“I call it the unaffordable care act,” he said. He reprised the line in his 2026 State of the Union address, blaming “the crushing cost of health care” on Obamacare.

Trump’s words also play off an ongoing congressional debate that began late last year with the expiration of the enhanced tax subsidies that had lowered the cost of ACA insurance for millions of Americans — and thrust the issue of ACA-related costs back to center stage.

Without those enhanced subsidies, the amount people pay toward monthly Obamacare premiums doubled, on average. The number of people enrolled in ACA coverage for this year has dropped by more than a million, and experts say more people could abandon coverage once premiums come due. Democrats are using this development to crank up the heat on Republicans ahead of the November elections and steer the conversation on the affordability issue.

Republicans fault the law itself for driving up these costs. For instance, Rep. Mike Lawler (R-N.Y.) has said that premiums “skyrocketed across the country since it took effect.”

Critics routinely point to several provisions within the ACA as the culprits — among them, essential health benefits, or EHBs. Under the law, Obamacare plans must cover certain essential services, including emergency care, hospitalization, maternity, and prescription drugs, without annual or lifetime dollar limits. But connecting EHBs to the premium increases felt by consumers is not straightforward.

Here’s a primer on key issues involved.

Checking the Numbers

It’s clear that Obamacare premiums have increased.

An analysis by the right-leaning Paragon Health Institute shows that the average premium for a 50-year-old with Obamacare grew by 129% since 2014. The average premium for employer-based plans grew 68% during that same time.

Paragon’s president, Brian Blase, told KFF Health News that this shows the ACA has made health care on the individual market more expensive.

Still, the comparison overlooks a couple of points. Pre-ACA, employer plans generally offered more generous coverage than individual market plans, so work-based coverage cost more. And individual plans were cheaper in part because they could bar applicants with health problems. Beginning in 2014, the ACA forced individual policies to look more like employer plans, covering a broader range of benefits and accepting both healthy and unhealthy applicants. As a result, premiums rose that first year. In the years that followed, ACA plans often experienced faster growth in premiums than job-based plans. Some policy analysts say this isn’t surprising because ACA plans started at a lower dollar base and had more room to rise.

States that saw less dramatic post-ACA premium increases, such as Massachusetts and New York, already mandated that individual-market plans provide EHB-like coverage, noted Edmund Haislmaier, a senior research fellow at the Heritage Foundation, a conservative think tank. These states also had higher premiums due to that and other provisions, such as not allowing plans to exclude people with preexisting conditions.

“It was a combination of things,” he said.

Blase acknowledges that the two types of insurance started at different price points. But he said the percentage change over time shows that the ACA faces “underlying inflationary pressures” — including the now-expired, more generous, covid pandemic-era subsidies — that affect its policyholders more so than employer plans.

Aside from that point, however, premiums on the individual insurance market were on the rise even before the ACA took effect.

An analysis by Jonathan Gruber at the Massachusetts Institute of Technology found that between 2008 and 2010, premiums grew by at least 10% a year and were highly variable across states and insurers.

Consumers’ Other Costs

Over time, ACA deductibles — the amounts policyholders must satisfy in a given year before insurance kicks in — have seen large increases, with “bronze” plans now averaging $7,476 annually, up from $5,113 in 2014, according to KFF, a health information nonprofit that includes KFF Health News. Bronze plans tend to have lower premiums than the other metal-level categories — “silver,” “gold,” and “platinum” — in part because of their higher deductibles.

The Trump administration is doubling down on high-deductible plans as part of its emphasis on affordability, making it easier this year for people age 30 and up to qualify for what are called “catastrophic plans.” These come with even larger deductibles than bronze plans.

The administration pitched a broad regulatory plan for 2027 to cement those changes, saying it was designed to lower premiums and expand choices. It would raise next year’s deductibles for catastrophic plans to $15,600 a year for an individual or around $30,000 for a family. It isn’t clear how popular such plans would be. Detailed enrollment figures for this year are not yet available, but estimates indicate only about 54,000 people chose catastrophic plans in 2025, and consumers can’t use federal subsidies to purchase them.

Before this Trump proposal, though, recent data showed that the rising rate of ACA plan deductibles had not outpaced deductibles for employer plans.

The weighted average — a calculation that gives more weight to ACA plans with the most people enrolled — shows about a 55% increase in annual deductible amounts since 2014, from $1,881 to $2,912. During that same period, deductibles in plans offered by employers rose on average 59%, from $1,186 to $1,886, according to KFF’s annual employer survey.

Essential What?

To be clear, the ACA’s catastrophic and bronze plans must cover essential health benefits, as do all Obamacare plans. These EHBs fall into 10 categories of medical services and were included in the ACA to ensure individual policies meet a minimum standard of coverage and are comparable to employer-based health insurance.

Preventive services, such as annual checkups, vaccines, and certain cancer screenings, must be covered at no additional cost to patients. All plans must completely cover the cost of specific vaccines, including the annual flu shot. And insurers cannot refuse to pay for emergency care provided at an out-of-network hospital. Other EHBs are subject to out-of-pocket costs, such as copays at the doctor’s office or pharmacy counter.

In some ways, EHBs save money because they’ve increased access to preventive care, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health.

Services such as cancer screenings and lab tests can lead to earlier detection of serious conditions, when treatment is less costly, and positive outcomes are more likely.

“If you look down the list of essential health benefits, I think most people would reach the judgment that those are health care services that people should have access to,” said Larry Levitt, KFF’s executive vice president for health policy.

Joseph Antos, a senior fellow emeritus at the conservative American Enterprise Institute, said ACA requirements — such as requiring insurers to accept anyone, regardless of their health status, and limiting insurers’ ability to charge older people more for coverage — also have played roles in boosting premiums.

“Really, it’s practically impossible to tease any one thing out,” Antos said.

States do have latitude to add benefits that fall under the EHB umbrella. For example, bariatric surgery is covered as an EHB in West Virginia, but not in Pennsylvania. Pennsylvania’s EHBs also don’t include hearing aids, but New Jersey’s do.

But the Trump administration’s 2027 regulatory proposal doesn’t cast this flexibility in a positive light: When “states enact benefit mandates, plan premiums must generally increase to account for the additional coverage,” it reads. It also signals that added benefits can raise consumer costs and proposes that states be required to use their own funds to offset some of those costs.

Paragon’s Blase echoed this take in his bottom line. Mandating that plans cover EHBs without annual or lifetime caps, as required under the ACA law, encourages clinicians to overbill and overprescribe, he said. That drives up premiums and means a bigger check for insurers and medical providers at the expense of taxpayers. “You just turn patients into money factories,” he said.

Stacey Pogue, a senior research fellow at Georgetown University’s Center on Health Insurance Reforms, disagrees, saying that whatever EHBs’ role, they aren’t to blame for the year-over-year premium hikes.

People aren’t consuming medical care at exponential rates just because certain services are now covered: “Me not paying anything for that colonoscopy doesn’t make me want to get more of them,” she said.

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Miller, quien es neurocientífica, dijo que consultó a varios psiquiatras y recibió receta tras receta de distintos medicamentos. Durante dos años, probó cuatro antidepresivos y dos antipsicóticos. Nada de eso ayudó hasta que su doctor de atención primaria notó niveles altos de un marcador autoinmune en su sangre.

Un especialista luego le hizo “todas las pruebas posibles”, dijo Miller. Finalmente, la diagnosticaron con la enfermedad autoinmune lupus y le recetaron un esteroide para reducir la inflamación. Algunos de sus síntomas mejoraron en cuestión de horas. Su depresión disminuyó poco después.

“Estaba convencida de que era un efecto placebo”, dijo Miller, “pero luego siguió funcionando”.

¿Había contribuido la inflamación a sus problemas de salud mental todo el tiempo? Miller cree que sí, aunque no puede saberlo con certeza. Sus psiquiatras nunca mencionaron esa posibilidad, dijo.

En la mayoría de las especialidades médicas, los doctores pueden confirmar si deben seguir un tipo de tratamiento mediante pruebas, como análisis de sangre, estudios de imagen y biopsias. Sin embargo, los trastornos mentales históricamente se han diagnosticado y tratado en base a síntomas visibles. Eso podría cambiar.

En un documento de enero, la Asociación Americana de Psiquiatría incluyó ideas sobre cómo podría incorporar biomarcadores —indicadores biológicos de enfermedad mental que pueden aparecer en pruebas diagnósticas— en futuras versiones de su Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM, por sus siglas en inglés).

El DSM, a veces llamado “la Biblia de la psiquiatría” por su influencia en el campo, proporciona criterios de diagnóstico. Lo utilizan clínicos que evalúan a pacientes y aseguradoras para decidir si cubren la atención.

Se necesita investigación “coordinada”

Los biomarcadores psiquiátricos aún no están listos para un uso generalizado, enfatiza el documento. Los científicos han investigado el tema por décadas, con pocos resultados. Se necesita más investigación para demostrar que estas mediciones son lo suficientemente válidas y confiables para usarse en la atención de pacientes, señala el documento de la asociación, y otros investigadores han planteado dudas sobre cómo su uso podría afectar los costos de la atención médica, la cobertura y la privacidad de los pacientes.

Agregar biomarcadores al DSM sería “algo muy importante”, dijo Jonathan Alpert, autor del documento de enero y vicepresidente del Comité Estratégico del Futuro del DSM de la asociación profesional.

El acceso a resultados de pruebas, junto con los síntomas, podría agilizar las decisiones de cobertura de seguros y ayudar a los clínicos a hacer diagnósticos y recomendaciones de tratamiento más rápidos y precisos, dijo. Si la biología de los pacientes sugiere que responderán mejor a un tratamiento que a otro, el doctor podría comenzar de inmediato con esa opción.

Actualmente, recetar medicamentos psiquiátricos puede ser “algo incierto”, ya que los clínicos no pueden predecir si funcionarán en un paciente en particular, dijo Matthew Eisenberg, director del Centro de Políticas de Salud Mental y Adicciones de la Escuela de Salud Pública Bloomberg de la Universidad Johns Hopkins.

En un ensayo esencial de principios de la década de 2000 financiado por el Instituto Nacional de Salud Mental, alrededor del 30% de los participantes con depresión vieron desaparecer sus síntomas con su primer tratamiento antidepresivo. Ese estudio sigue siendo uno de los ensayos más sólidos realizados sobre antidepresivos, aunque investigadores han indicado recientemente que menos personas se curan con estos medicamentos de lo que sugieren sus resultados.

Este enfoque de prueba y error puede llevar a recetas ineficaces e innecesarias, un tema criticado por defensores del movimiento Make America Healthy Again, encabezado por el secretario del Departamento de Salud y Servicios Humanos (HHS), Robert F. Kennedy Jr.

Kennedy ha sido especialmente crítico de los antidepresivos, al vincularlos con la violencia después de un tiroteo masivo sin evidencia y culpar a los doctores por recetar en exceso medicamentos a niños.

El HHS está analizando tendencias en diagnósticos y recetas psiquiátricas y evaluando enfoques alternativos de tratamiento en salud mental, con especial atención en niños, dijo la vocera Emily Hilliard en un comunicado. Hilliard no respondió a una pregunta sobre comentarios previos de Kennedy.

Los biomarcadores ya se utilizan para guiar tratamientos en otras áreas médicas, como la oncología. Arizona, Georgia, Kentucky, Texas y más de una docena de otros estados exigen que las aseguradoras cubran este tipo de pruebas. También se utilizan análisis de sangre y estudios de imagen para ayudar a diagnosticar la enfermedad de Alzheimer.

La Asociación Americana de Psiquiatría incluyó en su artículo varias formas en que los biomarcadores psiquiátricos podrían usarse en el futuro, como pruebas de actividad cerebral, perfiles genéticos o marcadores inmunológicos asociados con ciertas condiciones psiquiátricas, incluidas la esquizofrenia y las adicciones.

En la depresión, por ejemplo, alrededor de una cuarta parte de los pacientes tiene niveles elevados de una proteína inflamatoria llamada proteína C reactiva, que puede detectarse mediante un análisis de sangre. Las investigaciones han mostrado que las personas con niveles altos de esta proteína parecen responder mejor cuando reciben medicamentos que modifican los niveles de dopamina en el cerebro, en lugar de usar solo inhibidores selectivos de la recaptación de serotonina (ISRS), un tipo común de antidepresivo.

La proteína C reactiva aún necesita ser “validada de manera sólida” como biomarcador, según el documento de la APA, pero es una de las opciones más prometedoras bajo estudio.

Se necesita un esfuerzo de investigación “coordinado y bien financiado” para lograr esa validación, escribió la asociación, lo cual es incierto ya que la administración Trump recortó el financiamiento para investigación.

Solo al Instituto Nacional de Salud Mental se le cancelaron en 2025 al menos 128 subvenciones, por un valor de casi $173 millones, según una carta de investigación en la revista JAMA. Aunque desde entonces algunas subvenciones han sido restauradas, los investigadores que dependen de fondos federales aún temen recortes.

“Hay una gran necesidad de financiamiento continuo y activo para la investigación relacionada con la salud mental”, dijo Alpert, pero los científicos tendrán que enfrentar “incertidumbres en el panorama de financiamiento”.

Efectos en cobertura y costos

Los costos de la atención médica tienden a ser más altos entre pacientes con enfermedades mentales mal controladas, debido a gastos como hospitalizaciones, consultas ambulatorias y medicamentos. Algunas investigaciones sugieren que las pruebas de biomarcadores podrían ahorrar dinero al encontrar tratamientos adecuados más rápido y evitar algunos de estos costos.

Un estudio de modelado estimó que las pruebas para identificar componentes genéticos que pueden influir en la efectividad de un medicamento podrían ahorrar al sistema de salud de Canadá $956 millones en 20 años si se aplican en adultos con depresión mayor en British Columbia. Otro estudio, de investigadores españoles, encontró que estas pruebas redujeron costos para la mayoría de los 188 participantes con enfermedad mental grave.

No se sabe si ocurriría lo mismo en el sistema de salud de Estados Unidos. A corto plazo, dijo Eisenberg, un enfoque que use biomarcadores podría aumentar el gasto en atención médica debido al costo de las pruebas.

Las aseguradoras podrían negarse a cubrir pruebas de biomarcadores costosas, agregó. “Toma tiempo demostrar que la nueva evidencia científica es segura y efectiva”, dijo Eisenberg. “Y una vez que lo es, las aseguradoras no la cubren de inmediato”.

Algunos investigadores han expresado preocupación de que aseguradoras o empleadores puedan discriminar a personas cuyos perfiles biológicos sugieren riesgo de desarrollar afecciones neuropsiquiátricas graves.

Es un “momento crítico” para considerar enfoques legislativos que protejan a los pacientes y capaciten a los clínicos sobre cómo usar estas herramientas de manera adecuada, dijo Gabriel Lázaro-Muñoz, miembro del Centro de Bioética de la Escuela de Medicina de Harvard.

“No creo que el campo de la psiquiatría esté listo en este momento para manejar esto”, dijo.

El sistema de salud mental no está listo para “avanzar por completo”, dijo Andrew Miller, profesor de psiquiatría y ciencias del comportamiento en la Facultad de Medicina de la Universidad Emory, quien estudia la depresión relacionada con la inflamación. Pero la adopción de biomarcadores por parte de la asociación de psiquiatría marca “el inicio de una revolución”, dijo.

“Esto es un reconocimiento… de que lo que hemos hecho hasta ahora no ha sido suficiente”, dijo Miller. “Y podemos hacerlo mejor”.

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Miller, a neuroscientist, said she saw several psychiatrists and got prescriptions for drug after drug. Over two years, she tried four antidepressants and two antipsychotics. None of that helped — until her primary care doctor noticed high levels of an autoimmune marker in her blood.

A specialist then ran “every test in the book,” Miller said. Eventually, she was diagnosed with the autoimmune disease lupus and prescribed an inflammation-lowering steroid. Some of her symptoms let up within hours. Her depression subsided not long after.

“I was convinced it was a placebo effect,” Miller said, “but then it kept working.”

Had inflammation been contributing to her mental health problems all along? Miller thinks so, although she can’t know for sure. Her psychiatrists never raised that possibility, she said.

In most medical specialties, doctors can confirm whether to pursue a type of treatment through tests, such as blood work, imaging, and biopsies. Mental illnesses, however, have historically been diagnosed and treated based on outward symptoms. That could change.

The American Psychiatric Association in a January paper included ideas for how it might incorporate biomarkers — biological indicators of mental illness that could show up on diagnostic tests — into future versions of its Diagnostic and Statistical Manual of Mental Disorders.

The DSM, sometimes called “psychiatry’s bible” because of its influence in the field, provides criteria for diagnoses. It’s used by clinicians assessing patients and by insurance companies deciding whether to cover care.

‘Coordinated’ Research Needed

Psychiatric biomarkers are not ready for widespread use yet, the paper emphasized. Scientists have researched the topic for decades, with little to show for it. More research is needed to prove these metrics are valid and reliable enough to be used in patient care, the APA’s paper said, and other researchers have raised questions about how their use could affect health care costs, insurance coverage, and patient privacy.

Adding biomarkers to the DSM would be “a very big deal,” said Jonathan Alpert, an author of the January paper and vice chair of the APA’s Future DSM Strategic Committee.

Access to test results, along with symptoms, could streamline insurance coverage decisions and help clinicians make faster and more accurate diagnoses and treatment recommendations, he said. If patients’ biology suggested they’d respond better to one treatment than another, their doctor could waste no time in starting there.

Currently, prescribing psychiatric medications can be “a bit of a crapshoot,” with clinicians unable to predict whether they will work for a particular patient, said Matthew Eisenberg, director of the Center for Mental Health and Addiction Policy at the Johns Hopkins University Bloomberg School of Public Health.

In a seminal, early 2000s trial funded by the National Institute of Mental Health, about 30% of the study’s participants with depression saw symptoms disappear with their first antidepressant treatment. That study is still one of the most robust antidepressant trials conducted — although researchers have more recently argued that fewer people are cured by these medications than its results suggest.

Such a trial-and-error approach can lead to ineffective and unnecessary prescriptions, a topic of attack by proponents of the Make America Healthy Again movement, spearheaded by Health and Human Services Secretary Robert F. Kennedy Jr. Kennedy has been especially critical of antidepressants, having linked them to violence after a mass shooting without evidence and blaming doctors for overprescribing medications for children.

HHS is analyzing psychiatric diagnosis and prescription trends and evaluating alternative mental health treatment approaches, with a particular focus on children, spokesperson Emily Hilliard said in a statement. Hilliard did not respond to a question about Kennedy’s previous comments.

Biomarkers are already used to guide treatment in other medical disciplines, such as oncology. Arizona, Georgia, Kentucky, Texas, and more than a dozen other states require insurers to cover such testing. Blood and imaging tests are now used to help diagnose Alzheimer’s disease as well.

The APA included in its article a variety of ways psychiatric biomarkers could be used in the future — such as testing for brain activity, genetic profiles, or immune markers associated with certain psychiatric conditions, including schizophrenia and substance use disorders.

In depression, for example, about a quarter of patients have elevated levels of an inflammatory protein, called C-reactive protein, that can be found through a blood test. Research has shown that people with high levels of this protein seem to respond better when given drugs that alter dopamine levels in the brain, rather than using only selective serotonin reuptake inhibitors, or SSRIs, a common type of antidepressant. C-reactive protein still needs to be “robustly validated” as a biomarker, according to the APA’s paper, but it’s among the most promising currently under investigation.

A “coordinated, well-funded” research effort is needed to achieve such validation, the APA wrote — a tenuous prospect since the Trump administration slashed funding for research.

The National Institute of Mental Health alone had at least 128 grants, worth almost $173 million, canceled in 2025, according to a research letter in the journal JAMA. Though some grants have since been restored, researchers relying on federal money still fear their work is vulnerable to cuts.

“There’s a great need for continued, active funding of research related to mental health,” Alpert said, but scientists will have to grapple with “uncertainties of the funding landscape.”

Ripple Effects on Coverage, Costs

Health care costs tend to be higher among patients with poorly controlled mental illnesses, due to expenses like hospital visits, outpatient appointments, and prescriptions. Some research suggests biomarker testing could save money by landing on the right treatments faster and avoiding some of these costs.

One modeling study estimated that testing to look for genetic components that may influence a drug’s effectiveness could save the Canadian health system $956 million over 20 years if used among adults with major depression in British Columbia. Another study, by Spanish researchers, found that such testing reduced costs for most of the 188 participants with serious mental illness.

Whether the same would be true in the U.S. health care system is unknown. In the short term, Johns Hopkins’ Eisenberg said, an approach that uses biomarkers could raise health care spending due to the costs of testing.

Insurers may decline to cover pricey biomarker tests, he added. “It takes a while for new science to be proven safe and effective,” Eisenberg said. “And once it is, insurance companies don’t cover it immediately.”

Some researchers have raised concerns that insurers or employers could discriminate against people whose biological profiles suggest they’re at risk of developing serious neuropsychiatric conditions.

It’s a “critical moment” to consider legislative approaches to protect patients and train clinicians about how to appropriately use these tools, said Gabriel Lázaro-Muñoz, a member of Harvard Medical School’s Center for Bioethics.

“I do not think that the field of psychiatry is currently ready to manage this,” he said.

The mental health system isn’t ready to “jump in with both feet,” said Andrew Miller, a professor of psychiatry and behavioral sciences at the Emory University School of Medicine, who studies inflammation-related depression. But the APA’s embrace of biomarkers signals “the beginning of a revolution,” he said.

“This is a recognition … that what we’ve done up to this point has not been good enough,” Miller said. “And we can do better.”

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

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El dolor persistente por un accidente de auto ocurrido hace dos meses, sumado a una vida ya difícil, tiene a Angulo preocupada por su embarazo. Por eso sintió alivio cuando una camioneta móvil de medicina callejera de St. John’s Community Health llegó cerca de su asentamiento en febrero.

“Gracias a Dios que los tenemos”, dijo.

St. John’s, que opera 28 clínicas, la mayoría en el condado de Los Ángeles, forma parte de la red nacional de clínicas comunitarias sin fines de lucro que atienden a los habitantes más pobres del país. Alrededor del 80% de sus 144.000 pacientes, incluida Angulo, tienen Medi-Cal, la versión de California del programa Medicaid para personas con bajos ingresos o discapacidades.

Pero los recortes federales al gasto de Medicaid bajo la One Big Beautiful Bill, la ley aprobada por los republicanos, sumados al ajuste fiscal en Sacramento, podrían costarle a St. John’s hasta un tercio de sus ingresos anuales de $240 millones. Eso obligaría a recortar servicios que podrían incluir la medicina callejera, dijo Jim Mangia, presidente y director ejecutivo de la organización.

Si no se reemplaza el financiamiento perdido, clínicas más pequeñas y con menos recursos del condado podrían enfrentar consecuencias aun más duras y hasta cierres.

Por eso Mangia, junto con una coalición de clínicas comunitarias, trabajadores de salud y defensores, impulsa un impuesto a las ventas de medio centavo por cinco años en el condado más poblado del país para ayudar a cubrir la pérdida proyectada de fondos federales y estatales.

Hasta ahora, St. John’s ha aportado al menos $2 millones a la campaña.

Louise McCarthy, presidenta y directora ejecutiva de la Asociación de Clínicas Comunitarias del Condado de Los Ángeles (Community Clinic Association of Los Angeles County), dijo que no hay muchas opciones para salvar al sistema de salud de un desastre.

“Estamos en una situación crítica y desesperante”, agregó. “Esto tiene el potencial de cambiar el panorama. Compensaría de manera muy significativa las pérdidas”.

La Junta de Supervisores del condado de Los Ángeles aprobó la propuesta en febrero para incluirla en la boleta de las elecciones primarias del 2 de junio, pese a la oposición de algunas ciudades dentro del condado. Sus líderes argumentaron que el impuesto pondría presión sobre los consumidores y los dueños de negocios.

La mayor parte de un estimado de $1.000 millones en ingresos anuales se usaría para proteger la atención médica de la red de seguridad en clínicas comunitarias, hospitales y escuelas.

Luchando por mantenerse a flote

A nivel nacional, se espera que la ley presupuestaria del Partido Republicano reduzca el gasto federal en Medicaid en $911.000 millones a lo largo de 10 años. También podría aumentar en más de 14 millones el número de personas sin seguro médico.

La propuesta en la boleta del condado de L.A. es una de muchas iniciativas locales y estatales en todo el país, mientras clínicas, hospitales, trabajadores de salud, defensores y legisladores buscan nuevas fuentes de dinero para compensar los recortes.

En Michigan, donde se proyecta que la ley federal le costará al estado $32.000 millones en 10 años, la oficina de la gobernadora demócrata Gretchen Whitmer ha propuesto nuevos impuestos o aumentos de impuestos sobre el tabaco, productos de vapeo, apuestas en línea, apuestas deportivas y publicidad digital. Calcula que esto generaría cientos de millones de dólares al año.

En Rhode Island, un grupo de legisladores estatales espera aliviar parte del impacto de los recortes federales con un paquete de proyectos de ley que incluye un impuesto a los anuncios digitales y un recargo del 3% sobre ingresos gravables superiores a aproximadamente $640.000.

“El objetivo no es reemplazar los ingresos, sino reducir el daño”, dijo el representante estatal demócrata Brandon Potter, uno de los legisladores involucrados en estas leyes.

En Washington, el representante estatal demócrata Shaun Scott presentó recientemente una legislación para abordar la pérdida de fondos federales con un impuesto del 5% sobre la nómina de grandes empresas, aplicado a salarios de empleados que superen los $125.000 al año.

En California, la ley republicana reducirá la contribución federal a Medi-Cal en un estimado de $30.000 millones al año, o 25%. La inscripción en Medi-Cal podría caer en 3 millones para 2028 como resultado de los recortes federales y estatales, según un análisis del Centro de UCLA para la Investigación de Políticas de Salud y del Centro Laboral de la Universidad de California-Berkeley.

En julio, California reducirá los pagos de Medi-Cal que reciben las clínicas comunitarias por ciertos servicios brindados a pacientes con estatus migratorio “insatisfactorio” en alrededor de $1.000 millones al año. Estos pacientes incluyen residentes permanentes en el país por menos de cinco años, refugiados, personas con asilo y otras personas legalmente presentes.

Preparándose para una “nueva realidad”

Defensores y expertos en salud dicen que encontrar nuevas fuentes de ingresos es la única manera de evitar una crisis en el sistema de salud de California.

“¿Vamos a permitir que los vacíos creados por las políticas federales y los recortes del presupuesto estatal dejen a millones de personas sin seguro?”, dijo Laurel Lucia, subdirectora ejecutiva de programas del Centro Laboral de UC Berkeley. “Gran parte de esa pregunta se reduce a los ingresos”.

Algunos profesionales de la medicina dicen que se necesitan nuevos ingresos en el corto plazo, pero que el país también debe abordar su sistema de salud, conocido por ser costoso.

“Esta nueva realidad es que en el futuro tendremos que hacer nuestro trabajo con menos dinero”, dijo Hector Flores, presidente electo de la Asociación Médica del Condado de Los Ángeles. “Así que esta es una oportunidad para ver cómo podemos hacer las cosas mejor”.

Mientras tanto, abundan los esfuerzos por aumentar los impuestos para la atención médica.

Los votantes del condado de Santa Clara, hogar de Silicon Valley, aprobaron en noviembre pasado un aumento de 0,625% en el impuesto a las ventas durante cinco años para compensar recortes federales a Medicaid. Una medida similar estará en la boleta de junio en el condado de Contra Costa.

La iniciativa más conocida, y muy disputada, es una propuesta en la boleta de California patrocinada por sindicatos para aplicar una única vez un impuesto del 5% a los más de 200 multimillonarios del estado.

El gobernador demócrata Gavin Newsom se opone firmemente; el senador Bernie Sanders (independiente de Vermont) hizo campaña recientemente en California a favor de la propuesta y ha prometido presentar una versión nacional en el Congreso.

Los promotores del impuesto temporal a la riqueza dicen que recaudaría $100.000 millones, que en su mayoría se usarían para cubrir la pérdida de fondos federales y estatales en Medi-Cal y otros programas de la red de seguridad. Estos promotores intentan reunir cerca de 875.000 firmas necesarias para llevar la medida a la boleta de noviembre.

“Estamos al borde de un colapso de nuestro sistema de salud. Así que las personas más afortunadas entre nosotros pagan un impuesto modesto que nos dará tiempo y nos permitirá encontrar una solución a largo plazo”, dijo Suzanne Jimenez, jefa de gabinete del Sindicato Internacional de Empleados de Servicios–Trabajadores de la Salud Unidos West, principal patrocinador de la medida. “Aun así, seguirían siendo increíblemente ricos”.

Los multimillonarios responden

El plan ha generado gran controversia, no solo en California sino en todo el país, y ha provocado fuerte resistencia de multimillonarios y otros críticos.

Los críticos argumentan que la medida podría hacer que los multimillonarios abandonen California, lo que afectaría la innovación, los empleos y la recaudación fiscal. Algunos también advierten que podría terminar en una batalla legal, ya que quienes tendrían que pagar podrían impugnarla por múltiples vías.

“Si esto se aprobara, se esperaría que quedara frenado en los tribunales por algún tiempo”, dijo Jared Walczak, investigador temporal de la California Tax Foundation. “Es bastante posible que no entre ningún ingreso durante varios años, si es que llega a entrar alguno”.

La posibilidad de estas complicaciones ha llevado a algunos defensores de la salud a enfocarse en iniciativas locales que podrían empezar a generar ingresos más rápido, como el impuesto a las ventas propuesto en el condado de Los Ángeles.

Pero esa medida también tiene críticos, incluidos líderes de varias ciudades del condado que pidieron a los supervisores que rechazaran la propuesta porque, dicen, aumentaría las preocupaciones por el costo de vida de los consumidores y pondría presión sobre los negocios.

Kathryn Barger, republicana y la única supervisora del condado de Los Ángeles, que se opuso a incluir la medida en la boleta de junio, dijo en un comunicado que el impuesto propuesto haría que el condado fuera “menos accesible para las familias y menos atractivo para que los consumidores compren y las empresas operen”.

Pero los partidarios dicen que la atención médica de la red de seguridad ya está sintiendo el impacto de la reducción de fondos. Por ejemplo, en febrero, el Departamento de Salud Pública del condado anunció que cerraría siete clínicas debido a $50 millones en recortes de financiamiento federal, estatal y local.

Los inscritos en Medi-Cal también están preocupados.

“Recibimos muchas llamadas de pacientes en pánico que temen perder su Medi-Cal. Decenas de llamadas al día, cientos de llamadas a la semana”, dijo Mangia, de St. John’s.

“Les decimos que estamos trabajando en una solución y esperamos tener esa solución en junio”.

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But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.

“We really want people to factor that in,” said Kata Kertesz, managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”

There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.

In addition, as Medicare Advantage plan profits have sagged in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a study published in JAMA in February.

“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.

For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, six-month opportunity for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.

But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:

• People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy anytime during the year without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
• People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “trial right.”
• If a Medicare Advantage plan leaves Medicare or stops providing services in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
• If an individual moves out of the service area and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said Bonnie Burns, a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.

There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.

Patient advocates emphasize that it’s often useful to work with a counselor at the State Health Insurance Assistance Program, or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.

People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.

Beware: More Underwriting

In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.

The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a review by KFF of leading insurers’ applications.

When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said Nick Ortner, a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.

“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.

Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.

“They have access to a Medigap comparison tool in addition to what is existing on medicare.gov that can give you a very good estimate of what you may pay for those Medigap plans,” said Ryan Ramsey, associate director of health coverage and benefits at the National Council on Aging.

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When Mike McKee thinks about saving money for the future, he has a few priorities. Maxing out his retirement is one. Building up his kid’s college fund is another.

Opening up a health savings account? Not so much, even though he qualifies because of his high-deductible health plan.

“I’m so frustrated with the system that has anything to do with medical savings,” said McKee, 42, a self-employed musician in Nashville, Tennessee. “I’m just so turned off emotionally that I have to be really careful to be logical about it.”

More Americans are eligible to open an HSA — a kind of tax-free savings account that lets them sock away money for medical expenses — after changes that were part of new legislation last year. But an HSA can be a headache to set up and navigate.

Here’s what to know about how they work and when they’re worth it.

Like a Tax-Free Investment Account for Medical Expenses

With an HSA, you set aside money from your paycheck before taxes, and you can use that money to pay for medical expenses later. Most purchases related to health qualify, including medications, glasses, orthodontia, and many kinds of therapy.

You have options for the money in the account, including investing it. Some people call HSAs a “triple tax advantage”: There are no taxes on the money that goes in, no taxes on any interest earned, and no taxes on the money that comes out for medical expenses.

Pro tip: An HSA is not the same as an FSA, or flexible spending account, even though it sounds similar. An FSA also lets you put pretax income into an account for medical expenses, but you typically lose unspent money at the end of the calendar year. By contrast, HSA money stays in your account until you spend it. Think F for “forfeit” and H for “hold on to.”

The Admin Work of an HSA Can Be a Real Barrier

First, you have to find out whether your health plan allows for an HSA. Most high-deductible health plans do, but with these plans you might have to spend thousands of dollars before most benefits kick in. Starting this year, plans on the individual Affordable Care Act marketplace that are categorized as “bronze” or “catastrophic” are also eligible. (The easiest way to find out whether you qualify is to call the number on the back of your insurance card and ask.)

Then, you have to open the HSA on your own through a financial institution — although if you get health insurance through a job, your employer might have preferred institutions. And finally, you have to keep track of your qualified medical expenses. You pay for them using a special debit card or by submitting claims for reimbursement, usually through an online portal. Either way, it’s smart to hold on to receipts.

People and Policy

If you’re living paycheck to paycheck, you may find it difficult to take advantage of the tax savings that come with an HSA. “HSAs, in this way, tend to benefit more the higher-income enrollees, because those are the ones who have the disposable income to set aside at the end of the month,” said Michelle Long, a policy researcher at KFF, a health information nonprofit that includes KFF Health News. Plus, people with higher incomes and higher tax brackets have more to gain from getting discounts on their taxes, which is basically what an HSA provides.

Katherine Ruppelt at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer, approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and KFF Health News.

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Por eso, la joven de 31 años, de Henrico, Virginia, se quedó atónita cuando supo que Anthem finalmente tendría que pagar un tratamiento médico que le cambiaría la vida.

Durante dos años había luchado con la compañía para que cubriera infusiones de plasma sanguíneo llamadas inmunoglobulina intravenosa, o IVIG. En algunos casos, el tratamiento ha demostrado mejorar los síntomas asociados con la neuropatía de fibras pequeñas, una afección que hace que las extremidades de Ekirch se sientan como si estuvieran en llamas.

Pero Anthem había negado repetidamente la cobertura de IVIG, que cuesta alrededor de $10.000 por infusión. Luego, en febrero, una revisión externa de su caso realizada para la Oficina de Seguros de Virginia (Virginia Bureau of Insurance) revocó la negativa de Anthem.

Eso significaba que sus padres ya no tendrían que retirar dinero de los ahorros de jubilación de su padre para pagar el tratamiento de su propio bolsillo. Hasta entonces, ya habían gastado unos $90.000.

“Mi mamá estaba sollozando. Mi papá estaba de rodillas, llorando. No creo haberlo visto llorar así nunca”, dijo Ekirch al describir la reacción de sus padres ante la decisión.

“Creo que todavía estoy en shock por todo esto”, dijo.

En una declaración preparada, Stephanie DuBois, vocera de Anthem Blue Cross and Blue Shield, dijo que el tratamiento IVIG no “se ajustaba a nuestros estándares basados en evidencia”. Sin embargo, afirmó que la compañía respeta “la decisión del revisor externo” de revocar la negativa.

Mientras tanto, cada año millones de pacientes como Ekirch siguen enfrentando negativas a través del proceso de autorización previa, que exige que muchos pacientes o sus doctores obtengan aprobación anticipada de las aseguradoras antes de continuar con la atención médica.

Y a pesar de las promesas de reforma de las aseguradoras, las negativas siguen siendo una característica frustrante del sistema de salud.

En junio pasado, funcionarios de la administración Trump anunciaron en una conferencia de prensa que líderes de las aseguradoras de salud se habían comprometido a simplificar la autorización previa tomando medidas como “reducir el alcance de los reclamos” que requieren aprobación anticipada. También prometieron tiempos de respuesta más rápidos y “explicaciones claras y fáciles de entender” sobre sus decisiones.

Sin embargo, en febrero, cuando KFF Health News contactó a más de una docena de grandes aseguradoras que firmaron el compromiso, la mitad de ellas no proporcionó detalles específicos sobre los servicios de salud para los cuales ya no exigen autorización previa.

Un comunicado de prensa de enero indicó que la industria sigue comprometida con el esfuerzo. Pero doctores, consumidores y defensores de pacientes son pesimistas sobre la disposición de las aseguradoras a cumplir con estos cambios voluntarios.

“No tienen ningún deseo de hacer lo que es mejor para el paciente si eso va a afectar sus bolsillos”, dijo Matt Toresco, director ejecutivo de Archo Advocacy, una empresa de defensa y consultoría para pacientes.

“En el mundo de los seguros, la responsabilidad fiduciaria no es con el paciente”, dijo. “Es con Wall Street”.

¿Un cambio significativo?

El Departamento de Salud y Servicios Humanos de EE.UU. (HHS) no respondió a las preguntas para este artículo. Las pocas actualizaciones que el gobierno federal ha emitido desde junio sobre la reforma de la autorización previa incluyen un anuncio de septiembre sobre garantizar que los médicos puedan enviar solicitudes de forma electrónica.

AHIP, el grupo comercial de aseguradoras de salud que publicó el comunicado de enero, no proporcionó información sobre tratamientos, códigos, medicamentos o procedimientos específicos que sus miembros hayan eliminado del requisito de autorización previa desde que firmaron el compromiso.

“Tendremos actualizaciones adicionales sobre el progreso más adelante esta primavera”, dijo Kelly Parsons, vocera de la Asociación Blue Cross Blue Shield, que representa a 33 compañías independientes de Blue Cross y Blue Shield. Tampoco ofreció detalles específicos.

Las compañías de Blue Cross y Blue Shield que cubren pacientes en Alabama, Arkansas, Iowa, Michigan, Pennsylvania, Carolina del Sur, Dakota del Sur y Tennessee no respondieron a las preguntas para este artículo o remitieron las consultas a la Asociación Blue Cross Blue Shield.

En contraste, otras aseguradoras sí citaron ejemplos específicos de cambios.

Aetna CVS Health comenzó a agrupar autorizaciones previas para procedimientos musculoesqueléticos, así como para pacientes con cáncer de pulmón, mama y próstata, dijo el vocero Phil Blando.

Esta práctica permite que los proveedores presenten una sola solicitud de autorización para el tratamiento de un paciente en lugar de varias.

Y Humana eliminó los requisitos de autorización previa para servicios de diagnóstico relacionados con colonoscopías, entre otros cambios, dijo el portavoz Mark Taylor.

UnitedHealthcare, que fue objeto de intenso escrutinio por su uso de la autorización previa tras el asesinato de uno de sus ejecutivos a finales de 2024, eliminó el requisito de autorización previa el 1 de enero para ciertos estudios de imágenes nucleares, ultrasonidos obstétricos y procedimientos de ecocardiograma, entre otros cambios, dijo el vocero Matthew Rodriguez.

Aun así, algunos expertos del sistema de salud dudan que estos cambios tengan mucho impacto.

“Las aseguradoras han hecho promesas similares antes y no han cumplido con cambios significativos”, dijo Bobby Mukkamala, presidente de la Asociación Médica Estadounidense, que representa a doctores y estudiantes de medicina.

En 2018, varios grupos del sector salud, incluidos AHIP y la Asociación Blue Cross Blue Shield, anunciaron una alianza “para identificar oportunidades de mejorar el proceso de autorización previa”. Sin embargo, Mukkamala escribió en respuesta al compromiso de junio que el proceso sigue siendo “costoso, ineficiente, poco transparente y, con demasiada frecuencia, peligroso para los pacientes”.

“La transparencia es esencial para que todos puedan ver si realmente se están produciendo reformas”, dijo a KFF Health News.

Entusiasmo moderado

La autorización previa puede estar recibiendo más atención política, pero los datos muestran que los pacientes —especialmente quienes tienen afecciones crónicas que requieren tratamiento continuo— siguen enfrentando obstáculos para recibir la atención recomendada por sus doctores.

Entre los pacientes de ese grupo, el 39 % dijo que la autorización previa es “la mayor carga” para recibir atención, según una encuesta reciente de KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News.

Eso es cierto para Payton Herres, 25 años, de Dayton, Ohio, quien en 2012 tuvo un trasplante de corazón, lo que requiere que tome un medicamento recetado contra el rechazo por el resto de su vida.

Pero el año pasado, dijo, Anthem negó la cobertura del costoso medicamento. Lo había estado tomando durante más de 10 años.

“He estado con Anthem toda mi vida y, de repente —no sé qué pasó— empezaron a negármelo una y otra vez”, dijo. “Casi me quedo sin medicamento”.

DuBois, la vocera de Anthem, confirmó que la compañía ha aprobado el medicamento. Cuando negó la cobertura, la empresa no había tomado en cuenta el historial de tratamiento de Herres, dijo DuBois.

Pero Herres dijo que la compañía le exigirá obtener una nueva autorización para el medicamento en septiembre.

“¿Van a negar otras cosas también?”, preguntó. “Espero no tener que seguir luchando así por el resto de mi vida”.

Anna Hocum, de 25 años, se prepara para una lucha similar. En 2024 y 2025, su aseguradora negó repetidamente la cobertura de un tratamiento costoso utilizado para ralentizar la progresión de una afección genética rara que destruye la función de sus pulmones.

“Simplemente pensé que iba a morir”, dijo Hocum, de Milwaukee. “Estaba luchando por sobrevivir y luego estaba luchando para convencer a alguien de que merecía sobrevivir”.

Al igual que con Ekirch, los padres de Hocum pagaron el tratamiento mientras esperaban que la compañía de seguros revocara las negativas iniciales. Amigos y familiares donaron más de $30.000 a través de una campaña en GoFundMe para ayudar a cubrir los costos.

Luego, la primavera pasada, Hocum dijo que su aseguradora revocó la negativa sin una explicación aparente. Pero la aprobación es válida solo por 12 meses, por lo que necesitará otra autorización previa este año.

“Da miedo”, dijo. “No está garantizado que lo acepten”.

Aunque ahora es “un enorme alivio” que Anthem esté obligada a cubrir el tratamiento de Ekirch, su madre no sabe si o cómo la familia recuperará el dinero que ya ha pagado.

En una carta a Ekirch confirmando la decisión del revisor externo, Anthem explicó que la autorización será válida por un año a partir del 25 de septiembre de 2025. “Nos complace poder ofrecer una respuesta favorable en este caso”, escribió un analista de quejas y apelaciones de Anthem.

Ekirch dijo que la carta resaltó la hipocresía de la compañía.

“Actúan como si fueran una organización benevolente que me está haciendo un favor”. En realidad, dijo, “pelearon conmigo con uñas y dientes en cada paso del camino, hasta el punto de que hicieron de mi vida un infierno”.

Ahora, el acceso de Ekirch a la IVIG podría volver a estar en peligro. Su cobertura COBRA a través de Anthem vence a finales de marzo. En abril tendrá que cambiar a un nuevo plan médico, y se está preparando para otra ronda de autorizaciones previas.

“Simplemente tengo mucho miedo de no tener la fuerza para pasar por todo lo que se necesita”, dijo Ekirch, “para luchar esta batalla otra vez”.

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

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• Click here to hear Whitehead on The Georgia Health Report.
• Read Whitehead’s “New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard,” co-reported with Samantha Liss.

KFF Health News Colorado correspondent Rae Ellen Bichell discussed wage garnishment legislation on KUNC’s In the NoCo on March 5.

• Click here to hear Bichell on In the NoCo.
• Read Bichell’s “State Lawmakers Seek Restraints on Wage Garnishment for Medical Debt.”

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by KFF Health News has found. 

The “dark money” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.” 

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to Facebook’s Ad Library, a database of the social media company’s online ads. 

There’s no doubt health insurers are unhappy with a January proposal from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration. 

Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about 35 million members, more than half the people eligible for Medicare. 

CMS is set to announce a final rate decision by early next month. The agency solicited public comments on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online. 

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 published comments as of March 12. 

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them. 

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

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Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by KFF Health News has found.

The “dark money” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”

“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to Facebook’s Ad Library, a database of the social media company’s online ads.

There’s no doubt health insurers are unhappy with a January proposal from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.

Medicare Advantage plans differ from traditional Medicare because private insurance companies administer them. The insurance plans enroll about 35 million members, more than half the people eligible for Medicare. The plans offer things like vision and drug coverage, but Medicare Advantage insurers restrict the hospitals and doctors that patients can use and require prior approval for various procedures.

CMS is set to announce a final decision by early next month on the rate proposal. The agency solicited public comments on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views.

Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 comments published as of March 12.

The proposed rate plan “puts my access to care at risk,” the group’s template letter to policymakers reads in part. “If the investment made by Washington in the Medicare Advantage program is nearly flat year-over-year, I could lose benefits I rely on every day, including affordable prescriptions, capped out of pocket costs, and access to trusted doctors and specialists.”

“Medicare Advantage is not optional for me. The cost protections alone have saved me thousands of dollars and made my health care manageable. Without this program, I would face higher costs, fewer providers, and fewer benefits at a time when I can least afford it,” the letter states.

Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.

“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.

“There’s no way for the public to know what wealthy donors or special interests are funding dark money groups like this,” he said. “That means there’s no scrutiny of who’s really calling the shots.”

Some health care policy experts, who have long argued that the government overpays Medicare Advantage plans by tens of billions of dollars every year, believe industry groups or their surrogates routinely overstate possible negative impacts of rate decisions they don’t like.

“The plans always say that the sky is falling,” said Matthew Fiedler, a health care policy expert with the Brookings Institution. “The industry has a lot of money at stake here. They try to exert pressure on policymakers any way they can.”

At the same time, even critics concede that some of the millions of people enrolled in Medicare Advantage plans could face service cuts if insurance companies are not satisfied with government payments.

“It is legitimate for people to be worried,” said Julie Carter, counsel for federal policy at the Medicare Rights Center, a group that advocates for older adults and people with disabilities.

Her group argues that Medicare Advantage plans have never attained expected cost savings and instead have been overpaid for years at least partly due to “actions to maximize profits.” She said the health plans “are supposed to be saving money, not taking extra.”

People struggling to pay health care bills may have little use for the policy debate in Washington.

“If it wasn’t for being able to have this program, I really wouldn’t be able to afford any kind of medical services, to be honest,” said EsterAlicia Rose, 75, who works at the front desk of a hotel in Pagosa Springs, Colorado. She said she signed the Medicare Advantage Majority form letter to reach policymakers.

Kathy Lovely-Marshall, 66, a retired nurse who lives in Brookville, Ohio, did too. She said she receives “a lot of perks” from her plan, such as dental care, eyeglasses, and prescriptions.

“All those things are a big plus as far as I am concerned,” she said. “I’m very happy with the plan I have.”

But Corenia Branham, 90, a widow and cancer survivor who lives in Alum Creek, West Virginia, said she wants nothing to do with Medicare Advantage plans run by private health insurance companies. She said she didn’t turn in any of the four form letters under her name, which were posted online by CMS on Feb. 23 and signed, “Miss Corenia Branham Branham.” It’s not clear why her last name is signed twice.

Branham said she’s not on Medicare Advantage and doubts she could count on it for needed care.

“I wouldn’t recommend it to nobody,” she said. “I sure don’t want anything to do with it.”

Grubb, the Medicare Advantage Majority spokesperson, disputed that account. He said Branham responded to an ad on Facebook. On Feb. 6, she “completed the form with her information and chose to send her comment to CMS as well as to her representatives in Congress and the White House,” he said.

Other Medicare Advantage advocacy groups have stepped up ad campaigns as the rate decision looms.

The Better Medicare Alliance, whose “allies” include a range of health insurers, health care providers, and consumers, is urging seniors to “Tell Washington to Stand Up for Medicare Advantage.”

“We’ve mobilized beneficiaries to write letters and make phone calls, and we’ve run digital ads on streaming platforms,” spokesperson Susan Reilly said.

Reilly said that this year roughly 3 million seniors “were forced to find new coverage” because plans either shuttered operations or left some areas.

She also said Medicare Advantage plans have “scaled back” benefits such as offering transportation to medical appointments, nutrition support, and dental and vision coverage, while over the past two years beneficiaries have faced an average $900 increase in out-of-pocket maximums.

“We do view this as especially serious,” Reilly said. “This isn’t a single bad year; it’s the cumulative effect of years of underfunding and policy disruption from the previous administration that has left the program increasingly vulnerable.”

As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.

CMS spokesperson Catherine Howden said the agency would make more comments public “as soon as practicable.”

“The agency focuses on reviewing the substance of timely submissions and does not speculate on volume, sentiment, or potential impact of comments while the comment period is open/under review,” she said in a statement.

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

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