Still, even with three jobs, she worries about losing her health coverage when Nebraska, on May 1, becomes the first state to require certain Medicaid enrollees to work, train, or go to school under a rule mandated by congressional Republicans’ One Big Beautiful Bill Act.

Simpson, 46, has relied on Medicaid since her divorce in 2014. None of her employers offers health coverage. She said she lost her government food assistance after technical problems caused her to miss renewing in time, and she doesn’t trust the state to implement the new work rules without problems.

“Adding more barriers won’t make the program work any better,” she said.

Nebraska Medicaid officials say they are trying to make it as easy as possible for enrollees to comply, so people don’t lose their coverage for administrative reasons, such as failing to file the proper paperwork.

Enrollees with one of thousands of health conditions detailed by the state would be exempt.

“Our top priority is making sure members clearly understand changes to the program and how to maintain their coverage,” Drew Gonshorowski, the state’s Medicaid director, said in an early-April news release.

In a brief interview with ºÚÁϳԹÏÍø News on April 28 outside the National Press Club in Washington, D.C., Centers for Medicare & Medicaid Services Administrator Mehmet Oz said he applauds Nebraska for being the first state to begin implementing the work requirements. He acknowledged that the state is still “working out the kinks,” adding that his hope is “by the end of this year they will get into a more sophisticated place.”

But health policy analysts, advocates for the poor, and health industry groups remain skeptical, fearing thousands of Nebraska Medicaid enrollees will lose coverage and, with it, their access to health services and protection from medical debt.

Hospitals also worry an increase in uninsured patients will hurt their bottom lines, said Jeremy Nordquist, the president and CEO of the Nebraska Hospital Association.

“There is a lot of concern on many different levels,” he said. Many enrollees are unaware of the changes and might not realize they have to act to stay insured, he said.

The bill President Donald Trump signed last July requires the 42 states, along with the District of Columbia, that fully or partially expanded Medicaid under the 2010 Affordable Care Act to implement a work requirement starting in 2027. The full expansion enables adults with incomes of up to 138% of the federal poverty level — amounting to $22,025 for a single person this year — to be eligible for Medicaid, the government program covering people with low incomes or disabilities.

More than 20 million people gained coverage from Medicaid through expansion, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. The Congressional Budget Office estimates 4.8 million will become uninsured over the next decade as a result of the work requirement.

Under the law, enrollees must work or volunteer at least 80 hours a month, attend school at least part-time, or participate in job training. Or they must prove they qualify for certain exemptions, such as caring for a child 13 or younger or a disabled parent, or having a health condition that prevents employment.

Some states explored implementing work rules in the years before the GOP law passed. It gave states the option to launch their programs early.

Nebraska’s Plan

In Nebraska, which is implementing the provision eight months before the law requires, about 70,000 Medicaid enrollees will need to meet the requirement, said Collin Spilinek, a spokesperson for the Nebraska Department of Health and Human Services.

About 72% of them probably won’t have to do anything to keep their coverage, because the state already knows their work or exemption status via state or national databases, Spilinek said.

To check whether enrollees meet the requirement, Nebraska and other states plan to tap into various databases, including Medicaid claims information and data controlled by credit rating agencies. Enrollees for whom Nebraska doesn’t have data will be notified and can complete an online form to confirm they meet the new rules.

While a number of states say they plan to hire extra administrative staff, the Nebraska Medicaid agency is not adding any employees to implement its work requirement.

“The fact that they say they do not need additional resources raises questions” as to whether “they will be able to pull this off without future headaches,” Nordquist said.

Proving employment status will require documentation, but Nebraska officials say they will allow enrollees to self-attest that they volunteer, go to school, or qualify for exemptions, such as for poor health or caring for a disabled parent. “Supporting documentation, such as medical records, will not be required,” Spilinek said.

That could make it easier for enrollees to get exempted under the law’s “medical frailty” exception. The long list of health conditions that can be considered for the exemption was posted last week by the state and includes many types of cancers and mental health and heart conditions.

Kelsey Arends, senior staff attorney for Nebraska Appleseed, an advocacy group, said the state’s long list of medical billing codes for conditions that would be exempted is still not long enough. She said different levels of illness severity are not included.

The exemption is crucial for Crystal Schroer, 30, who has been on Medicaid since 2022 and unemployed since 2024. She said it has been difficult to find work near her home in Kearney, Nebraska, that will allow her to take along her psychiatric service dog, Tarot, who helps her with anxiety.

“I am insanely worried,” said Schroer, who lives with a friend. “It’s made my depression way worse.”

Whether self-attestation will broadly be allowed in other states will depend on CMS’ rules for work requirements, expected to be set this summer. Oz told ºÚÁϳԹÏÍø News that “we don’t like self-attesting” and that “documentation is critical.”

Several advocacy groups had asked the state to exempt enrollees with specific conditions, including the American Diabetes Association, HIV+Hepatitis Policy Institute, and National Bleeding Disorders Foundation. Losing coverage, the groups said, would mean losing access to medications that keep people healthy and out of the hospital.

Adding a work requirement to Medicaid has been a priority for Trump since his first term. In 2018, his administration became the first to allow states to adopt the policy, but only Arkansas implemented it. In the nine months the policy was in place before a federal judge deemed it unlawful, more than 18,000 people lost coverage — nearly 1 in 4 of those subject to the requirement.

Most lost coverage not because they did not meet the requirements but for failing to correctly submit paperwork in time. 

Georgia has had a work requirement under its partial Medicaid expansion since 2023. Only about 8,000 people signed up for the coverage in its first two years — far fewer than the 25,000 that state officials predicted for the first year alone — and many have been denied benefits because of paperwork issues.

National Mandate

During the congressional debate over the law last year, Republicans pushed a work requirement for Medicaid as a way to get “able-bodied” adults benefiting from government assistance into the workforce. House Speaker Mike Johnson said it would help preserve Medicaid “for people who rightly deserve it,” not young men “sitting on their couches playing video games.”

Republicans have argued mandating employment will nudge people into finding work, leaving Medicaid to help children and people who are pregnant or have disabilities.

They were not swayed by studies showing already work or go to school or have health conditions preventing them from doing so.

A in the Annals of Internal Medicine found about one-third of adults at risk of losing coverage under the new work requirement reported that they have a physical or mental illness or disability.

“This is not a case that we have mostly healthy adults choosing not to work,” said Darshali Vyas, a study co-author and health policy researcher at Beth Israel Deaconess Medical Center in Boston. “It’s a vulnerable group, and I am not sure there are clear protections as we begin to roll out work requirements.”

In Nebraska, about two-thirds of Medicaid expansion enrollees , according to KFF. Nebraska’s unemployment rate is 3%, one of the lowest in the nation.

Andrea Skolkin, the CEO of Omaha-based One World Community Health Centers, said it’s an unsettling time for her clinic and their patients. “We are still concerned about the expanded Medicaid folks losing coverage,” she said.

About 4,000 of their 52,000 patients are covered under the Medicaid expansion, Skolkin said. She said many enrollees received letters from the state about the work requirement, but she worries many did not understand them.

Losing 10% of those patients would mean $500,000 less in revenue for the nonprofit centers, she said. To help patients, they plan to add staff to help people fill out the forms to get and maintain coverage.

Nebraska Appleseed’s Arends said she’s skeptical of the state’s promises to use automation to confirm that enrollees meet the work rules. “We remain very concerned about the early implementation,” she said.

People who lose coverage may have a harder time getting health bills covered if they reenroll in the Medicaid program, because the federal law also reduces retroactive eligibility from three months to one month for expansion enrollees.

Because many people sign up for Medicaid when seeking care for an emergency and it can take weeks or months to complete enrollment, hospitals are concerned the change will leave them to cover the costs when people lose coverage, Nordquist said.

Only two other states plan to implement the work requirement early: Montana, which plans to launch in July, and Iowa, which plans to go live in December.

Many states will be closely watching Nebraska’s implementation to see what lessons they can learn ahead of their own launches in January, said Andrea Maresca, a senior principal at Health Management Associates, a consulting firm.

States are better prepared to enact work requirements than they were when Arkansas tried in 2018, she said. After reconfirming millions of enrollees’ eligibility post-covid, they have more experience using public and private databases to automate the process and more practice communicating with enrollees, Maresca said.

Still, “it won’t be perfect,” and states will have to adapt as they go, she said.

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It was “just like a mosquito bite, nothing major, and I just scratched it,” said Toska, a political science professor.

Then she began to itch everywhere. She couldn’t see anything in the dark, so her husband shined his phone light on her.

She was covered in hives.

Because she also felt pressure in her chest, the family quickly went to an urgent care clinic. A doctor there recognized she was experiencing , a life-threatening, fast-moving allergic reaction.

The doctor rushed her to a room without checking her in, saw her blood pressure was low, and administered two epinephrine injections and IV fluids, Toska said. The itching stopped, and the tightness in her chest went away.

But the doctor said she needed to be monitored in an emergency room for at least two hours in case the reaction flared up again. Toska said the doctor insisted she take an ambulance to a nearby hospital, Atrium Health Lake Norman.

Minutes later, she found herself lying on a stretcher in the ER.

A doctor she described as “lovely” came in and spoke to her for no more than five minutes, Toska said. A nurse administered medicine through the IV line inserted at the urgent care clinic.

Toska was exhausted, but her mind was on her daughters. “I had two little kids who were scared, so I was playing with them and trying to distract them.”

After about an hour and a half, the doctor returned briefly, then the family went home, she said.

“That’s it,” Toska said. “Nothing happened at the ER.”

Then the bill came.

The Medical Service

Toska said the ER doctor reviewed her vitals and discussed her allergic reaction and what to watch for when she got home. She also received a dose of famotidine, a drug often used to treat an upset stomach that is also administered for allergic reactions.

The Bill

The in-network hospital system charged Toska’s insurer, Blue Cross Blue Shield of North Carolina, $6,746.50 for the ER visit, including $20.60 for the famotidine and $6,445.60 in “critical care” charges. Toska, who had not met her insurance deductible, was responsible for a $150 copay and $3,100.24 of the charges.

The Billing Problem: Critical Care

“Paying $3,100.24 for literally sitting in the ER entertaining my kids for an hour and a half feels kind of incredible,” Toska said.

Medical providers in the United States use a uniform coding system to bill for procedures and services. Most of Toska’s ER charges stemmed from Atrium Health’s use of two billing codes for “critical care” — one for 30 to 74 minutes of care, at $5,617.85 (code 99291), and another for an additional 30 minutes (code 99292), at $827.75.

According to the coding system, critical care is when a doctor “directly” provides at least 30 minutes of care to a patient with “a probability of imminent or life-threatening deterioration.”

According to the ER’s visit notes, which Toska shared with ºÚÁϳԹÏÍø News, Toska told the doctor there she was feeling “significantly better” when she arrived, and the doctor reported providing 90 minutes of personal critical care.

Anaphylactic shock is treated under code 99291, according to the . Though Toska’s symptoms may have indicated she was no longer in shock, treatment guidelines require at least two hours of monitoring, said Arjun Venkatesh, the chair of emergency medicine at the Yale School of Medicine.

With anaphylaxis, “some people are going to progress and require admission to the ICU, and some won’t,” Venkatesh said.

Toska was under critical care because of what could have happened, not what did happen, Venkatesh said. Hospitals use the same billing codes for the ER visit, whether a patient’s condition deteriorates or not.

“The billing rules are not built around this,” Venkatesh said.

Laura Eberhard, a spokesperson for Blue Cross Blue Shield of North Carolina, said Toska’s claims “were submitted by the provider using critical care codes, which represent a higher level of severity and reimbursement, and were processed in-network under the terms of the member’s plan.” She did not answer questions about whether Blue Cross Blue Shield negotiated the charges.

A spokesperson for Atrium Health did not answer questions from ºÚÁϳԹÏÍø News about Toska’s visit.

The Resolution

Toska said she called Blue Cross Blue Shield of North Carolina, trying to get a better explanation for why the bill for so little hands-on care was so high.

“The doctor determines the severity of the situation, and that’s the code we have,” the insurance representative said, according to Toska’s recollection. “This is critical care, and that’s what it costs.”

After Toska contacted the hospital, Atrium Health’s Audit and Appeals Department replied in a letter that the critical care designation was “based on the presenting problem that brought you to the emergency room, the treatment provided, and the nursing staff that took care of you.”

“It also includes the room, supplies, and equipment utilized during the visit,” the letter continued. “The charge is not based on time spent in the facility or with clinicians.”

Asking why the ER visit cost so much was more a matter of principle than necessity, she said, though she thought back a few years to a time when it would have been much harder for her to pay.

“The system is so broken,” Toska said.

The Takeaway

“Her experience is, sadly, very typical,” said Barak Richman, a professor of business law and co-director of the Health Law and Policy program at George Washington University. “Once you are brought onto the train of health care delivery, you have no control over where the stops are.”

Emergency rooms — for many the for medical care — are notorious for high costs, he said, adding that insurance companies should always try to negotiate critical care codes.

Toska was fortunate to dodge another problem common in emergencies: The bill for taking an ambulance to the ER was about $275, she said, notable since ambulance rides frequently result in bigger bills that may not be covered by insurance.

Patients can dispute charges with their insurance and the hospital. Like Toska, they should come to the phone with an itemized bill, medical records, and any other relevant documents, such as explanation-of-benefits statements.

Regardless of whether that’s a fight they can win, some who see one ER bill , especially if it might put them in .

In early March, Toska had a second allergic reaction. “OK,” she recalled thinking, “Do I go get the EpiPen? Do I go to the ER and get another massive bill?”

She decided against the trip and took Benadryl instead.

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

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Public schools and her church’s pantry help Lafortune accomplish the first two goals. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants at a traumatic brain injury rehab center near Tampa, Florida, Lafortune and her husband cannot afford the health insurance benefits offered by their employer. And they earn too much for their daughters to qualify for subsidized coverage through , the state’s safety net health insurance program for children in low-income families.

Her family also can’t afford the $525 monthly cost to enroll her two daughters in KidCare at full price, so she purchased a family plan for $500 a month on the Affordable Care Act marketplace with no dental coverage and higher out-of-pocket costs.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare to close the gaps for families like Lafortune’s, raising the eligibility threshold so that coverage would extend to more than 40,000 children. But the expanded coverage has not taken effect — even after it was approved by federal regulators following a federal lawsuit — because the administration of Florida Gov. Ron DeSantis, a Republican, has not implemented the changes.

Instead, Florida’s KidCare expansion has been mired in lawsuits and ongoing negotiations between the state and federal regulators. While the delay continues, Florida could be violating the law.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Asked to comment on the delay, DeSantis’ office referred ºÚÁϳԹÏÍø News to a on March 31, during which the governor directed questions to the state’s Agency for Health Care Administration, which oversees KidCare. The state agency did not respond to ºÚÁϳԹÏÍø News’ repeated requests for an interview or information on the delayed expansion.

Entitlement vs. Personal Responsibility

At issue is a , adopted under the Biden administration, that requires all states to continue to provide 12 months of coverage for children in Medicaid and in the Children’s Health Insurance Program, known as KidCare in Florida. That means insurance coverage would not lapse even if parents miss a monthly premium payment.

But only Florida has challenged the rule in court, suing the federal government for the right to disenroll children from KidCare for unpaid premiums and delaying the planned expansion.

“We’ve had to do a lot of back and forth with CMS on various things,” DeSantis said during the March press conference, referring to the Centers for Medicare & Medicaid Services, which regulates public health insurance programs.

In December, Texas also said it opposed the rule. Cecile Erwin Young, who was then the executive commissioner of Texas Health and Human Services, wrote to Mehmet Oz, the CMS administrator, asking him to rescind CHIP rules that require states to keep children enrolled for 12 months at a time, prohibit waiting periods for coverage, and prevent states from imposing financial benefit limits.

“These policy changes effectively redefine CHIP to be more like an entitlement program — a strategy not supported by law and which conflicts with the core program design adopted by Texas,” Young wrote.

Like Texas, Florida views KidCare as a “personal responsibility program” designed to help families by “supporting independence and a ladder towards economic self sufficiency,” according to legal filings and .

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said , policy director for the Florida Health Justice Project. The nonprofit legal aid group, together with the National Health Law Program, on March 9, asking a judge to order the state to implement the approved expansion.

The state agencies had not filed a response to that lawsuit as of April 22. The court ordered the state to explain by mid-May why the expansion should not be implemented.

Williams called the state’s tactic “largely political theater.”

Health policy researchers and advocates also noted that Florida’s refusal to implement the KidCare expansion goes against the Trump administration’s strategy to “.” Last year, a commission appointed by President Donald Trump recommended a series of policy changes, including a collaboration between CMS and state CHIP programs, to promote “evidence-based prevention and wellness initiatives for children at the local level.”

Numerous studies have found that CHIP coverage can improve children’s health by , , and .

“This should go without saying, but you can’t make children healthy again by taking away their health coverage,” said , chief strategy and development officer for Florida Policy Institute, a nonprofit that has advocated for the state to implement the KidCare expansion.

The White House did not respond to a request for comment on Florida’s and Texas’ opposition to the rule requiring continuous enrollment in CHIP.

Those two states have among the . In Texas, more than 1 million children, or 13.5%, have no health insurance, while in Florida more than 400,000 children, or 8.5%, are uninsured.

Texas has followed the federal rule on continuous coverage despite its opposition, but Florida has ignored the requirement and continues to disenroll children for unpaid premiums.

Choosing Between School Supplies and Health Insurance

According to the Florida Healthy Kids Corp., the nonprofit contracted by the state to determine eligibility for and administer KidCare, about 250,000 children received subsidized coverage from Dec. 1, 2024, to Nov. 30, 2025. Of those, 43,000 children were disenrolled after their parents failed to pay the premium.

, director of the Center for Children and Families at Georgetown University, said the Trump administration should act on the evidence that Florida is the only state defying the rule.

“Thousands and thousands of children are routinely losing their coverage in violation of federal law,” she said, “and the Trump administration has done nothing about that. At the same time, they’re pulling money from states like Minnesota for alleged fraud violations that haven’t even been proven yet.”

Families tend to miss premium payments in July and August, when it’s time to buy back-to-school supplies, and again in December and January, around the holidays, Alker said.

“That is very, very sad,” Alker said. “You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance.”

This year, enrollment in KidCare has fallen below the state’s projections, leading to a $32 million surplus in the program. On April 17, legislators from the program and redirect it to the general fund, with that the expansion had not yet been implemented.

Lawmakers voted to expand KidCare eligibility to families earning up to 300% of the federal poverty level. The change would raise the income threshold for a family of four from about $5,500 a month to about $8,250 a month. Monthly premiums for subsidized coverage would also rise, from the current $15 to $20 a month to a maximum of $195 a month, regardless of the number of children a family enrolls.

The program provides coverage than ACA marketplace plans. KidCare has no deductible or coinsurance, and maximum copayments of $15. It also includes dental and vision coverage.

With her ACA plan, Lafortune must pay a $35 copayment for doctor visits. Her family deductible is $1,600, and the coinsurance — or the share of covered services she must pay after meeting the deductible — is 20%. The plan’s maximum out-of-pocket cost is $7,250.

“I tried to get something cheaper, but it’s not like I cannot have it,” Lafortune said of the need for health insurance. “I have to do something.”

The state’s initial lawsuit challenging the continuous eligibility rule was dismissed in May 2024, and a second lawsuit was withdrawn this February. The state and CMS told the judge they were “working to determine the most expeditious way to resolve the dispute” and have yet to update the court on their discussions.

But three days after withdrawing the lawsuit, Florida sued CMS for a third time, accusing the federal agency of ignoring the state’s public records request related to CMS’ approval of the KidCare expansion.

As the legal wrangling continues, the cost of health insurance has skyrocketed.

For those with ACA marketplace coverage, the expiration of enhanced subsidies has hit hard. About half of those who re-enrolled in ACA marketplace coverage for 2026 said their healthcare costs are “a lot higher” this year, according to .

For Lafortune, Florida’s KidCare expansion can’t come soon enough.

“Children are the ones who are going to replace everyone here,” she said. “When you give them opportunities — for their health, for school, to eat — you make your country healthy and better.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ºÚÁϳԹÏÍø News and share your story.

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They discussed the pivotal role the president of the United States plays in health policy — whether it is building support for or opposition to new plans and proposals. “Presidents have a level of authority which is often underappreciated, especially in health care,” Blumenthal said.

Blumenthal and Rovner also discussed the historical reasons the U.S. has been unable to enact universal health care, incrementalism versus sweeping change, and what he described as “the dance” between proponents and opponents — usually a clear party-line split between Democrats and Republicans — of major health care reforms.

Today, the split seems to have come to a head, as public health, science, and expertise are being viewed by one end of the political spectrum as “the opposition,” Blumenthal said, which will complicate efforts. Still, he outlined ideas for moving forward.

An abbreviated version of this interview aired April 23 on Episode 443 of What the Health? From ºÚÁϳԹÏÍø News: “RFK Jr. vs. Congress.”

Blumenthal’s latest book, Whiplash: From the Battle for Obamacare to the War on Science, co-written with James A. Morone, offers a behind-the-scenes look at how three presidential administrations pursued very different health policy goals.

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More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.

“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.

While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.

A Chubb spokesperson did not respond to requests for comment on the increase.

More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to KFF, meaning they could be vulnerable to large costs if they have a serious illness.

In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.

“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.

Climbing Numbers

Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to KFF. That amount has likely risen since.

“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.

In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to ºÚÁϳԹÏÍø News by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.

For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.

Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.

Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”

Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.

“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.

Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.

“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.

Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.

“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”

But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.

How This Plays Out

People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.

Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.

have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.

An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.

Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.

“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.

There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.

For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to KFF, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.

Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.

Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.

Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.

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But officials warned that all optional Medicaid services are still under review as the state health department looks for cuts to offset a shortfall driven by higher-than-expected Medicaid costs.

Jon Ebelt, a spokesperson with the Montana Department of Public Health and Human Services, said the agency is preparing a request to the federal government to add doula care to the state’s Medicaid program. It would cost the state about $118,000 in its first year to provide doula Medicaid reimbursements, according to .

His April 15 comments came three weeks after department officials told ºÚÁϳԹÏÍø News that the state budget deficit had put those plans on hold. Ebelt denied that a final decision had been made in March to scrap the doula Medicaid payments, which state lawmakers approved in a bill last year. The coverage is “now proceeding as planned,” he said.

“At the time of your initial inquiry, we were still in the process of analyzing the appropriation,” Ebelt said.

Federal health officials must approve any amendments to the state’s Medicaid program before payments can begin. reimburse doulas through Medicaid.

Doulas are trained, nonmedical workers who support people through pregnancy and after they give birth. The care they provide is in health complications, which has prompted more states to cover doula services in recent years.

Montana lawmakers who supported expanding Medicaid to cover doula care in 2025 cited scarce maternity services, especially in rural and Indigenous communities. But this year, the state has a Medicaid budget deficit of more than and is expecting a similar shortfall next year. Plus, federal policy changes slated to take effect later this year are expected to increase costs.

“ There’s a need and a desire for doula services, but a lot of people can’t afford it,” said Sheri Walker, a Helena-based doula and president of the . “So that means many of us have other jobs that we have to juggle.”

Walker is a part-time labor and delivery nurse outside of her doula work.

On March 25, health department spokesperson Holly Matkin said in an email to ºÚÁϳԹÏÍø News that the agency “will not be moving forward with the implementation of doula services in the Montana Medicaid benefit package at this time.” She had added that it was unclear whether state law gives the department the authority to authorize coverage during the budget shortfall.

State Sen. , a Democrat who sponsored last year’s bipartisan doula reimbursement bill, said she didn’t know about the department’s plans until she saw ºÚÁϳԹÏÍø News’ reporting. Neumann said she and groups that had backed the legislation began calling health officials, making the case for doula services as a low-cost way to provide critical care.

After about a week, Neumann said, state officials told her the agency was moving ahead with doula services after all.

“They were on the chopping block,” Neumann said. “This is a story of how important it is for all Montanans to pay attention and stay connected to what’s happening.”

Ebelt did not clarify what led the department to change its position. However, he warned that optional Medicaid services, such as doula services, may still be cut.

“All optional services, including this service, are being reviewed,” Ebelt said, referring to doula care. He did not respond to a follow-up query as to whether the department might still decide to postpone the program following federal approval.

are types of care that states choose to cover through their Medicaid programs but aren’t required by federal law. That can include covering eyeglasses, prescription drugs, and prosthetics, and more specialized care such as physical therapy, or inpatient psychiatric services for people under 21.

Those services may not sound optional, said , who studies Medicaid financing at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. But she said they’re one of the few avenues states have to make adjustments when budgets get tight.

Congressional Republicans’ One Big Beautiful Bill Act, the spending measure President Donald Trump signed into law last July, is expected to put more states in a budget crunch as its provisions start to take effect by the end of the year. The federal government has estimated that the law will reduce federal Medicaid spending by nearly $1 trillion over 10 years. The law also left states with a higher share of the costs to provide food assistance.

Williams said many states expanded services in recent years by boosting optional Medicaid benefits and provider pay.

“We could see them walk those back,” Williams said.

Montana’s financial problems preceded federal changes. Last year, state lawmakers cut some of the health department’s funding and underestimated Medicaid use. The state also overestimated what the federal government would pay toward Montana’s Medicaid costs.

Health officials must outline a plan to cut costs before the state’s 2027 budget year begins on July 1. Simultaneously, the agency is trying to hire more staffers to begin vetting whether Medicaid enrollees meet or are exempt from new work requirements that also go in place July 1. The new rules, mandated through long-delayed state legislation and the federal spending law, will have a three-month grace period.

Stephanie Morton, executive director of , said she’s grateful the state is back on track to pay for doula services through Medicaid. But she said she’s worried about potential health care cuts to come.

“We know that doulas are a critical piece of that infrastructure, but standing alone and losing other sources of care really isn’t optimal,” Morton said. “These are not robust systems as it stands.”

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McLeod, who lives near Charleston, South Carolina, is still paying off chemotherapy bills that followed her 2017 diagnosis. She also now faces an onslaught of out-of-pocket costs for follow-up monitoring and care, including regular visits to a pulmonologist and allergist.

McLeod, 45, said she had already spent $2,500 in the first two months of the year and owes an additional $1,300 from a January colonoscopy. That’s on top of the $895 monthly premium for a health insurance plan that covers her family of six.

Those costs have led McLeod to ration her other care. Despite feeling intense chest pain since February, for example, she is putting off a CT scan and a visit to a heart specialist.

“You’re forced to pick and choose as to where your priorities really need to be,” said McLeod, director of strategic programs and partnerships at the Cancer Hope Network, a nonprofit that supports cancer patients. Even in that role, she struggles to navigate the financial aftermath of surviving the disease.

The cost of postcancer care often “keeps us hostage,” she said.

McLeod is one of nearly 19 million U.S. cancer survivors, many of whom continue to need prescriptions, doctor visits, and procedures to monitor their condition and manage posttreatment side effects. Of more than 1,200 cancer patients and survivors , about 47% said they had carried medical debt, with nearly half having owed more than $5,000, according to the American Cancer Society Cancer Action Network.

Yet health policy researchers and patient advocates said the experiences of cancer survivors reveal the limits of the Trump administration’s proposals to lower premiums, which may not help patients who accumulate large medical bills year after year. The proposals center on increasing the availability of high-deductible health plans, which have lower monthly payments but require patients to pay thousands of dollars out-of-pocket before coverage kicks in.

In addition, the administration has supported allowing insurers more leeway to sell plans that are not compliant with the Affordable Care Act. Such plans could bar people who have preexisting health conditions, like a cancer diagnosis, and exclude that ACA plans are required to cover.

The administration did not answer a request for comment on how its proposals would affect cancer survivors. But its supporters say, in general, people would have more flexibility to personalize coverage and more options for plans with lower monthly fees.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank, believes patients would have better control over spending, and the option to choose what kind of care gets covered, if health plans were exempted from the ACA’s regulations. A person could opt for a plan that includes cancer treatment but not maternity care, for example.

History proves insurance coverage is not that simple, especially for people with preexisting conditions, said Jennifer Hoque, an associate policy principal with the American Cancer Society Cancer Action Network. When health plans could “pick and choose” enrollees based on preexisting conditions prior to the ACA, people needing the costliest care often struggled to find coverage, she said.

“They’re not going to choose a cancer survivor,” Hoque said of health insurers.

That was the case for Veronika Panagiotou, who said private insurers refused her coverage back in September 2013 because she had a high body mass index. Two months later, as a 25-year-old uninsured graduate student, she was diagnosed with non-Hodgkin lymphoma. The hospital treated her, she recalled, “and sent me all the bills.”

In January 2014, Panagiotou was able to buy one of the first ACA plans that went into effect. It covered chemotherapy and immunotherapy treatment, imaging, medications, hospital stays, weekly blood draws, a blood transfusion, and emergency room visits.

Now Panagiotou, 37, is cancer-free and works as director of advocacy and programs at Cancer Nation, a nonprofit advocacy group. Even though she is covered through her employer, Panagiotou said treatment-related expenses weigh heavily on her life decisions.

“Every choice I make, I think about cancer,” she said.

Chris Bond, a spokesperson for AHIP, the main health insurance trade association, said its members are working to improve access to coverage. But that can be a challenge when doctors and drugmakers are hiking prices, he said. Health plans are trying to “shield Americans from the full impact of those rising costs,” Bond said.

The Lymphoma Research Foundation has seen a 10% increase in applications to its patient aid fund this year, CEO Meghan Gutierrez said. “This trajectory suggests that financial safety nets, when they exist, are straining,” she said.

Rising prices are affecting everyone, regardless of the kind of health insurance they have, if any, said Brian Blase, president of Paragon Health Institute, a Republican-aligned think tank. “The biggest challenge for cancer patients isn’t the type of coverage,” he said. “It’s the underlying cost of care.”

Blase pointed to President Donald Trump’s as potentially helpful to cancer survivors. The Medicare Drug Price Negotiation Program, established by the Inflation Reduction Act of 2022, required the Department of Health and Human Services to negotiate prices for certain high-cost drugs, to lower prices for the federal health insurance program for people ages 65 and older. Drugs for breast, prostate, and kidney cancers are already on that list, .

Yet Hoque fears efforts to weaken ACA protections and financial support for marketplace plans will give cancer survivors — who she said tend to “hang on to insurance for dear life” — fewer options, especially between jobs or during career changes.

Erin Jones, a 31-year-old food policy researcher living in Fort Collins, Colorado, who was diagnosed with Hodgkin lymphoma as a young adult, is now cancer-free but still sees two oncologists, visits a high-risk breast clinic, and gets a breast MRI annually. Jones gets health insurance through the university where she works, and said she recently deferred acceptance to a PhD program partly due to uncertainty over affordable coverage.

“I don’t have the freedom to do the things I want to do as easily,” she said, “because I am constantly worried about health insurance.”

Costs related to surviving cancer, including monitoring for recurrence and treatment of side effects, were expected to reach $246 billion by 2030, up from $183 billion in 2015, according to .

Advancements in both detecting and curing cancer have resulted in a higher percentage of people surviving five years or more after diagnosis, according to the American Cancer Society. The number of survivors is expected to grow to more than 22 million people by 2035, .

Despite these advancements, the cost of treatment can steal the spotlight, said Ezekiel Emanuel, a co-director of the Healthcare Transformation Institute at the University of Pennsylvania and a onetime health policy adviser to former President Barack Obama.

An oncologist, Emanuel said he had observed patients make the difficult decision to delay or skip postcancer care as a result.

“Even when we triumph,” he said, “we don’t seem to be able to have a celebration.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ºÚÁϳԹÏÍø News and share your story.

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After some federal financial aid expired, many Americans found that high-deductible health plans were the only option they could afford.

In a new episode of NPR’s Life Kit podcast, ºÚÁϳԹÏÍø News reporter Jackie Fortiér and podcast host Marielle Segarra discuss what these plans are, and why they can feel so confusing. Imagine paying $100 out-of-pocket for a routine doctor visit that used to cost you $20. Imagine shouldering thousands of dollars in bills before your insurance pays a cent.

Still, for some people — especially those who rarely need medical care — high-deductible plans work. Listen to the episode to explore how timing your care and taking advantage of free preventive services can help you make the most of your coverage.

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The Office of Personnel Management 65 insurance companies to provide monthly reports with detailed medical and pharmaceutical claims data of more than 8 million people enrolled in federal health plans, ºÚÁϳԹÏÍø News reported earlier this month. The request, which could dramatically expand the personally identifiable medical information OPM can access, alarmed health ethicists, insurance company executives, and privacy advocates.

Now, OPM Director Scott Kupor has two letters on his desk — one from 16 U.S. senators and another led by Rep. Robert Garcia, the top Democrat on the House Oversight Committee — asking him to drop the agency’s proposal.

“The collection of broad, personally identifiable data regarding medical care and treatment raises concerns that OPM could target certain federal employees seeking vital health care services that the Administration disagrees with on political grounds,” the Democratic House members , citing ºÚÁϳԹÏÍø News.

The letters from congressional Democrats alone are unlikely to reverse OPM’s plans. Republicans — who control Congress and, ultimately, any oversight activities — have not weighed in on OPM’s notice.

OPM did not immediately respond to a request for comment on the letters. The agency, which said in its notice that it will use the data for oversight and to manage the federal health plans, has not publicly addressed written concerns about its proposal.

The notice, posted and sent to insurers in December, states that insurers are legally permitted to disclose “protected health information” to OPM and does not provide instructions to redact identifying information, such as names or diagnoses, from the claims.

That data could be used to implement cost-saving measures, health policy experts told ºÚÁϳԹÏÍø News earlier this month. But it would also give the Trump administration — which has laid off or fired tens of thousands of federal workers — access to a vast trove of personal information.

In the letters, Democratic lawmakers lay out a number of concerns about potential consequences of OPM’s obtaining detailed medical claims for millions of federal workers.

The — led by Adam Schiff of California and Mark Warner of Virginia — argues that OPM is not equipped to safeguard such sensitive data and that the administration could share the records across government agencies, as it has done with personal information on millions of Medicaid enrollees.

They also assert that the agency does not have a legal right to the data and that insurers’ sharing the information with OPM would “violate the core principles of the Health Insurance Portability and Accountability Act.” HIPAA requires certain organizations that maintain identifiable health information — such as hospitals and insurers — to protect it from being disclosed without patient consent. The proposal, the senators warn, threatens patients’ relationships with their clinicians, especially “sensitive disclosures regarding mental health, chronic illness, or other deeply personal conditions.”

“For these reasons, we strongly urge you to cease any further consideration of this proposal,” states the letter, which was sent to Kupor on April 19.

The American Federation of Government Employees, the largest union for federal employees, to ºÚÁϳԹÏÍø News’ reporting. The union noted in a statement from its national president, Everett Kelley, that OPM’s proposal “comes in the context of coordinated attacks on federal employees and repeated stretching of the legal boundaries for sharing sensitive personal data across government agencies.

“The question of what this administration intends to do with eight million Americans’ most private health information is not academic,” the AFGE statement read. “It is urgent.”

In an emailed statement, Kelley applauded the congressional letters.

“We are pleased that Democratic lawmakers on the Hill are just as outraged as we are over this administration’s blatant attempt to breach the privacy of millions of Americans across the country,” Kelley wrote. “We share their concerns regarding potential misuse of the information to continue illegally targeting workers and their demand for OPM to withdraw this proposal.”

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ºÚÁϳԹÏÍø News Michigan correspondent Kate Wells discussed urgent care clinics offering abortions on Apple News Today on April 15.

• Read Wells’ “Urgent Care Clinics Move To Fill Abortion Care Gaps in Rural Areas.”

ºÚÁϳԹÏÍø News Montana correspondent Katheryn Houghton discussed doula Medicaid reimbursements on Montana Public Radio on April 9.

• Read Houghton’s “This Northern Cheyenne Doula Was About To Start Getting Paid — Then Medicaid Cuts Hit.”

ºÚÁϳԹÏÍø News contributor Michelle Andrews discussed farm bureau health plans on The Yonder Report on April 8.

• Read Andrews’ “Farm Bureau Health Plans Beat the ACA on Prices With an Age-Old Tactic: Rejecting Sick People.”

This <a target="_blank" href="/on-air/on-air-april-18-2026-urgent-care-abortion-doulas-farm-bureau-health-plans/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">