. 

Emily in interview: I mean, if we have a reporter on tape rattling papers, I feel like that’s probably okay.

Julie Appleby: Okay. That’s a plan, man.

Emily in interview: Yeah. Why don’t we start out, could you just like, tell us your name and what you do and where you work?

Julie Appleby: So this is Julie Appleby. I’m senior correspondent at ºÚÁϳԹÏÍø News.

Emily in interview: What sort of stuff do you cover?

Julie Appleby:  I cover healthcare policy, but that’s a broad term. So everything from cost to, the Affordable Care Act, to what’s going on with Medicare, all kinds of different things involving health care programs and insurance.

Emily in interview: So we were really excited to talk with you, because we wanted to cover, you know, all the changes to the marketplace plans, that you’ve been writing about. And, it just so happens that I need to enroll in a marketplace plan.

Julie Appleby: So let’s give you kind of the rundown. There’s like, there’s kind of like two things going on here. One of them is that just premiums are going up as they do every year. Although this year it’s bigger than it’s been since 2018. So the median increase nationwide, and this is according to some data research by KFF, is about 18%. So that’s a big jump, right? 

Emily in interview: Yeah. Yeah. In your reporting you called it a double whammy. Rates are going up, enhanced subsidies are probably going away. 

Julie Appleby: Right. That’s the second half of the double whammy.

Dan: OK, breaking in here– gonna do this a couple of times for Obamacare vocabulary. Emily just mentioned an important term, went by kinda fast: enhanced subsidies. Obamacare has always included subsidies for most people — that’s part of the “Affordable” part of Affordable Care Act. But for lots of people, Obamacare policies still were… pretty expensive!

So, in 2021 — like, as part of a COVID recovery package — Congress added extra subsidies for Obamacare policies: Enhanced subsidies. 

Julie Appleby: Basically, they made the coverage more generous on both ends of the income spectrum. In fact, I think I was looking at some statistics this morning and something like, 80% of people who have coverage right now have a plan that’s $10 a month or less.

Dan: These are folks with lower incomes — where paying sixty or eighty dollars a month is a big bite. With “enhanced” subsidies, that became ten dollars — or even zero.

But people with higher incomes also got help. Before the enhanced subsidies, people with incomes above a certain level didn’t get ANY subsidy. People called it an “income cliff.”

For the last four years these enhanced subsidies, kind of erased that cliff. If your income was higher, you just paid a percentage of your income. Enhanced subsidies picked up the rest.

But the enhanced subsidies weren’t permanent. They’ll expire at the end of this year, unless Congress extends them. Otherwise… 

Julie Appleby: people who make more than the four times the federal poverty level will not qualify for any help with their premiums under the Affordable Care Act. There will be that cliff.

Emily in interview: Right, right. 

Dan: And it turns out Emily is basically standing on that cliff. She shows Julie the numbers.

Emily: We found this calculator from KFF that attempts to show the changes in premiums if the subsidies expire. And maybe I’ll just share my screen and we can look at – we can look at what I’m looking at.

Okay, you guys see KFF? Maybe just reload and I can enter some Emily figures in here. So, they ask you about where you live and your yearly household income. 

Dan in interview: what’s the amount that you’ve entered as income?

Emily in interview: I have entered $63,000. And it says, without enhanced subsidies, you will likely lose financial help. Because my income is 418% of the federal poverty level.

Dan: Oy. a little more Obamacare vocabulary. First: Federal poverty level. Four times that level is where you fall off the income cliff, no subsidies. 400 percent. And the calculator – which we should say, is a year out-of-date, so the numbers aren’t precise, but they give us an idea– that calculator says Emily’s at 418.

And next:  Obamacare plans come in different “levels,” like Olympic medals: Bronze, Silver, Gold… Bronze plans are the cheapest, and cover the least. 

If Emily got a subsidy, the calculator says a silver plan would be like 400-and some dollars a month, but it says Emily wouldn’t GET a subsidy, so… 

Emily in interview: It would be about $880 a month for a silver plan, or $675 a month for a bronze plan. So for me, that is stressful to read. 

Julie Appleby: That’s a lot of money. 880 bucks a month. So you’re in the situation where you don’t get any, subsidies because your income is over that amount. But I played around with one of these calculators too when I wrote a story recently. And I also plugged in somebody, let’s say who’s earnings are kind of at the lower end of the income scale, say just over 150% of the federal poverty level. So they’re still gonna pay more. They’re, it’s gonna go from paying sort of a national average of about $2 a month to 72 bucks a month, or $864 a year. And remember, this is somebody who’s making 23,000 a year. So $864 is a lot of money. 

Dan in interview: Emily, can you put that calculator back up on the screen for us?

Emily in interview: Sure can.

Dan in interview: The scary calculator. I mean, what would happen if your income were just a little bit lower? If you just shave $3,000 from your income, what does it look 

Emily in interview: So maybe like 60? 

Julie Appleby: I bet you could even shave a little bit less. Why didn’t you make it 62?

 (Sfx: Buzzer) 

Dan: How about 61? What does 61 do for us?

Emily in interview: Can I get a 61 

(SFX: Buzzer) 

 Dan: how about $60,500?

 (SFX: Buzzer) 

Dan in interview: I feel like this is like an auction reverse.

Julie Appleby: in reverse.

Emily in interview: I know this is like the auction from hell

Dan in interview: Yeah, we’re, we’re lowering your income. So let’s keep going. $60,200,

 (SFX: Ding!) 

Dan in interview: That is it. Holy crap it’s a giant cliff. It’s a $5,000 cliff

Dan: Breaking in one last time:  Five thousand dollars is how much money Emily might save on Obamacare premiums if her income stays below that 400 percent line.  Put another way: It’s how much more she’d have to pay if she steps over that cliff.

Dan in interview: Julie, what does that look like to you, seeing that?

Julie Appleby: I think this also, this illustrates a lot of things. I mean, people are gonna have to keep in mind that cliff for next year if these tax credits aren’t extended. This is a projection, this is what you think you’re going to earn next year. So that’s one thing that to keep in mind, okay? And something could happen. Emily could, I don’t know, maybe she wins the lottery or she goes to the casino and wins a bunch of money and that puts her over. 

Emily in interview: Or offers me, you know, a freelance job that’s really interesting. It doesn’t pay that much, but just puts me over, you know? 

Dan in interview: You have to say, I’m sorry, that freelance job is gonna cost me more than $5,000 to accept.

Dan: So, Emily: listening back to that conversation now. What are you feeling?

Emily: I mean, I was trying to stay calm but internally I was freaking out. As Gen Z likes to say, I was crashing out.

Dan: It was really emotional. We both needed time to cool off, just to put this story together.

Emily: Yeah, this situation is stressful. I don’t know for sure how much money I’m even going to make next year. And it feels kind of weird to put all this out here. I don’t know how any of this sounds to other people. Because maybe it sounds like 400% of the federal level is a lot of money. And in some parts of the country it definitely is. But I live in New York City. So my income doesn’t go that far. And that $880 bucks a month we were talking about? That’s actually a big hit. 

Dan: Yeah and — not to pile on, but: the data behind the calculator where we got that number, 880 — that’s last year’s data.  So it doesn’t include the big premium increases that Julie was writing about. The actual amount you’d  be paying every month would be bigger. And you looked up the deductible: more than four thousand dollars. 

Emily: Right, which I won’t have lying around at the beginning of next year either. Yeah so honestly, all of it still makes me want to scream. 

Dan: Yeah, and you’re a case study for a LOT of people. Julie read us a really sobering number, where one consulting group estimated that with this double-whammy Obamacare enrollment could drop by like half or more. 

And, in fact, one of the reasons insurers say they’re raising prices this year is– without the enhanced subsidies, they figure a lot of healthy people will just opt out. 

Emily:  I can see why people don’t sign up. I mean,  I don’t have that choice. But in order to get a subsidy, I’d have to lower my income, and to a very specific number – which is less than I live on now. And watch it to make sure I don’t take in a penny more. 

Dan: While still paying hundreds of dollars a month for Obamacare – even with a subsidy.

Emily: And look. This is a thing a lot of people do. All the time. –intentionally limit their income to qualify for assistance.. To keep Medicaid, people skip out on jobs, careers, marriage. 

 So my situation is NOT unique. It’s definitely not the worst.

Dan: You’re our in-house case study. You can’t stand in for everybody.

I mean, just to add one more wrinkle: If you didn’t live in a super-expensive city, your premiums would actually be lower..

I used that calculator to look up what you’d pay for a silver plan in … Chicago, like where I live? Way, way cheaper. Like, unsubsidized? A lot less than a New York plan *with* a subsidy. I’m just saying.

Emily: That’s… wild. No shade on Chicago But I don’t think I’m ready to make a long distance  move for health insurance yet.

Dan: I’m just saying… 

Emily: But while we’ve been looking ahead to 2026 insurance, I’ve actually had a more-immediate decision to make.

Dan: Right.

Emily: LIke I said before, I had insurance through my old employer. But that’s ending. While we were doing this story, I had to figure out health insurance for the last three months of 2025.

Dan: You ended up getting some help from a real expert.

Emily: I sure did.

Dan: And: I called up An Arm and a Leg’s insurance broker.

Because like we said: If Emily’s a case study, so am I. We’re so small, and I’m the only one here who’s needed health insurance from this tiny little enterprise. Now, things are a little different.

What we’ve learned, and what’s next. That’s just ahead.

This episode of An Arm and a Leg is produced in partnership with ºÚÁϳԹÏÍø News. That’s a nonprofit newsroom covering health issues in America. Their journalists — like Julie Appleby — do amazing work. We’re honored to be their colleagues.

Emily: Julie Appleby left me with a little advice: Connect with an ACA navigator.

Dan: Navigators: These are folks who can guide you through the process of signing up for Obamacare. They’re not brokers, they don’t make a commission. They’re paid by the government. 

Emily: But they’re not government employees — local organizations work on government-funded contracts.

Dan: Which makes sense– Obamacare plans themselves are basically local: The menu of plans to pick from, they don’t just vary from state to state: They can be different from one county to another.

Emily: And I wanted a little perspective on how the whole navigator program works.

Dan: And it turns out: We know someone at the organization that coordinates all the navigators in New York state.

Elisabeth Benjamin: My name is Elizabeth Benjamin. I’m Vice President for Health Initiatives at the Community Service Society of New York.

Dan: We’ve spoken with Elisabeth before — a bunch of times — about her work pushing hospitals in NY to quit suing people over medical debt.

And yes, it turns out her shop also runs the network of navigators throughout New York.

Emily: But when we talked, it turned out, her connection to the navigator program is a little different than I’d expected.

Elisabeth Benjamin: I don’t, you know, run it day to day, but I, myself do help people individually enroll. Because it’s really important to understand what people are experiencing, what their concerns are. I have like a small group of people that I help every year, Lots of friends, children.

Emily in interview: Oh, that’s awesome. Okay. Yeah, I bet you’re like a great like auntie to have..

Elisabeth Benjamin: You know, people that turn 26 and the parents are like, I know, please, will you help me?

Emily: She was like: Look, everybody needs help.

Elisabeth Benjamin: The bottom line is, you know, it isn’t for the faint of heart. It is hard to work through these websites. I mean, they are as user friendly as possible, but there’s like little kind of little moguls that you have to kind of ski over and it’s easy to kind of miss a mogul and faceplant, and we don’t want that to happen.

Emily: And when I told her about how my story fits into this episode, she was immediately like.

Elisabeth Benjamin: Oh, well, I can help you.

Emily: Not with my whole 2026 dilemma: there’s just no information about 2026 plans out there yet. But for my immediate question — what do I do about the rest of 2025 – she was like, I’m pretty free tomorrow.

Elisabeth Benjamin: You can tape your enrollment.

Emily in interview: Oh my gosh, that would be amazing.

Dan: Seriously amazing. I mean, it sounded like good tape, which we always like. 

But also — we talked that day, you and me: You were really weighing some big decisions. 

Emily: I mean one was: Do I sign up for Obamacare for the rest of the year, or do I stay on my old employer’s plan?

Because a law called Cobra means they have to allow me to buy in — but I’d have to pay the whole monthly premium, which was SUPER high. More than a thousand dollars.

So Obamacare was looking good. Those extra subsidies are still in place through the end of the year.

Dan: There was a downside.

Emily: Yeah — starting a brand-new plan would mean starting with a brand new deductible– money I’d have to pay out of pocket before the new insurance kicked in for most things.

Dan: Those can be like thousands of dollars. 

Emily: Yeah, but then there was an amazing surprise: In New York, where I live, a new state law means that all Obamacare plans include insulin with no copay. Even if you haven’t paid out and hit your deductible. That’s a deal I’ve *never* gotten from any insurance, ever.

AND this deal included other diabetes supplies — like my continuous glucose monitor. That stuff can be hugely expensive.

So my thinking was like: I’ll grab the cheapest Obamacare plan– and get all my diabetes supplies — and I’ll try not to go to the doctor for the rest of the year. 

Elisabeth Benjamin: Okay, so ready?

Emily in interview: I’m ready.

Emily: The next morning, I showed up at Elisabeth Benjamin’s apartment.

Elisabeth Benjamin: All right. So Emily, here you are, you’re on my dashboard. Oh, wait, here I can make this easier for you. Let’s do the big screen. Okay. 

Emily: Elisabeth started walking me through the application.  Name, date of birth, address… pretty routine to start. 

Elisabeth Benjamin: That’s your phone number…

Emily: And at this stage I’m wondering if I should’ve just done it all myself and left poor Elisabeth alone.

But after a while — once we started actually looking at plans, I was like: Oh wow. Elisabeth was able to like really zip through things. It was a whole vibe.

Elisabeth Benjamin: Hold on one second. That’s not, that’s not important I wanna see if this is in network…

Emily: And she spotted things I would have totally missed.

Elisabeth Benjamin: So this is kind of an interesting plan. ’cause you would be able to go to a doctor or a specialist before the deductible.

Dan: Wait, you could do a doctor visit before you spent that deductible? That’s a thing?

Emily: Yeah, in that one plan, I guess? But even Elisabeth had to really dig to figure that out. 

Elisabeth Benjamin: Like see, it’s sort of a little frustrating because you wouldn’t, you couldn’t really tell that from this. This is why it’s helpful to have a navigator

Emily: I mean, super-helpful: With Elisabeth’s help, I got a plan 

Elisabeth Benjamin: and you’re done. 

Emily: where OK, I can’t actually SEE a doctor before the deductible. Not in person. But I CAN do telehealth. So if god forbid I get some kind of weird infection, I could get a prescription. Oh, and my actual doctor, like my endocrinologist, is covered. And the deductible is much, much lower than the other plans I’d been looking at. I mean, it’s still scary as hell, but HALF as scary-as-hell?

Dan: And the only catch is: You have to do this all over again in November or December. Except then — unless Congress extends the extra subsidies — you may be looking at much higher monthly payments.

Emily: Right. Actually, let’s come back to me in a minute. Because the good news in my case: At least I’ll be able to get Elisabeth’s help again. Like, she offered to, which was so nice. But also: even if she’s super-busy, I’ll be able to talk to another navigator. Because I live in New York.

Dan: Yeah. This is one of the things we learned from Elisabeth. It goes back one of the reasons we wanted to talk with her in the first place. Because there’s another big change with Obamacare this year: the federal government is cutting funding for navigators by like 90 percent. We wanted to hear from Elisabeth — how is that gonna affect her group’s work.

Emily: And — this was a surprise: She said it won’t affect her work at all– because New York navigators are funded by the state government. Turns out the same thing is true for about half the states. But I talked with Elisabeth’s counterpart in a state where that is not the case. 

Nicholas Riggs: We are not gonna be able to reach the number of people we did before. That’s just reality. You can’t do more with less. People will lose their coverage because of this.

Emily: That’s Nicholas Riggs. He runs the NC Navigator Consortium.

Nicholas Riggs: We cover all 100 counties. We’re the only navigator entity in North Carolina.

Emily: He says a big piece of their work is actually outreach– finding people who may not know they can get this kind of help.

Nicholas Riggs: You know, there’s no list of the uninsured.

Emily: And they don’t just help people pick Obamacare plans– they help people sign up for Medicaid. A 90 percent budget cut hits all of that. He says they’re looking for more volunteer navigators, but it won’t be the same as having experienced staff. 

Nicholas Riggs: What you’re losing is institutional knowledge. Volunteer navigators are great. But sometimes it takes a few years to really get a handle on some more complex cases.

Dan: I mean, Emily — you experienced first hand how big a deal it was to hae, like,  a real expert walk you through this process.

Emily: Elisabeth spent almost an hour with me!

Dan: A lot of people won’t have access to that kind of help. It’s one more crummy thing we’re trying to help people plan for. You found a map that shows which states fund their own navigators. We’ll post a link — so people can see what the deal is in their state.

And Emily, let’s come back to you for a minute: You’re lucky to have access to the world’s greatest navigator, but unless Congress extends the enhanced subsidies, that next conversation with her is gonna be a lot tougher.

Emily: I mean, unless I get another job with health insurance first. 

Dan: So, about that: While you were having your first conversation with Elisabeth, I was talking with An Arm and a Leg’s health insurance broker, Kurt Kaufman.

Because I was like: What can I do to make it possible for Emily to stick around?

I asked Kurt, could we set things up for Emily to buy into An Arm and a Leg’s plan? Like, at all?

Our insurance is from Blue Cross Blue Shield of Illinois. Could it cover Emily in New York? He was like

Kurt K: Yeah, that’s fine.

Dan: Then she,

Kurt K: a hundred percent.

Dan: She could be insured on our Illinois based plan, 

even though she’s in New York.. Is that right?

Kurt K: All day long.

Dan: All day long,

Kurt K: yep., 

Oh, yeah.

Dan: So I was like: Um, how much would it COST?

He said, based on your age — insurance gets more expensive as you get older — like, five, six hundred.

Emily: That’s a LOT less than what the scary calculator said I’d pay for a Silver plan with no subsidies. That was showing like nine hundred dollars.

Dan: Yeah. I mean: These are 2025 numbers, just like everything else we’ve been looking at. Everything in 2026 is gonna be higher. But it seems like An Arm and a Leg gets a better deal than you’d get with Obamacare. However, there’s a but. You’d need to be full-time.

Emily: Aha!

Dan: Yeah. I mean we’ve got you at 20 hours a week.

Emily: Yeah.

Dan: I was like Oh my god. I’d have to DOUBLE that? But Kurt was like: Actually, no. The way insurance looks at it, if you were working an average of 30 hours a week, then you could qualify.

Kurt K: She could be meeting that definition of quote unquote full-time employee.

Dan:  Which, you know, isn’t in my budget for next year– and I’m still working to make sure some other parts of our scrappy little budget get funded– but it’s not DOUBLE. I’m starting to think about it– like, a stretch goal. I mean, I’d LOVE to have more of your time. I dunno.

Emily: I mean I like the idea a lot! But there are just a lot of unknowns, right?

Dan: Yeah, here’s where we’ve landed: You’ve got health insurance lined up for the rest of 2025. And after that, there’s so much we don’t know. Will I find more money? Will you take another job? 

And: Will Congress extend the enhanced subsidies? When we first started working on this story, over the summer, experts were like, “That’s not gonna happen.”

But in the last few weeks, SOME Republicans have been proposing it. We definitely don’t know — and it’s nothing we can count on.

It’s all, honestly, a little scary.

Emily: Honestly, more than a little.

Dan: BUT: We know more than we did. We’ve started really confronting the scary numbers and the unknowns. You’ve taken a practice run at picking insurance.

Emily: That was actually kind of a big thing.

Dan: It was, right?  And: I’ve started thinking about stretch goals.

We’re more prepared.

And — here was the point of doing this whole case study– I HOPE we’ve just helped a lot of other people get more prepared, to start planning. 

We’ll keep you posted on how things go for us. Some updates will show up in our First Aid Kit newsletter. 

If you’re not getting First Aid Kit, go check it out. 

Emily: While we were reporting this story, we published a guide there: Get ready, emotionally and financially, for 2026 health insurance.

Dan:  It has links to resources we talked about here, and we’ll have more in this week’s First Aid Kit. 

What you wanna do is go tor at Arm and a Leg show dot com, slash, first aid kit.

You’ll find the whole archive there — including notes about honestly, some extremely exciting projects that Arm and a Leg listeners are doing — and how you can pitch in. 

We’ll be back with another podcast episode in a few weeks. Till then, take care of yourself.

Emily: This episode of An Arm and a Leg was produced by me, Emily Pisacreta 

Dan: and me, Dan Weissmann. 

Emily: With help from Janmaris Perez and Lauren Gould.

Dan: And edited by Ellen Weiss.

Dan: Adam Raymonda is our audio wizard. Claire Davenport is our engagement producer.

Dan: Our music is by Dave Weiner and Blue Dot Sessions.

Dan: Bea Bosco is our consulting director of operations.

Big thanks to Lynne Johnson, who just wrapped up her run as our operations manager. Lynne, your work has done SO much to make our work more sustainable. I can’t thank you enough.

Dan: An Arm and a Leg is produced in partnership with ºÚÁϳԹÏÍø 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.

Dan: Zach Dyer is senior audio producer at ºÚÁϳԹÏÍø News. He’s the editorial liaison to this show.

Dan: An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

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

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

[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 ºÚÁϳԹÏÍø News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with ºÚÁϳԹÏÍø News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies â€” the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly â€” in the words of longtime Congress watcher  â€” a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year â€” but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when â€¦ we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers â€” which are actually stronger than many predicted, with fewer people actually dropping coverage â€” reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But â€¦ I think what Julie said is it’s â€¦ the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the , and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time â€¦ 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more â€” the out-of-pocket cost of insurance for millions of Americans, 20-ish million â€” but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but â€¦ I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high â€” in economically â€” zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not â€¦ it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers â€” and I’ll post a link to them â€” you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside â€” they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why â€” because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right â€” you know, again, including senators like Cassidy, but also these activist groups â€” they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the , which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication â€¦ I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

¸é´Ç±¹²Ô±ð°ù:ÌýSo, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

OK, we’re going to take a quick break. We will be right back. 

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there â€¦ who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs â€¦  

Rovner: Puberty blockers! 

Edney: â€¦ they’re taking â€” exactly â€” and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now â€” most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat â€¦ the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer â€¦ they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion â€” that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over â€” I’m not exactly sure how many years â€” 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes â€” some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health â€” that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just â€¦ like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people â€” and to Alice’s point about how this hasn’t saved money â€” more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just â€¦ a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 â€¦ now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away â€” you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell â€” he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t â€¦ you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer â€” if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

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

Edney: Sure. So my extra credit is from MedPage Today: “.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians â€” how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “,” and it was really great, because there’s certain things I think that we who â€” like, I don’t know how all of you watch it â€” but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS â€” or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X , or on Bluesky . Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky  and still on X . 

Rovner: Joanne. 

Kenen: I’m mostly on  or on  . 

Rovner: Anna. 

Edney:  or X . 

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

[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 ºÚÁϳԹÏÍø News and WAMU Public Radio in Washington, D.C. Welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø 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 â€” say, you left your job and then needed to find some other health insurance after a period of time â€” 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 â€” it wasn’t really insurance â€” 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 â€” which now we’ve started calling these the ACA marketplaces or Obamacare markets or that sort of thing â€” 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 â€” the raw total gross, whatever word you want to say, how much the insurance company is charging â€” 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 â€” which is what Congress is debating right now â€” 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 â€¦ 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 â€” if everyone waits until they’re sick to get health insurance and only sicker people are buying health insurance â€” 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 â€” 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 â€” effectively getting rid of the individual mandate â€” 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 â€” 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 â€” because you have to have an income of at least the poverty level to be getting a subsidy in this market â€” 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 â€” since you have to be 65 to get on Medicare â€” 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 , 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 â€” 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 â€” 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 â€” if that actually does come to be â€” 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 â€” and I obviously would feel more comfortable signing up on my own without the help of someone â€” 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 â€” who were here legally â€” 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 â€” which they normally don’t want to do â€” 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  or on Bluesky . Cynthia, are you hanging on social media these days? 

Cox: Yes. @cynthiaccox on both  and . 

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

[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 ºÚÁϳԹÏÍø News and, starting this week, from WAMU public radio in Washington, D.C., and welcome to “What the Health?” I’m Julie Rovner, chief Washington correspondent for ºÚÁϳԹÏÍø News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So here we go. Today, we are joined via video conference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Good to be here. 

Rovner: And we welcome back to the podcast one of our original panelists, Paige Winfield Cunningham of The Washington Post. So great to see you again. 

Winfield Cunningham: Hi, Julie. It’s great to be back. 

Rovner: Before we dive in, we have a little of our own news to announce. Starting this week, we’re partnering with WAMU, Washington D.C.’s public radio station, to distribute the podcast. That means you can also now find us on the NPR app. And welcome to all you new listeners. OK, onto the news. We are now 30 days into the federal government shutdown, and there is still no discernible end in sight. And this Saturday is not only the start of open enrollment in most states for the Affordable Care Act health plans, which we’ll talk more about in a minute. It’s also the day an estimated 42 million Americans will lose access to food stamps after the Trump administration decided to stop funding the SNAP [Supplemental Nutrition Assistance] program. That’s something the administration did keep funding during the last Trump shutdown in 2019, and, according to budget experts, could continue to do now. So what’s behind this? As I think I pointed out last week, not such a great look to deprive people of food aid right before Thanksgiving. 

Ollstein: So I think this follows the pattern we’ve seen throughout the shutdown, which is just a lot of picking and choosing of what gets funded and what doesn’t. The angle of this I’ve covered is that out of all of the uniformed forces of the government, the Trump administration dug around and found money to keep paying the armed members, but not the public health officers, who are also part of the uniformed branches of the country. And yeah, you’re seeing this in the SNAP space as well. President Trump and his officials have openly threatened to go after what they see as Democrat programs. So it’s just interesting what they consider in that category. But you’re seeing a lot of choices being made to exert maximum political pressure and force various sides of this fight to cave, but we’re not seeing that yet either. 

Rovner: Yeah, they are. I mean, it seems this is also backwards because it’s usually the Republicans who are shutting down the government, the Democrats who are trying to pressure them to reopen it. And now, of course, we’re seeing the opposite because the Democrats want the Republicans to do something about the Affordable Care Act subsidies, and the Republicans are going after previously what had been kind of sacrosanct bipartisan programs like food stamps and the WIC [the Special Supplemental Nutrition Program for Women, Infants, and Children] program, for pregnant and breastfeeding moms and babies. And now, apparently, they’re going to stop funding for Head Start, the preschool program for low-income families with kids. On the one hand, you’re right, they are programs that are very cherished by Democrats, but I feel like this whole shutdown is now sort of going after the most vulnerable people in America. 

Goldman: It’s also been interesting because [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has tried to use SNAP as a vehicle for his Make America Healthy Again agenda, right? Trying to get states to limit the sugary drinks that their SNAP programs offer. And he’s, like, really touted that as part of the agenda. And now there does not seem to be any interest from HHS in speaking out about that. 

Rovner: Well, of course, and SNAP isn’t an HHS program. 

Goldman: Exactly. Exactly. 

Rovner: It’s a program in the Department of Agriculture, which is even more confusing, but you’re absolutely right. I mean, it’s odd that some of the things that he’s been pointing to are things that this administration is kind of trying to lay at the Democrats’ feet, as in, You want this program, reopen the government. So as I mentioned, Saturday is the start of Obamacare open enrollment in most of the states. And, Paige, you got a for plans in the 30 states that use the federal marketplace, which is now open for what we call window-shopping before open enrollment officially begins. What did you find? 

Winfield Cunningham: Yeah. So I got some documents at the end of last week showing that the average premium for the second-lowest-cost silver plan — which, of course, is what, we know … that’s what the subsidies are pegged to — is going up 30%, which is the second-highest premium increase. The highest we saw was 2017 to 2018. But this is a really, really significant increase. And of course, CMS [the Centers for Medicare & Medicaid Services] didn’t include that number in the document that it finally released this week. So the documents I saw had some sort of numbers like that, which were all stripped out of the official documents. But all of this is just so interesting because I was thinking about, back to 2017-2018, and the politics of this are so flipped right now because basically it was the Democrats then who didn’t want to talk about premium increases and the Republicans who were yelling about it. 

So it’s funny how that has changed. But I guess on the politics of this, it seemed for a while like Democrats were thinking maybe the Nov. 1 start of open enrollment would provide this out for them to pass the spending bill because they could say, like, OK, we tried. Now open enrollment has started, or the premiums are kind of baked, so we can’t really do anything to change it now. But I don’t think we’re going to have anything this week. It seems like both sides are pretty dug in still. I mean, I guess the other thing I would say on these costs, it’s really highlighting a weakness that we’ve known for a long time in the Affordable Care Act, which is that, like, yes, it made health insurance affordable for a lot of people, but there’s always been this smaller number of people that are above 400% federal poverty that have had no shield from insurance costs. They have the last four years, and now they’re not going to have one anymore. And it’s funny because Democrats are talking about this, but that’s sort of a problem they hadn’t wanted to acknowledge for a long time in the early years of the Affordable Care Act. And as you guys all know, there’s not going to be any political will for bipartisan work to create affordable options for these folks unless the subsidies get extended, which, of course, that doesn’t seem very likely at the moment from how things stand. 

Rovner: Yeah. Going back to what the Republicans sort of announced, their talking points, is that, well, first the premium increases aren’t that big and that the expiring extra subsidies aren’t that big a piece of it, both of which are actually kind of true. But, of course, that’s not where the sticker shock is coming from. The sticker shock is coming from the expiration of those tax credits that’s going to …  

So people who had been shielded from these very high premiums are no longer going to be shielded from them. And that’s why, if you look at social media, you see all these screenshots now of insurance that costs $3,000 a month for people who were paying $150 a month, which is obviously not affordable. Why is it so difficult to explain the difference? I’ve been working on different ways to explain it for the last three weeks. 

Goldman: I was trying to figure this out last night, when I was writing something for my newsletter today. And I think one of the really confusing parts about this is that, like Paige said, like Paige scooped, premiums are going up a certain amount, and that’s not actually what people are seeing. That’s not what almost anyone is going to actually face. Either you’re getting that huge sticker shock because you’re losing your subsidies that you had this year or you’re continuing to have subsidies, they’re not quite the same, but you’re still not going to pay a 30% increase. And so I think that that’s really confusing for me even, and hard to explain. 

Winfield Cunningham: I think one way to think about this is like the party that is going to bear the brunt of the premium costs to a large degree is the government because for people that are before 400% federal poverty, they are basically guaranteed under the Affordable Care Act that they’re not going to have to pay more for premiums over a certain percentage of their income. And so this just means, like, the subsidies are getting really expensive for the federal government, which goes back to the issue of kind of like why Democrats didn’t extend these enhanced premiums indefinitely — because it’s just expensive to do it. This is the government subsidizing private health insurance. And then it’s also significant again for those people over 400% poverty who had had a cap on what they would pay. I think it was 9.5% of their income under the enhanced … and now they have no cap. 

Rovner: I think 8.5% of their income, actually, under the enhanced premiums. 

Winfield Cunningham: Under the enhanced. OK. 

Rovner: It’s going to go back to 10%. 

Winfield Cunningham: Yeah. Yeah. But there’s no cap if you’re like over, over 400%. 

Rovner: 400%. 

Winfield Cunningham: Right. Yeah. Yeah. 

Rovner: That’s right. 

Winfield Cunningham: Yeah. But that’s why people are confused. And the other thing is, like, the administration is correct, that the vast majority of people in the marketplaces will continue to get subsidies. And we are basically going back to what the situation was before covid, but it’s that smaller number of people that are at the higher income levels. But the other thought I had was, of course, the health care industry and Democrats are talking a lot about this and spreading these huge premium increases far and wide and making sure everybody hears about them, but it’s like a relatively small number of people, if you think about it. 

And I think it’s only like a couple million people in the marketplaces who are at that higher income levels. And I wonder if that factors into Republicans’ calculations here, where they’re looking at how many voters are actually seeing these massive premium increases, having to pay for all of them. And in the whole scheme of the U.S. population, it’s not like a ton of people. So I just wonder if that’s one reason they’re sort of, like, seem to be increasingly dug in on this and very reticent to extend these subsidies. 

Rovner: Although I would point out that when the Affordable Care Act started, it was only a small number of people who lost their insurance, and that became a gigantic political issue. 

Winfield Cunningham: This is very true. 

Rovner: So it’s the people who get hurt who sometimes yell the loudest, although you’re right. I mean, at that point, the Democrats stayed the course and eventually, as Nancy Pelosi said, people came to like it. So it could work out the same way. It does help explain why everybody’s still dug in. Maya, you wanted to say something. 

Goldman: I was just going to say, I think it’ll be interesting to see, if subsidies aren’t extended, how this affects premiums next year for people and for the federal government, because if a couple million people drop out of the ACA marketplace because it’s too expensive, and those people tend to be healthier, then the remaining pool of people is sicker, and then that’s the death spiral, right? So … 

Rovner: Yeah. Although it is … 

Goldman: Obviously, that’s a lot of what ifs, but … 

Rovner: … only the death spiral that goes back to prior to covid, which — it was kind of stable at 12 million. I’m sort of amused by seeing Republicans complaining about subsidizing insurance companies. It’s like, but this was the Republicans’ idea in the first place, going back to the very origin of the ACA. 

Ollstein: And we should not forget that there is a group of people who are going to be losing all of their subsidies, not just the enhanced subsidies. And that’s legal immigrants, and that’s hundreds of thousands of people. So, like Maya said, that will probably mean a lot of younger, healthier people dropping coverage altogether, which will make the remaining pool of people more expensive to insure. So these things have ripple effects, things that impact one part of the population inevitably impact other parts of the population. And again, these are legal tax-paying immigrants with papers — will be subject to the full force of the premium increases because they won’t have any subsidies. 

Rovner: Yes, our health system at work. All right, we’re going to take a quick break. We will be right back with more health news.  

Moving on, the federal government is technically shut down, but the Trump administration is still making policy. You might remember last summer, a federal judge blocked a Biden administration rule that prevented medical debt from appearing on people’s credit reports. The Trump administration chose not to appeal that ruling, thus killing the rule. Now the administration is going a step further — this week, putting out guidance that tries to stop states from passing their own laws to prevent medical debt from ruining people’s credit, and often their ability to rent, or buy a house, or purchase a car, or even sometimes get a job. According to the acting head of the federal Consumer Financial Protection [Bureau], Russell Vought — yes, that same Russell Vought who’s also cutting federal programs as head of the Office of Management and Budget — states don’t have the authority to restrict medical debt from appearing on credit reports, only the federal government does, which of course he has already shown he doesn’t want to do. Who does this help? I’m not sure I see what the point is of saying we’re not going to do it and states, you can’t do it either. Part of this, I know, is Russell Vought has made no secret of the fact that he would like to undo as much of the federal government as he can. In this case, is he doing the bidding of, I guess it’s the people who extend credit, who, I guess, want this information, want to know whether people have medical debt, think that that’s going to impact whether or not they can pay back their loans, or is this just Russell Vought being Russell Vought? 

Goldman: I guess, in theory, maybe it goes back to the idea that if you have consequences for medical debt, then people will pay their bills, and maybe that would help the health systems in the long run. But I also think that — I don’t know what health systems have said about this particular move, to be honest — but I think there’s an interest in making medical debt less difficult for people to bear in the whole health system. So I’m not sure how popular that is. 

Rovner: Yeah. Yes. Another one of those things that’s sort of like, we’re going to hurt the public to thwart the Democrats, which kind of seems to be an ongoing theme here. Well, as we tape this morning, the Senate health committee was supposed to be holding a hearing on the nomination of RFK Jr. MAHA ally Casey Means to be U.S. surgeon general. Casey Means was going to testify via video conference because she is pregnant, but, apparently, she has gone into labor, so that hearing is not happening. We will pick up on it when that gets rescheduled. Perhaps she will appear with her infant. 

Back at HHS, a U.S. district judge this week indefinitely barred the Trump administration from laying off federal workers during the shutdown, but at the Centers for Disease Control and Prevention, it appears the damage is already done. The New York Times’ global health reporter, Apoorva Mandavilli, reports that the agency appears to have had its workforce reduced by a third and that the entire leadership now consists of political appointees loyal to HHS secretary Kennedy, who has not hidden his disdain for the agency and the fact that he wants to see it dissolved and its activities assigned elsewhere around the department. What would that mean in practice if there, in effect, was no more CDC? 

Winfield Cunningham: Hopefully we don’t have another pandemic. There’s just a lot of stuff the CDC does. And it’s been really confusing to follow these layoffs because in this last round, I remember trying to figure out with my colleague Lena Sun how many people were sent notices and then hundreds were sort of, those were rescinded and they were brought back. But yeah, I mean, I think we’re going to see the effects of this over the next couple of years. When I’ve asked the administration broadly about the reductions to HHS, what they say is that the agency overall has grown quite a lot in its headcount through the pandemic, which is true. I think they got up to like 90,000 or so. And then, according to our best estimates, maybe they’re back around 80,000, although I’m not entirely sure if that’s accurate. Again, it’s really been hard to track this. 

Rovner: Yeah. I’ve seen numbers as low as 60,000. 

Winfield Cunningham: It may be lower. Yeah. Yeah. So I think actually the 80,000, that may have been the headcount before the pandemic. Anyway, all that to say, it did grow during the pandemic, and that’s kind of the argument that they’re making, is that they’re just bringing it back to pre-pandemic levels. 

Rovner: But CDC, I mean, it really does look like they want to just sort of devolve everything that CDC does to the states, right? I mean, that we’re just not going to have as much of a federal public health presence as we’ve had over these past 50, 60 years. 

Winfield Cunningham: For sure. They’ve definitely targeted CDC. I mean, they mostly left CMS alone and FDA because, statutorily, I think it’s easier for them to shrink CDC, but it definitely is going to have massive effects over the next couple of years, especially as we see future pandemics. 

Ollstein: And the whole argument about returning to pre-covid, that doesn’t fit with what they’re actually cutting. I mean, they’re gutting offices that have been around for decades — focused on smoking, focused on maternal health, all these different things. And so this is not just rolling back increases from the past few years. This is going deeper than that. 

Winfield Cunningham: Well, yeah, it’s not like they’re just cutting the roles that were added since the pandemic. 

Ollstein: Exactly. 

Rovner: It’s not a last-in, first-out kind of thing. Well, as I said, since it looks like public health is now mostly going to be devolved to the states, let’s check in on some state doings. In Florida, where state Surgeon General Joseph Ladapo last month announced a plan to end school vaccination mandates. My ºÚÁϳԹÏÍø News colleague Arthur Allen has a story about how health officials, including university professors and county health officials, who actually do believe in vaccinating children, are effectively being muzzled, told they cannot speak to reporters without the approval of their supervisors, who are likely to say no. Seeing the rising number of unvaccinated children in a state like Florida, where so many tourists come and go, raising the likelihood of spreading vaccine preventable diseases, this all seems kind of risky, yes? 

Goldman: Yes. That was a fantastic article from your colleague, and there was a really illuminating line, which I think had been reported before, but a reporter asked the surgeon general if he had done any disease modeling before making the decision. And he said, Absolutely not, because this to him was a personal choice issue and not a public health issue. And I think that just goes to show that we have no idea what is going to happen as a result of this public health decision and it could have massive ripple effects. 

Rovner: But what we are already seeing are the rise of vaccine-preventable diseases around the country. I mean, measles, first in Texas, now in South Carolina; whooping cough in Louisiana; I’m sure I am missing some, but we are already seeing the consequences of this dwindling herd immunity, if you will. Alice, you’re nodding your head. 

Ollstein: Yeah. And I’ve heard from experts that measles is really sort of the canary in the coal mine here because it’s so infectious. It spreads so easily. You can have an infected person cough in a room and leave the room, and then a while later, someone else comes in the room and they can catch it. Not all of these vaccine-preventable illnesses are like that. So the fact that we’re seeing these measles outbreaks is an indication that other things are probably spreading as well. We’re just not seeing it yet, which is pretty scary. 

Rovner: And of course, one of the things that the CDC does is collect all of that data, so we’re probably not seeing it for that reason, too. Well, meanwhile, in Texas, Attorney General and Republican Senate candidate Ken Paxton is suing the makers of Tylenol. He’s claiming that Johnson & Johnson spun off its consumer products division — that includes not just Tylenol, but also things like Band-Aids and Baby Shampoo — to shield it from liability from Tylenol’s causing of autism, something that has not been scientifically demonstrated by the way — even Secretary Kennedy admits that has not been scientifically demonstrated. My recollection, though, is that Johnson & Johnson was trying to shield itself from liability when it spun off its consumer products division, but not because of Tylenol, rather from cancer claims related to talc in its eponymous Baby Powder. So what’s Paxton trying to do here beyond demonstrate his fealty to President Trump and Robert F. Kennedy Jr.? 

Ollstein: I was interested to see some GOP senators distancing themselves from the Texas lawsuit and saying like, Look, there is no proof of this connection and this harm. Let’s not go crazy. But as I’ve reported, it’s just very hard to get good information out to people because there just isn’t enough data on the safety of various drugs, because testing drugs on pregnant women was always hard and it’s gotten even harder in recent years. And so, based on the data we have, this is a correlation, not causation. But it would be easier to allay people’s fears if we had more robust and better data. 

Rovner: Yeah. Does a lawsuit like this, though, sort of spread the … give credence to this idea that — I see you nodding, Maya — that there is something to be worried about using Tylenol when pregnant? Which is freaking out the medical community because Tylenol is pretty much the only drug that currently is recommended for pregnant women to deal with fever and pain. 

Goldman: Yeah. I think some of my colleagues have reported on the concern of another death spiral here, right? Where people get concerned, perhaps without basis, of taking Tylenol or any other drugs, vaccines even, because there are lawsuits and then the makers of these drugs say it’s not worth it for us to make these anymore. And then they don’t make them. And then it’s like a bad cascade of events. And so it’s obviously too soon to see if that’s what’s happening here, but it’s certainly something to watch. 

Rovner: But as we’ve pointed out earlier, not treating, particularly, fever can also cause problems. So … 

Ollstein: Right. Basically all of the alternatives are more dangerous. Not taking anything to treat pain and fever in pregnancy can be dangerous and can lead to birth effects. And taking other painkillers and fever reducers are known to have dangerous side effects. Tylenol was the safest option known to science. And now that that’s being questioned in the court of public opinion, people are worried about these ramifications. 

Winfield Cunningham: I think about the effect on moms who have kids with autism who are now thinking back to their pregnancies and thinking, Oh my gosh, how much Tylenol did I take? I know I took, I had pregnancies that I took plenty of Tylenol during. My nephew has autism, and I was talking to my sister about this, and she was like, “I took Tylenol.” And what they’re doing is, I guess, other reflection I have on it is, in general, there’s just less research on most things than we need. And there are some studies showing a correlation, which as we all know is not causation. And what it looks like the administration did was they took those tiny little nuggets of suggestions and have blown them up into this overly confident declaration of Tylenol and pregnancy and probably unnecessarily causing many women to blame themselves or think, Should I have done something differently during my pregnancy? when they were really just doing what their doctor recommended they do. 

Ollstein: I’m surprised that we haven’t seen legal action from Tylenol yet. I imagine we might at some point, especially if there is some kind of government action around this, like a label change. I think we will see some sort of legal action from the company because this is absolutely going to impact their bottom line. 

Rovner: Yeah. All right. Well, finally this week, more news on the reproductive health front. California announced it would help fund Planned Parenthood clinics so they can continue providing basic health services, as well as reproductive health services, after Congress made the organization ineligible for Medicaid funds for a year and the big budget bill passed last summer. California’s the fourth state to pitch in joining fellow blue states Washington, Colorado, and New Mexico. Meanwhile, family planning clinics in Maine are closing today due to that loss of Medicaid funding. And at the same time, the Health and Human Services Office of Population Affairs, which oversees the federal family planning program, Title X, is down apparently from a staff of 40 to 50 to a single employee, . Is contraception going to become the next health care service that’s only available in blue states, Alice? 

Ollstein: So Title X has been in conservatives’ crosshairs for a long time. There have been attempts on Capitol Hill to defund it. There have been various policies of various administrations to make lots of changes to it. Some of those changes have really limited who gets care. And so it’s been a political football for a while. Of course, Title X doesn’t just do contraception. It’s one of the major things they do, providing subsidized and sometimes even free contraception to millions of low-income people around the country. But they also provide STI testing, even some infertility counseling and other things, cancer screenings. And so this is really hitting people at the same time as the anticipated Medicaid cuts, and at the same time Planned Parenthood clinics are closing because they got defunded. And so it’s just one on top of another in the reproductive health space. Each one alone would be really impactful, but taken all together, yeah, there’s a lot of concern about people losing access to these services. 

Winfield Cunningham: I think the politics of this are more interesting to me than the practical effect. I mean, under the ACA, birth control has to be covered, right? by marketplace plans. Generally speaking, if people have insurance, they do have coverage for a range of birth control. But the Title X program is interesting because it seems to like overlap between the MAHA priorities and the social conservatives. Of course, as Alice said, this has long been a target of social conservatives. I think in Project 2025 called for any Title X, I believe. And then there’s this current in the MAHA movement that’s kind of like anti-hormonal birth control and there’s also these kinds of streams of pronatalist people, of have more babies, don’t take birth control. So that’s kind of interesting to me because there’s this larger narrative I think in HHS right now of the RFK MAHA people versus the traditional conservative, anti-abortion people. So that’s just like one program where I see overlap between the two. 

Rovner: One of my favorite pieces of congressional trivia is that Title X has not been reauthorized since 1984, which, by the way, is before I started covering this. But I’ve been doing this 39 years and I have never covered a successful reauthorization of the Title X program. So it’s obviously been in crosshairs for a very, very long time. Maya, did you want to add something? 

Goldman: I was just going to say to Paige’s point, telling women that they can’t take any painkillers during pregnancy is not a good way to raise the birth rate. 

Rovner: Yes. That’s also a fair point. Well, meanwhile, red states are trying to expand the role of crisis pregnancy centers, which provide mostly nonmedical services and try to convince those with unplanned pregnancies not to have abortions. In Wyoming, state lawmakers are pushing a bill that would prohibit the state or any of the localities from regulating those centers “based on the center’s stance against abortion.” This comes after a similar proposal became law in Montana, the efforts being pushed by the anti-abortion group Alliance Defending Freedom. Is the idea here to have crisis pregnancy centers replace these Title X clinics and Planned Parenthoods? 

Ollstein: I think there are a lot of people that would like to see that, but, as you said, they do not provide the same services, so it would not be a one-to-one replacement. Already, there are way more crisis pregnancy centers around the country than there are Planned Parenthood clinics, for example, but that doesn’t mean that everyone has access to all the services they want. 

Rovner: And many of these crisis pregnancy centers don’t have any medical personnel, right? I mean, some of them do, but … 

Ollstein: It’s really a range. I mean, some have a medical director on staff, or maybe there’s one medical person who oversees several clinics, some do not. Some offer ultrasounds, some don’t, some just give pamphlets and diapers and donated items. It’s just really a range around the country. And states have also been grappling with how much to, on the conservative side, support and fund such centers. And on the other side, states like California have really gone to battle over regulating what they tell patients, what they’re required to tell patients, what they can’t tell patients. And that’s gotten into the courts and they’ve fought over whether that violates their speech rights. And so it’s a real ongoing fight. 

Rovner: Yes, I’m sure this will continue. All right, that is the news for this week. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read too. Don’t worry if you miss it; we’ll put the links in our show notes on your phone or other mobile device. Maya, why don’t you go first this week? 

Goldman: Sure. So this story is from ºÚÁϳԹÏÍø News and New England Public Media. It’s called “As Sports Betting Explodes, States Try To Set Limits To Stop Gambling Addiction,” by Karen Brown. And I think this stood out to me because I was just in Vegas last week for health, but this, I think, is a really interesting issue to explore through a public health lens, the issue of sports betting and betting addiction. And there are states that are trying to do a lot of work around this and just organizations. And then of course the gaming companies themselves have their own pushback on that, and I think this story just lays it out really well and it’s an important issue that gets very overlooked. 

Rovner: Yeah, it is a public health issue, an interesting one. Alice? 

Ollstein: I chose a story from ProPublica by reporter, Eric Umansky, and it’s called “.” So this is one of many examples that you could give of policies intended to target transgender folks having spillover effects and impacting cisgender folks, too. In this instance, it’s now harder for male veterans to qualify to get treatment for breast cancer. Men can get breast cancer. Let’s just say that. Men can and do get breast cancer, and it can be harder to detect and very lethal, and obviously very expensive to treat if you don’t have coverage. And so this story has a lot of sad quotes from folks who are losing their coverage, especially because they likely acquired cancer by being exposed during their service to various toxic substances. And so I think, yeah. 

Rovner: Yeah. A combination of a lot of different factors in that story. 

Ollstein: Definitely. 

Rovner: Paige? 

Winfield Cunningham: Yeah. So my story is by, actually, my colleague Mark Johnson. I sit next to him at The [Washington] Post, and the headline is “.” I was really struck by this story because it talks about how patients with advanced lung cancer, they were given the covid vaccines and it somehow had the effect of supercharging their immune systems. And, actually, their median survival rates went up by 17 months compared with those that weren’t given the vaccines. And, of course, this administration has really gone after the covid vaccines and the mRNA research, in particular, and canceled $500 million in funding for mRNA research. And all of the ACIP’s [Advisory Committee on Immunization Practices’] moves on vaccines have gotten so much attention. But I think the thing that also is going to be perhaps even more impactful is pulling back on this really promising research, because it has sort of become politicized because the covid vaccines have become politicized. And it seems a shame that we’re pulling back on this really promising research. So I thought that was a really interesting story by my colleague. 

Rovner: Yes. Yet another theme from 2025. My extra credit this week is from my ºÚÁϳԹÏÍø News colleague Bernard J. Wolfson, and it’s called “Many Fear Federal Loan Caps Will Deter Aspiring Doctors and Worsen MD Shortage.” And it’s a good reminder about something we did talk about earlier this year when the Republican budget bill passed. It limits federal grad school loans to $50,000 per year at a time when the median tuition for a year in medical school is more than $80,000. The idea here is to push medical schools to lower their tuition, but in the short run, it’s more likely to push lower-income students either out of medicine altogether or to require them to take out private loans with more stringent repayment terms, which could in turn push them into pursuing more lucrative medical specialties rather than the primary care slots that are already so difficult to fill. It’s yet another example of how everybody agrees on a problem: Medical education is way too expensive in this country. But nobody knows quite how to fix it.  

OK. That is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder, “What the Health?” is now available on WAMU platforms, the NPR app, and wherever else you get your podcasts, as well as, of course, kffhealthnews.org. If you already follow the show, nothing will change. The podcast will show up in your feed as usual. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me at X, , or on Bluesky, . Where are you folks hanging these days? Maya? 

Goldman: I am on X as and I’m also on . 

Rovner: Alice? 

Ollstein: on Bluesky and on X.  

Rovner: Paige? 

Winfield Cunningham: I am still on X. 

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

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–

Over the summer, our pals at ºÚÁϳԹÏÍø News published a story with the headline: “Insurers and customers brace for double whammy to Obamacare premiums.”

Basically– whammy number one — insurers are planning to raise premiums for 2026 —

And whammy number two: federal subsidies for Obamacare policies are scheduled to get a lot less generous. 

Together, these whammies mean millions of people will be looking at paying a LOT more every month — like hundreds of dollars more. 

Folks are going to need as much advance warning as possible, to figure out how to prepare for a hit like that.

Meaning: This is our kind of story. 

And this one hits a little close to home. Because one of those folks is An Arm and a Leg’s senior producer, Emily Pisacreta.

Emily: Yeah, it’s a wild time. I’ve never had to do this before. Cuz I’ve always had health insurance through work. I’ve totally shaped my life around that because I have diabetes, and without health insurance, I can’t afford what I need.

Dan: But that health insurance has never come from An Arm and a Leg. When Emily started working here as an intern, she was the first person besides me to work more than a few hours a week. We didn’t have an employee health plan because we didn’t have employees.

And we’re still so tiny, so tiny. Apart from summer interns, there’s still only ever been one other person working more than a few hours a week besides the two of us. I’m still the only full-time person, and we still don’t have an employee health plan.

Emily: And until recently, that worked for me– I had another part-time job, and it had health benefits.

Except my contract with that job just ended. 

So for the first time, like more than 20 million other people, I’m looking at open enrollment. And I gotta say, it’s one hell of a year to do that. 

Dan: You’re a double-whammy case study. 

And to get a broader perspective, the two of us talked with Julie Appleby, the reporter who wrote that “double-whammy” story, and since then you’ve continued to do more homework. 

Emily: It’s been pretty intense!  

Dan: For real. And I’m a little bit of a case study too:

Suddenly I’m finding out what our country’s “system” — where health insurance gets tied to jobs — looks like … from the employer side. It’s a whole new adventure. 

We don’t know exactly what we’re going to do. Honestly, I don’t think anybody does.

But we’ve learned a ton. About what we’re up against — along with millions of other people — and our options.

And by tackling this right now — six weeks before open enrollment starts — I hope we can help a lot of other people start planning early with solid information. Let’s go.

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 picked 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.

So, we started by checking in with the person whose reporting first got us looking at this story.

Julie Appleby: It’s recording. It looks like it says 10, 11,

Dan in interview: perfect.

Julie Appleby: I have notes and I’ll try not to rattle the papers. 

Emily in interview: I mean, if we have a reporter on tape rattling papers, I feel like that’s probably okay.

Julie Appleby: Okay. That’s a plan, man.

Emily in interview: Yeah. Why don’t we start out, could you just like, tell us your name and what you do and where you work?

Julie Appleby: So this is Julie Appleby. I’m senior correspondent at ºÚÁϳԹÏÍø News.

Emily in interview: What sort of stuff do you cover?

Julie Appleby:  I cover healthcare policy, but that’s a broad term. So everything from cost to, the Affordable Care Act, to what’s going on with Medicare, all kinds of different things involving health care programs and insurance.

Emily in interview: So we were really excited to talk with you, because we wanted to cover, you know, all the changes to the marketplace plans, that you’ve been writing about. And, it just so happens that I need to enroll in a marketplace plan.

Julie Appleby: So let’s give you kind of the rundown. There’s like, there’s kind of like two things going on here. One of them is that just premiums are going up as they do every year. Although this year it’s bigger than it’s been since 2018. So the median increase nationwide, and this is according to some data research by KFF, is about 18%. So that’s a big jump, right? 

Emily in interview: Yeah. Yeah. In your reporting you called it a double whammy. Rates are going up, enhanced subsidies are probably going away. 

Julie Appleby: Right. That’s the second half of the double whammy.

Dan: OK, breaking in here– gonna do this a couple of times for Obamacare vocabulary. Emily just mentioned an important term, went by kinda fast: enhanced subsidies. Obamacare has always included subsidies for most people — that’s part of the “Affordable” part of Affordable Care Act. But for lots of people, Obamacare policies still were… pretty expensive!

So, in 2021 — like, as part of a COVID recovery package — Congress added extra subsidies for Obamacare policies: Enhanced subsidies. 

Julie Appleby: Basically, they made the coverage more generous on both ends of the income spectrum. In fact, I think I was looking at some statistics this morning and something like, 80% of people who have coverage right now have a plan that’s $10 a month or less.

Dan: These are folks with lower incomes — where paying sixty or eighty dollars a month is a big bite. With “enhanced” subsidies, that became ten dollars — or even zero.

But people with higher incomes also got help. Before the enhanced subsidies, people with incomes above a certain level didn’t get ANY subsidy. People called it an “income cliff.”

For the last four years these enhanced subsidies, kind of erased that cliff. If your income was higher, you just paid a percentage of your income. Enhanced subsidies picked up the rest.

But the enhanced subsidies weren’t permanent. They’ll expire at the end of this year, unless Congress extends them. Otherwise… 

Julie Appleby: people who make more than the four times the federal poverty level will not qualify for any help with their premiums under the Affordable Care Act. There will be that cliff.

Emily in interview: Right, right. 

Dan: And it turns out Emily is basically standing on that cliff. She shows Julie the numbers.

Emily: We found this calculator from KFF that attempts to show the changes in premiums if the subsidies expire. And maybe I’ll just share my screen and we can look at – we can look at what I’m looking at.

Okay, you guys see KFF? Maybe just reload and I can enter some Emily figures in here. So, they ask you about where you live and your yearly household income. 

Dan in interview: what’s the amount that you’ve entered as income?

Emily in interview: I have entered $63,000. And it says, without enhanced subsidies, you will likely lose financial help. Because my income is 418% of the federal poverty level.

Dan: Oy. a little more Obamacare vocabulary. First: Federal poverty level. Four times that level is where you fall off the income cliff, no subsidies. 400 percent. And the calculator – which we should say, is a year out-of-date, so the numbers aren’t precise, but they give us an idea– that calculator says Emily’s at 418.

And next:  Obamacare plans come in different “levels,” like Olympic medals: Bronze, Silver, Gold… Bronze plans are the cheapest, and cover the least. 

If Emily got a subsidy, the calculator says a silver plan would be like 400-and some dollars a month, but it says Emily wouldn’t GET a subsidy, so… 

Emily in interview: It would be about $880 a month for a silver plan, or $675 a month for a bronze plan. So for me, that is stressful to read. 

Julie Appleby: That’s a lot of money. 880 bucks a month. So you’re in the situation where you don’t get any, subsidies because your income is over that amount. But I played around with one of these calculators too when I wrote a story recently. And I also plugged in somebody, let’s say who’s earnings are kind of at the lower end of the income scale, say just over 150% of the federal poverty level. So they’re still gonna pay more. They’re, it’s gonna go from paying sort of a national average of about $2 a month to 72 bucks a month, or $864 a year. And remember, this is somebody who’s making 23,000 a year. So $864 is a lot of money. 

Dan in interview: Emily, can you put that calculator back up on the screen for us?

Emily in interview: Sure can.

Dan in interview: The scary calculator. I mean, what would happen if your income were just a little bit lower? If you just shave $3,000 from your income, what does it look 

Emily in interview: So maybe like 60? 

Julie Appleby: I bet you could even shave a little bit less. Why didn’t you make it 62?

 (Sfx: Buzzer) 

Dan: How about 61? What does 61 do for us?

Emily in interview: Can I get a 61 

(SFX: Buzzer) 

 Dan: how about $60,500?

 (SFX: Buzzer) 

Dan in interview: I feel like this is like an auction reverse.

Julie Appleby: in reverse.

Emily in interview: I know this is like the auction from hell

Dan in interview: Yeah, we’re, we’re lowering your income. So let’s keep going. $60,200,

 (SFX: Ding!) 

Dan in interview: That is it. Holy crap it’s a giant cliff. It’s a $5,000 cliff

Dan: Breaking in one last time:  Five thousand dollars is how much money Emily might save on Obamacare premiums if her income stays below that 400 percent line.  Put another way: It’s how much more she’d have to pay if she steps over that cliff.

Dan in interview: Julie, what does that look like to you, seeing that?

Julie Appleby: I think this also, this illustrates a lot of things. I mean, people are gonna have to keep in mind that cliff for next year if these tax credits aren’t extended. This is a projection, this is what you think you’re going to earn next year. So that’s one thing that to keep in mind, okay? And something could happen. Emily could, I don’t know, maybe she wins the lottery or she goes to the casino and wins a bunch of money and that puts her over. 

Emily in interview: Or offers me, you know, a freelance job that’s really interesting. It doesn’t pay that much, but just puts me over, you know? 

Dan in interview: You have to say, I’m sorry, that freelance job is gonna cost me more than $5,000 to accept.

Dan: So, Emily: listening back to that conversation now. What are you feeling?

Emily: I mean, I was trying to stay calm but internally I was freaking out. As Gen Z likes to say, I was crashing out.

Dan: It was really emotional. We both needed time to cool off, just to put this story together.

Emily: Yeah, this situation is stressful. I don’t know for sure how much money I’m even going to make next year. And it feels kind of weird to put all this out here. I don’t know how any of this sounds to other people. Because maybe it sounds like 400% of the federal level is a lot of money. And in some parts of the country it definitely is. But I live in New York City. So my income doesn’t go that far. And that $880 bucks a month we were talking about? That’s actually a big hit. 

Dan: Yeah and — not to pile on, but: the data behind the calculator where we got that number, 880 — that’s last year’s data.  So it doesn’t include the big premium increases that Julie was writing about. The actual amount you’d  be paying every month would be bigger. And you looked up the deductible: more than four thousand dollars. 

Emily: Right, which I won’t have lying around at the beginning of next year either. Yeah so honestly, all of it still makes me want to scream. 

Dan: Yeah, and you’re a case study for a LOT of people. Julie read us a really sobering number, where one consulting group estimated that with this double-whammy Obamacare enrollment could drop by like half or more. 

And, in fact, one of the reasons insurers say they’re raising prices this year is– without the enhanced subsidies, they figure a lot of healthy people will just opt out. 

Emily:  I can see why people don’t sign up. I mean,  I don’t have that choice. But in order to get a subsidy, I’d have to lower my income, and to a very specific number – which is less than I live on now. And watch it to make sure I don’t take in a penny more. 

Dan: While still paying hundreds of dollars a month for Obamacare – even with a subsidy.

Emily: And look. This is a thing a lot of people do. All the time. –intentionally limit their income to qualify for assistance.. To keep Medicaid, people skip out on jobs, careers, marriage. 

 So my situation is NOT unique. It’s definitely not the worst.

Dan: You’re our in-house case study. You can’t stand in for everybody.

I mean, just to add one more wrinkle: If you didn’t live in a super-expensive city, your premiums would actually be lower..

I used that calculator to look up what you’d pay for a silver plan in … Chicago, like where I live? Way, way cheaper. Like, unsubsidized? A lot less than a New York plan *with* a subsidy. I’m just saying.

Emily: That’s… wild. No shade on Chicago But I don’t think I’m ready to make a long distance  move for health insurance yet.

Dan: I’m just saying… 

Emily: But while we’ve been looking ahead to 2026 insurance, I’ve actually had a more-immediate decision to make.

Dan: Right.

Emily: LIke I said before, I had insurance through my old employer. But that’s ending. While we were doing this story, I had to figure out health insurance for the last three months of 2025.

Dan: You ended up getting some help from a real expert.

Emily: I sure did.

Dan: And: I called up An Arm and a Leg’s insurance broker.

Because like we said: If Emily’s a case study, so am I. We’re so small, and I’m the only one here who’s needed health insurance from this tiny little enterprise. Now, things are a little different.

What we’ve learned, and what’s next. That’s just ahead.

This episode of An Arm and a Leg is produced in partnership with ºÚÁϳԹÏÍø News. That’s a nonprofit newsroom covering health issues in America. Their journalists — like Julie Appleby — do amazing work. We’re honored to be their colleagues.

Emily: Julie Appleby left me with a little advice: Connect with an ACA navigator.

Dan: Navigators: These are folks who can guide you through the process of signing up for Obamacare. They’re not brokers, they don’t make a commission. They’re paid by the government. 

Emily: But they’re not government employees — local organizations work on government-funded contracts.

Dan: Which makes sense– Obamacare plans themselves are basically local: The menu of plans to pick from, they don’t just vary from state to state: They can be different from one county to another.

Emily: And I wanted a little perspective on how the whole navigator program works.

Dan: And it turns out: We know someone at the organization that coordinates all the navigators in New York state.

Elisabeth Benjamin: My name is Elizabeth Benjamin. I’m Vice President for Health Initiatives at the Community Service Society of New York.

Dan: We’ve spoken with Elisabeth before — a bunch of times — about her work pushing hospitals in NY to quit suing people over medical debt.

And yes, it turns out her shop also runs the network of navigators throughout New York.

Emily: But when we talked, it turned out, her connection to the navigator program is a little different than I’d expected.

Elisabeth Benjamin: I don’t, you know, run it day to day, but I, myself do help people individually enroll. Because it’s really important to understand what people are experiencing, what their concerns are. I have like a small group of people that I help every year, Lots of friends, children.

Emily in interview: Oh, that’s awesome. Okay. Yeah, I bet you’re like a great like auntie to have..

Elisabeth Benjamin: You know, people that turn 26 and the parents are like, I know, please, will you help me?

Emily: She was like: Look, everybody needs help.

Elisabeth Benjamin: The bottom line is, you know, it isn’t for the faint of heart. It is hard to work through these websites. I mean, they are as user friendly as possible, but there’s like little kind of little moguls that you have to kind of ski over and it’s easy to kind of miss a mogul and faceplant, and we don’t want that to happen.

Emily: And when I told her about how my story fits into this episode, she was immediately like.

Elisabeth Benjamin: Oh, well, I can help you.

Emily: Not with my whole 2026 dilemma: there’s just no information about 2026 plans out there yet. But for my immediate question — what do I do about the rest of 2025 – she was like, I’m pretty free tomorrow.

Elisabeth Benjamin: You can tape your enrollment.

Emily in interview: Oh my gosh, that would be amazing.

Dan: Seriously amazing. I mean, it sounded like good tape, which we always like. 

But also — we talked that day, you and me: You were really weighing some big decisions. 

Emily: I mean one was: Do I sign up for Obamacare for the rest of the year, or do I stay on my old employer’s plan?

Because a law called Cobra means they have to allow me to buy in — but I’d have to pay the whole monthly premium, which was SUPER high. More than a thousand dollars.

So Obamacare was looking good. Those extra subsidies are still in place through the end of the year.

Dan: There was a downside.

Emily: Yeah — starting a brand-new plan would mean starting with a brand new deductible– money I’d have to pay out of pocket before the new insurance kicked in for most things.

Dan: Those can be like thousands of dollars. 

Emily: Yeah, but then there was an amazing surprise: In New York, where I live, a new state law means that all Obamacare plans include insulin with no copay. Even if you haven’t paid out and hit your deductible. That’s a deal I’ve *never* gotten from any insurance, ever.

AND this deal included other diabetes supplies — like my continuous glucose monitor. That stuff can be hugely expensive.

So my thinking was like: I’ll grab the cheapest Obamacare plan– and get all my diabetes supplies — and I’ll try not to go to the doctor for the rest of the year. 

Elisabeth Benjamin: Okay, so ready?

Emily in interview: I’m ready.

Emily: The next morning, I showed up at Elisabeth Benjamin’s apartment.

Elisabeth Benjamin: All right. So Emily, here you are, you’re on my dashboard. Oh, wait, here I can make this easier for you. Let’s do the big screen. Okay. 

Emily: Elisabeth started walking me through the application.  Name, date of birth, address… pretty routine to start. 

Elisabeth Benjamin: That’s your phone number…

Emily: And at this stage I’m wondering if I should’ve just done it all myself and left poor Elisabeth alone.

But after a while — once we started actually looking at plans, I was like: Oh wow. Elisabeth was able to like really zip through things. It was a whole vibe.

Elisabeth Benjamin: Hold on one second. That’s not, that’s not important I wanna see if this is in network…

Emily: And she spotted things I would have totally missed.

Elisabeth Benjamin: So this is kind of an interesting plan. ’cause you would be able to go to a doctor or a specialist before the deductible.

Dan: Wait, you could do a doctor visit before you spent that deductible? That’s a thing?

Emily: Yeah, in that one plan, I guess? But even Elisabeth had to really dig to figure that out. 

Elisabeth Benjamin: Like see, it’s sort of a little frustrating because you wouldn’t, you couldn’t really tell that from this. This is why it’s helpful to have a navigator

Emily: I mean, super-helpful: With Elisabeth’s help, I got a plan 

Elisabeth Benjamin: and you’re done. 

Emily: where OK, I can’t actually SEE a doctor before the deductible. Not in person. But I CAN do telehealth. So if god forbid I get some kind of weird infection, I could get a prescription. Oh, and my actual doctor, like my endocrinologist, is covered. And the deductible is much, much lower than the other plans I’d been looking at. I mean, it’s still scary as hell, but HALF as scary-as-hell?

Dan: And the only catch is: You have to do this all over again in November or December. Except then — unless Congress extends the extra subsidies — you may be looking at much higher monthly payments.

Emily: Right. Actually, let’s come back to me in a minute. Because the good news in my case: At least I’ll be able to get Elisabeth’s help again. Like, she offered to, which was so nice. But also: even if she’s super-busy, I’ll be able to talk to another navigator. Because I live in New York.

Dan: Yeah. This is one of the things we learned from Elisabeth. It goes back one of the reasons we wanted to talk with her in the first place. Because there’s another big change with Obamacare this year: the federal government is cutting funding for navigators by like 90 percent. We wanted to hear from Elisabeth — how is that gonna affect her group’s work.

Emily: And — this was a surprise: She said it won’t affect her work at all– because New York navigators are funded by the state government. Turns out the same thing is true for about half the states. But I talked with Elisabeth’s counterpart in a state where that is not the case. 

Nicholas Riggs: We are not gonna be able to reach the number of people we did before. That’s just reality. You can’t do more with less. People will lose their coverage because of this.

Emily: That’s Nicholas Riggs. He runs the NC Navigator Consortium.

Nicholas Riggs: We cover all 100 counties. We’re the only navigator entity in North Carolina.

Emily: He says a big piece of their work is actually outreach– finding people who may not know they can get this kind of help.

Nicholas Riggs: You know, there’s no list of the uninsured.

Emily: And they don’t just help people pick Obamacare plans– they help people sign up for Medicaid. A 90 percent budget cut hits all of that. He says they’re looking for more volunteer navigators, but it won’t be the same as having experienced staff. 

Nicholas Riggs: What you’re losing is institutional knowledge. Volunteer navigators are great. But sometimes it takes a few years to really get a handle on some more complex cases.

Dan: I mean, Emily — you experienced first hand how big a deal it was to hae, like,  a real expert walk you through this process.

Emily: Elisabeth spent almost an hour with me!

Dan: A lot of people won’t have access to that kind of help. It’s one more crummy thing we’re trying to help people plan for. You found a map that shows which states fund their own navigators. We’ll post a link — so people can see what the deal is in their state.

And Emily, let’s come back to you for a minute: You’re lucky to have access to the world’s greatest navigator, but unless Congress extends the enhanced subsidies, that next conversation with her is gonna be a lot tougher.

Emily: I mean, unless I get another job with health insurance first. 

Dan: So, about that: While you were having your first conversation with Elisabeth, I was talking with An Arm and a Leg’s health insurance broker, Kurt Kaufman.

Because I was like: What can I do to make it possible for Emily to stick around?

I asked Kurt, could we set things up for Emily to buy into An Arm and a Leg’s plan? Like, at all?

Our insurance is from Blue Cross Blue Shield of Illinois. Could it cover Emily in New York? He was like

Kurt K: Yeah, that’s fine.

Dan: Then she,

Kurt K: a hundred percent.

Dan: She could be insured on our Illinois based plan, 

even though she’s in New York.. Is that right?

Kurt K: All day long.

Dan: All day long,

Kurt K: yep., 

Oh, yeah.

Dan: So I was like: Um, how much would it COST?

He said, based on your age — insurance gets more expensive as you get older — like, five, six hundred.

Emily: That’s a LOT less than what the scary calculator said I’d pay for a Silver plan with no subsidies. That was showing like nine hundred dollars.

Dan: Yeah. I mean: These are 2025 numbers, just like everything else we’ve been looking at. Everything in 2026 is gonna be higher. But it seems like An Arm and a Leg gets a better deal than you’d get with Obamacare. However, there’s a but. You’d need to be full-time.

Emily: Aha!

Dan: Yeah. I mean we’ve got you at 20 hours a week.

Emily: Yeah.

Dan: I was like Oh my god. I’d have to DOUBLE that? But Kurt was like: Actually, no. The way insurance looks at it, if you were working an average of 30 hours a week, then you could qualify.

Kurt K: She could be meeting that definition of quote unquote full-time employee.

Dan:  Which, you know, isn’t in my budget for next year– and I’m still working to make sure some other parts of our scrappy little budget get funded– but it’s not DOUBLE. I’m starting to think about it– like, a stretch goal. I mean, I’d LOVE to have more of your time. I dunno.

Emily: I mean I like the idea a lot! But there are just a lot of unknowns, right?

Dan: Yeah, here’s where we’ve landed: You’ve got health insurance lined up for the rest of 2025. And after that, there’s so much we don’t know. Will I find more money? Will you take another job? 

And: Will Congress extend the enhanced subsidies? When we first started working on this story, over the summer, experts were like, “That’s not gonna happen.”

But in the last few weeks, SOME Republicans have been proposing it. We definitely don’t know — and it’s nothing we can count on.

It’s all, honestly, a little scary.

Emily: Honestly, more than a little.

Dan: BUT: We know more than we did. We’ve started really confronting the scary numbers and the unknowns. You’ve taken a practice run at picking insurance.

Emily: That was actually kind of a big thing.

Dan: It was, right?  And: I’ve started thinking about stretch goals.

We’re more prepared.

And — here was the point of doing this whole case study– I HOPE we’ve just helped a lot of other people get more prepared, to start planning. 

We’ll keep you posted on how things go for us. Some updates will show up in our First Aid Kit newsletter. 

If you’re not getting First Aid Kit, go check it out. 

Emily: While we were reporting this story, we published a guide there: Get ready, emotionally and financially, for 2026 health insurance.

Dan:  It has links to resources we talked about here, and we’ll have more in this week’s First Aid Kit. 

What you wanna do is go tor at Arm and a Leg show dot com, slash, first aid kit.

You’ll find the whole archive there — including notes about honestly, some extremely exciting projects that Arm and a Leg listeners are doing — and how you can pitch in. 

We’ll be back with another podcast episode in a few weeks. Till then, take care of yourself.

Emily: This episode of An Arm and a Leg was produced by me, Emily Pisacreta 

Dan: and me, Dan Weissmann. 

Emily: With help from Janmaris Perez and Lauren Gould.

Dan: And edited by Ellen Weiss.

Dan: Adam Raymonda is our audio wizard. Claire Davenport is our engagement producer.

Dan: Our music is by Dave Weiner and Blue Dot Sessions.

Dan: Bea Bosco is our consulting director of operations.

Big thanks to Lynne Johnson, who just wrapped up her run as our operations manager. Lynne, your work has done SO much to make our work more sustainable. I can’t thank you enough.

Dan: An Arm and a Leg is produced in partnership with ºÚÁϳԹÏÍø 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.

Dan: Zach Dyer is senior audio producer at ºÚÁϳԹÏÍø News. He’s the editorial liaison to this show.

Dan: An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

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

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