“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”.

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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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.

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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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.”

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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That’s why Ekirch, 31, of Henrico, Virginia, was stunned when she learned Anthem would finally have to pay for life-changing medical treatment.

For two years, she had battled the company to cover blood plasma infusions called intravenous immunoglobulin, or IVIG. The treatment has been shown, in some cases, to improve symptoms associated with small-fiber neuropathy, a condition that makes Ekirch’s limbs feel like they’re on fire.

But Anthem had repeatedly denied coverage for IVIG, which costs about $10,000 per infusion. Then, in February, an external review of her case conducted for the Virginia Bureau of Insurance overturned Anthem’s denial. It meant her parents would no longer need to withdraw money from her father’s retirement savings to pay out-of-pocket. Already, they’d spent about $90,000.

“My mom was sobbing. My dad was on his knees, sobbing. I don’t think I’ve ever seen him cry like that,” said Ekirch, describing her parents’ reaction to the reversal.

“I think I’m in shock from it all,” she said.

In a prepared statement, Stephanie DuBois, a spokesperson for Anthem Blue Cross and Blue Shield, said IVIG did not “align with our evidence-based standards.” But she said the company respects “the external reviewer’s decision” to overturn the denial.

Meanwhile, each year millions of patients like Ekirch continue to face denials through the prior authorization process, which requires many patients or their doctors to seek preapproval from health insurers before proceeding with medical care. And despite promises of reform from insurance companies, denials remain a frustrating hallmark of the American health care system.

Last June, Trump administration officials announced in a press conference that health insurance leaders had pledged to simplify prior authorization by taking steps such as “reducing the scope of claims” subject to preapproval. The insurers also promised faster turnaround times and “clear, easy-to-understand explanations” of their decisions.

Yet in February, when KFF Health News contacted more than a dozen major insurers that signed the pledge, half of them failed to provide specifics about health care services for which they no longer require prior authorization.

A January press release said the industry remains committed to the effort. But physicians, consumers, and patient advocates are pessimistic about the insurers’ willingness to follow through with these voluntary changes.

“They have no desire to do what’s in the best interest of the patient if it’s going to hurt their pockets,” said Matt Toresco, CEO of Archo Advocacy, a patient advocacy and consulting company.

“In the insurance world, the fiduciary responsibility is not to the patient,” he said. “It’s to the Street,” he said, referring to Wall Street.

Meaningful Change?

The Department of Health and Human Services did not respond to questions for this article. The few updates the federal government has issued since June on prior authorization reform include a September announcement about ensuring clinicians can submit requests electronically.

AHIP, the health insurer trade group that issued the January press release, did not provide information about specific treatments, codes, medications, or procedures that its members have released from prior authorization since signing the pledge.

“We will have additional progress updates coming out later this spring,” said Kelly Parsons, a spokesperson for the Blue Cross Blue Shield Association, which represents 33 independent Blue Cross and Blue Shield companies. She also offered no specifics.

Blue Cross and Blue Shield companies that cover patients in Alabama, Arkansas, Iowa, Michigan, Pennsylvania, South Carolina, South Dakota, and Tennessee either did not respond to questions for this article or deferred to the Blue Cross Blue Shield Association.

By contrast, other insurers cited specific examples of change.

Aetna CVS Health began “bundling” prior authorizations for musculoskeletal procedures, as well as for lung, breast, and prostate cancer patients, spokesperson Phil Blando said. This practice allows providers to file one authorization request for a patient’s treatment instead of several.

And Humana removed prior authorization requirements for “diagnostic services across colonoscopies,” among other changes, spokesperson Mark Taylor said.

UnitedHealthcare, which came under intense scrutiny for its use of prior authorization following the fatal shooting of one of its executives in late 2024, removed prior authorization requirements on Jan. 1 for “certain nuclear imaging, obstetrical ultrasound and echocardiogram procedures,” among other changes, spokesperson Matthew Rodriguez said.

Yet some health care insiders doubt these changes will amount to much.

“Insurers have made similar promises before and failed to deliver meaningful change,” said Bobby Mukkamala, president of the American Medical Association, which represents U.S. physicians and medical students.

In 2018, various health industry groups, including AHIP and the Blue Cross Blue Shield Association, announced a partnership “to identify opportunities to improve the prior authorization process.” Yet, Mukkamala wrote in response to the June pledge, the process remains “costly, inefficient, opaque, and too often hazardous for patients.”

“Transparency is essential so everyone can see whether real reforms are happening,” he told KFF Health News.

Curbed Enthusiasm

Prior authorization may be getting more political attention, but data shows patients — particularly those with chronic conditions that require ongoing medical treatment — continue to face barriers to doctor-recommended care.

Among patients in that group, 39% said prior authorization is “the single biggest burden” in receiving care, according to a recent poll by KFF, a health information nonprofit that includes KFF Health News.

I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.

Anna Hocum

That’s true for Payton Herres, 25, of Dayton, Ohio, who in 2012 received a heart transplant, which requires her to take an antirejection prescription medication for the rest of her life.

But last year, she said, Anthem denied coverage for the expensive drug. She’d been taking it for more than 10 years.

“I’ve been with Anthem my entire life, and then, all of a sudden — I don’t know what happened — they just started denying me over and over,” she said. “I almost ran out of medication.”

DuBois, the Anthem spokesperson, confirmed the company has approved the medication. It had not taken Herres’ treatment history into account when it denied coverage for the drug, DuBois said.

But Herres said the company will require her to obtain a new authorization for the medication in September.

“Are they going to deny other things, too?” she asked. “I hope I don’t have to keep fighting like this for the rest of my life.”

Anna Hocum, 25, is preparing for a similar fight. In 2024 and 2025, her insurer repeatedly denied coverage for expensive treatment used to slow the progression of a rare genetic condition that destroys her lung function.

“I just thought I was going to die,” said Hocum, of Milwaukee. “I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.”

Like with Ekirch, Hocum’s parents paid while they waited for her insurance company to overturn the initial denials. Friends and family donated more than $30,000 through a GoFundMe campaign to help defray the costs.

Then last spring, Hocum said, her insurer reversed the denial without an apparent explanation. But the approval is valid for only 12 months, so she will need another prior authorization approval this year.

“It is scary,” she said. “It’s not guaranteed that it’ll be accepted.”

They fought me tooth and nail every step of the way, to the point that they made my life a living hell.

Sheldon Ekirch

Even though it’s a “huge relief” that Anthem is now obligated to cover Ekirch’s treatment, her mother doesn’t know if or how the family will recoup the money it has already paid.

In a letter to Ekirch confirming the external reviewer’s decision, Anthem explained that the authorization would be valid for a year beginning on Sept. 25, 2025. “We are pleased we can provide a favorable response in this case,” a grievance and appeals analyst for Anthem wrote.

Ekirch said the letter highlighted the company’s hypocrisy.

“They act as though they are a benevolent organization doing me a favor.” In reality, she said, “they fought me tooth and nail every step of the way, to the point that they made my life a living hell.”

Now, Ekirch’s access to IVIG may be in jeopardy again. Her COBRA coverage through Anthem expires in late March. In April, she will need to transition to a new insurance plan — and she’s bracing herself for another round of prior authorization.

“I just am so afraid that I don’t have the strength to go through and do what it takes,” Ekirch said, “to fight this battle again.”

Do you have an experience with prior authorization you’d like to share? Click here to tell KFF Health News your story.

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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Julie Rovner
KFF Health News

@jrovner

@julierovner.bsky.social

Read Julie’s stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

This month marks host Julie Rovner’s 40th anniversary reporting on health policy in Washington. Over that time, she’s covered a vast range of topics, from the response to the AIDS epidemic, to Medicare and Medicaid changes, to the fight over the “Patients’ Bill of Rights” — and a half-dozen major reform fights, including the introduction of the Affordable Care Act and the efforts to repeal it.

In honor of the occasion, Rovner invited two of her longtime sources to chat about what has — and has not — changed in health policy over the past four decades.

Click to open the transcript

Transcript: 40 Years of Health Policy

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News. Usually we’re joined by some of the best reporters covering Washington, but today we’re bringing you something special. I hope you enjoy it. We’re taping this episode on Friday, Feb. 27, at 4 p.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

I have two special guests today, who I will introduce in a moment. But first I’m going to explain why I chose them. I started reporting on health policy in 1986, covering health and welfare on Capitol Hill and at the Department of Health and Human Services for what was then the Congressional Quarterly “Weekly Report.” This month marks my 40th anniversary on the health beat, and as anniversaries so often do, it got me thinking about everything I’ve seen and covered, including a half a dozen major health reform fights, a dozen budget reconciliation bills, years-long fights over everything from the Patients’ Bill of Rights and human cloning to bioterrorism and a pandemic. It also got me thinking about where I thought the U.S. health system would be four decades after I began, and where it actually is. And I thought it might be fun to reminisce with a couple of people who not only were there when I started, but who also taught me a lot of what I know. So without further ado, let me introduce my guests. Chip Kahn just stepped down as president and CEO of the Federation of American Hospitals after 25 years in that post. Chip previously worked in both the House and the Senate for the major health committees and also headed the Health Insurance Association of America, the industry group now known as AHIP. I’m pleased to announce that Chip is not actually retiring — that, among other activities, he’s going to be a colleague of mine here at KFF as a senior fellow. Chip will also host a podcast starting later this spring on the business of health care. Chip, thanks for being here, and welcome. 

Chip Kahn: Really happy to be here and celebrate with you. 

Rovner: Joining Chip is Chris Jennings, who not only worked in the Senate for a decade, but also worked in the White House as a senior health staffer for Presidents [Bill] Clinton and [Barack] Obama and advised President [Joe] Biden as well. Today, Chris is president of the health care consulting firm Jennings Policy Strategies. Chris, welcome and thanks for playing along. 

Chris Jennings: Julie, it’s been great to age together. 

Rovner: So let’s start with a little bit of a tour of each of your careers. Chip, you go first. How did you first get started in shaping health policy, and what was your trajectory to today? 

Kahn: It was a scary long time ago. I guess I got started in politics in 1968, actually, when I met Newt Gingrich in New Orleans and then managed his two congressional campaigns. But then I went to graduate school in public health, and finally broke into the Hill in 1983 and worked for a year for Dan Quayle, and then worked in the Senate, worked in the House, went out and worked for the health insurers, came back and worked in the House again during the ’90s — many, many years of health policy. And then, as you said, for almost 25 years, worked at the Federation of American Hospitals, representing 20% of the hospital industry and all the health policy battles. 

Rovner: And behind your head it says “AEI,” so in your not-retirement, you’re going to be here at KFF, and you’re also going to be at AEI [American Enterprise Institute]. What else are you planning on doing? 

Kahn: Well, other than being a think tanker … and a podcaster, I’m looking at a number of areas where I’d like to do some writing on the health policy issues that I’ve been involved with over the years, and maybe try to impact their future by some of the things I have to say. That’s my, will be primary, although I’m also working with the dean of the School of Public Health at Tulane on developing a health policy center there. And I do photography, street photography, and I’ve got a project there too. So I’m not retiring. I’m just moving on. 

Rovner: You are busier than I am, and I thought I was busy. Chris, how did you come to health policy? 

Jennings: Well, I know you’re a Michigan gal, Julie, but I’m from Ohio. And I came, actually, the same year that Chip came in, in 1983. John Glenn hired me as a very, very young assistant. I don’t think I got to know you until … 1986, shortly behind. But I remember in ’86 I was hired by the chairman of the Aging Committee, the then-chairman of the agency committee [Special Committee on Aging], John Melcher, and he held the first hearing in a blizzard on the Medicare Catastrophic [Protection] illness coverage Act, and I worked through … that was ’88-’89, we repealed the policy, as you will recall. By that time, you may have moved on to the National Journal. I can’t even remember when you were there and in NPR, but I followed you as you followed me. And I worked on another chairman, David Pryor, on the Pepper Commission, where I got to know Chip — love, hate, mostly respect Chip — on the Pepper Commission, which both succeeded and immediately failed.  

Rovner: And we’ll get to that.  

Jennings: And it set the stage, really, and that’s where I think people started to know me on the Aging Committee, on the Finance Committee, on the Pepper Commission. And then, I’d go on and on. But, of course, I was eventually tapped to help Hillary Clinton do the Health Security Act, where we spectacularly failed, but learned our lessons, and we moved on. And I was there for all eight years of the Clinton administration, set up my own consulting firm, went back into the White House, as you said, and have been proud to be involved with some, you know, both extraordinary successes and failures, but progress that I think sometimes people don’t acknowledge in this debate. So hopefully we get to talk about that as well. 

Kahn: You know, Julie, one thing I think you can say about both of us is that there hasn’t been anything congressionally in delivery or financing, over your entire 40 years, that Chris and I were not involved in in one way or another. 

Rovner: That was why I decided I wanted you guys. I well know that you’ve had your fingers in everything this entire time. Well, let’s go back to the spring of 1986, when I first started covering health care on Capitol Hill. Congress was just finishing the COBRA [Continuation of Health Coverage] budget reconciliation bill, for which the health care continuation provisions that everybody knows are named, even though that was just one of literally hundreds of provisions, of different health care provisions in that bill. And from the “Some Things Never Change” file, that bill was very late. It had been kicking around since the middle of the year before one of the first big feature stories I wrote that spring was about how the U.S. had no real program to pay for long-term care for the elderly, something that is still true today. What were you guys focused on in 1986? 

Kahn: I think in 1986, as you said, every year during the ’80s and into the early ’90s, almost like clockwork, there was a budget bill, although some of those budget bills, like COBRA, lapped over. And I could, I could recite, until about 1990, I think, all the key provisions of every one of those bills. So whether it was Medicare in terms of payment modifications and payment improvements, or payment reforms, or whether it was Medicaid in terms of incrementalism, in terms of expanding to different populations. You know, we sort of saw it all. 

Jennings: There were notable reforms. In fact, it’s important to remember back then, health care really was the domain of the Congress. Presidents, barely, you know, they were for technical assistance, they provided information. But the big players in health care in the ’80s were — and it’s a very impressive group of people, both members and staff. And I don’t want to sound like an old person, but those were days when you actually did get bipartisan policies done. They weren’t easily done, but they were done, and I think it’s important to recognize that. I go — you’re saying ’86, so I’m going to stick with ’86. But ’86 was a big year … I think that was also — when did we do COBRA? ’85-’86 we were implementing COBRA.  

Kahn: It was done in ’86. 

Jennings: Yeah, ’86. 

Rovner: It was in COBRA. 

Jennings: Yeah, yeah. So, you know, that is, again, a policy that a number of people actually do utilize and it’s very, very important. 

Rovner: And EMTALA was in that bill. 

Jennings: EMTALA was in that bill, yes. 

Kahn: But besides these bills, and you brought it up, Medicaid Catastrophic, which was started a little bit after that, actually was a Reagan administration initiative. Dr [Otis] Bowen, the secretary of HHS [Department of Health and Human Services], was the major proponent. Then it became, obviously, very congressional. And so the major piece of health legislation that was just a health bill that wasn’t connected to one of these big budget bills, these big reconciliations, it passed, and it passed overwhelmingly in both chambers. After a lot of work, we could talk about that, if you want. And then within a year, you know, it was repealed. And one of the weird experiences of my life, was that, on the one hand, Bill Gradison in the House was one of the original framers of that legislation. 

Rovner: Your boss at the time. 

Kahn: One of my bosses at the time. But the day before repeal was considered in the House, I had to write for Bill Gradison a draft of a statement for him. And I, but I also worked for Bill Archer, who was one of the authors of the Archer-Donnelly amendment, which would repeal Medicare Catastrophic. So I also had to write a draft of a statement for him. Actually, let me say, I didn’t write them on the same day because I couldn’t bring myself to. But I was really sort of — I got to be careful here — “schizophrenic” on the issue, because I worked both on the legislation and then on its repeal. 

Jennings: Julie, also, I just have to say there’s another irony that I think no one knows really about, but the lead sponsor of the repeal was John McCain. John McCain, who raised all the issue of the so-called surtax, OK? Do you remember this? 

Rovner: I do. I wrote a big story about John McCain. 

Jennings: People think John McCain is Mr. Savior of the Affordable Care Act, but he also repealed the most significant, at the time, bipartisan, bicameral health care reform bill that actually, we should also say, did include an incremental Medicare prescription drug benefit. 

Rovner: John McCain was very sorry. He actually felt bad that he ended up … he tried to undo the repeal that he led. 

Kahn: And also, there was a secret weapon in there, which actually was very expensive, which was a Bill Gradison initiative, which was to change the skilled nursing facility benefit so that Medicare would basically cover six months without three days prior hospitalization.  

Jennings: Yeah. 

Kahn: And that was something that CBO said, the Congressional Budget Office said would just cost a few 100 million dollars. It was actually costing billions almost immediately, because all the states immediately changed those dual-eligible patients, dual eligible for Medicare and Medicaid, and made them Medicare patients because of the six months. So there was even a long-term care provision in there, despite the fact that some felt that Medicare Catastrophic didn’t touch long-term care. 

Rovner: Well, while we’re on the subject of the poor, be-knighted, repealed Medicare Catastrophic bill, which we all experienced, that led to the Clinton health reform bill. Chris, you were instrumental in that. What had you learned from the passage and repeal of catastrophic that you tried to put into place when you were working on the Clinton plan? 

Jennings: Sure. Well, first, Julie, I think we learned from all of our mistakes, and you learn more from your mistakes than you learn from your successes. And sometimes you mislearn your successes in major ways. But I do want to say the one thing that we did not repeal in the Medicare Catastrophic [Protection] coverage Act was the Pepper Commission. And the Pepper Commission was the first attempt to do the comprehensive reform proposal, and it was reported out, but in a really humorous, terrible scene, which I won’t bore people with, but — Chip was there, and I was there, and it was painful, and that people actually almost came to blows over that policy. Physical, physical blows between my boss, David Pryor, and Pete Stark, of all people. So that’s another story. But yes, after that, there was a[n] election in Pennsylvania — and this is sort of interesting historical context — it was a special election by [Sen.] Harris Wofford, who won, and it was all about health reform. And his political advisers, interesting, was James Carville and Paul Begala, and health care suddenly became, comprehensive health care reform became, oh, this is a big issue. And every candidate who was running at that time — really, people who … no one even knew the people running, because no one wanted to run against George W. Bush — but Bill Clinton was running against it, and he, he ended up winning, as you know, and then he chose … 

Rovner: It was George H.W. Bush. 

Jennings: George H. … George H. was so popular that the primary Democratic candidates didn’t want to run against him. So people just said, I’ll just try. And, long story short, Bill Clinton wins. And he designates Hillary Clinton. And Hillary Clinton, because I had done some work for their campaign and helped in the transition, I was asked to become the congressional liaison. So now, what did I learn from that? Well, there’s so many things to learn, and we applied them almost all to the Affordable Care Act. And of course, we’re going to have to give Chip his — you know, Chip’s the star of “Harry and Louise,” and proudly contributed to … 

Rovner: We’ll get to that. 

Jennings: … the demise. But I will say, even if we had perfectly executed the Health Security Act policy, because of the time and the delay of it and how in the environment in which it was in, it probably would have been very, very difficult to pass and enact at that time. We can talk about that. But one thing we learned is it’s really important for presidential candidates to have a vision and a way to finance their vision, but not to micromanage exactly the specific policies you need to get congressional investment in those policies. And if you impose details, the details will get, will be picked apart before you get the momentum to pass legislation. And you won’t have time to get both members of Congress and stakeholders, who inevitably you can’t pick, you can’t have everyone be your enemy if you’re going to pass health care reform, and we succeeded in getting most everyone against us. That wasn’t completely my fault, but sure, I’ll take whatever responsibility there is. But those are two big reasons. You know me, Julie. I could go on forever, but I’m going to stop with that and let Chip take his victory lap or whatever. 

Rovner: Yeah, because Chip, at that point, you were with the health insurers, who were not thrilled with the Clinton plan. 

Kahn: Well, let me say this. I always have to say this when I talk about the Health Insurance Association of America. Bill Gradison went over there in early ’93, and he took me with him. I was his executive vice president at that point. And the health insurers that we represented were for some kind of universal coverage structure. They weren’t for the model that was developed by the Clinton administration that they took to Congress. But I think Chris made a very important point: All the noise from the campaign around “Clinton Care,” pro and con, there were a lot of things going on. First, a new administration only gets so many bites at the apple, even if they’ve got big majorities in Congress. And they chose to do their big budget bill and a gun bill, which were very difficult votes for many members of Congress, before starting, in September, on the Hill with the presidential speech to lead into health reform. So I think they went in with a clock that was against them, in terms of how much a new administration has. Second, I don’t think everybody completely understood it at the time, but we had congressional control by the Democrats of the House for 40 years, and in some ways, they were a bit bankrupt, and there were a lot of issues around, you know, their unity. And we didn’t know it until the election in ’94 — and Clinton Care had had some effect on that election — but we were about to see the Republican revolution taking place. But the soundings of that and the effects of that played out in Clinton Care. But, all that being said, if you believe that campaigns make a difference in policy process and elections, there were campaigns that said Clinton Care, as proposed, needs to change. And the Health Insurance Association of America did the Harry and Louise campaign, which I managed. And actually there was one point … 

Rovner: I would say, for those who don’t remember, Harry and Louise were a couple of actors. Those were their names, actually, Harry and Louise, who sat around their kitchen table wondering how they were going to pay for their health insurance if the Clinton plan passed. 

Kahn: And that concept came from over the summer, leading into that August, before the Clinton Care process began in Congress. Bill Gradison had been going around giving speeches, saying that health reform was going to be decided around the kitchen tables of America. So I told our advertising firm, First Tuesday [Strategies], go test that. And that’s how it all got started. And they came up with the concept, and we spent a lot of time on scripts. And our whole point was not to defeat but to raise questions and actually just get a seat at the table. Well, I could give anecdotes about why we didn’t get a seat at the table, and thus we began a campaign that was one of the components of the opposition to health reform that really defeated Clinton Care. 

Jennings: And Julie, I’ll just say I think it’s important to note that we also played into it by complaining so much about [how] it got lot of free airtime, too. So then the media covered it even more than the other one. And so it was the amount of money they paid for those ads versus the amount of ads people who see that ads was an extraordinary ROI [return on investment] for Chip Kahn and Bill Gradison. But I do feel it’s important to note that a lot of the predicate for rationale behind and policy underpinning the Affordable Care Act, you’ll find a lot in the seeds of the Health Security Act, and then you’ll see them again in the debate between Barack Obama and Hillary Clinton. And in many ways, Hillary Clinton’s policy is more like what ultimately was passed and enacted in 2008 and 2009. So it’s a very interesting circle of the process. And the other thing that I think people don’t understand, is, right after that we had another health care debate, which was the “Contract With America” and, or on America, as we used to call it, and, and that was a huge Medicare-Medicaid fight, which didn’t, which also failed. But I think you almost had to have these two attempts to have an attempt to make some progress. That led to things like the Children’s Health Insurance Program and beyond, so all of which — and by the way, HIPAA, insurance reforms beyond that — which began to lay the predicate for it. Yes. 

Rovner: All right. Well, we’re going to take a quick break. We will be right back. 

OK, we’re back. In the 1990s, after the death of the Clinton health reform plan, there was this huge sort of flow of big, important health bills: the Children’s Health Insurance Program; like you say, HIPAA, the Health Insurance Portability and Accountability Act, which was a whole lot more than just the confidentiality provisions. In fact, my favorite piece of trivia is that there were no medical records confidentiality provisions because it was a requirement for Congress to write them, which they never bothered to do.  

Kahn: If you want an anecdote on that, I’ll give you an anecdote.  

Rovner: OK. 

Kahn: That’s there because of me. But I can only take credit for a few things: diabetic shoes and HIPAA confidentiality. 

Rovner: I do remember diabetic shoes, but I will not make you explain that. But do explain how the confidentiality … because HIPAA was actually about being able to change jobs without losing your health insurance — it was literally about portability of health insurance, and the confidentiality stuff got tacked on at the last minute. 

Kahn: No, no, no. It didn’t. It didn’t. No, the point of HIPAA — and, frankly, I wasn’t the author of this; I sort of stole this idea — but HIPAA was either the seven-point plan or the nine-point plan. And the idea of the way we structured HIPAA in the House was to take four or five different things — and it was, it was much more than just insurance reform —and build out aspects of health reform, sort of small-ball health reform. And the confidentiality was one part of it. And we thought at the time that there was an administrative simplification portion of the bill, which came from a congressman from Ohio that, frankly, as a staffer, I was the one in the House that put that in the bill, and I and our expectation was that Congress would come back and do confidentiality, but we needed to require it, to set a framework for it. And there was one day when the bill was in conference, when Dean Rosen, who was working for Ms. [Sen. Nancy] Kassebaum …  

Jennings: Yeah, it was Kassebaum. 

Kahn: … called me and said, Do we really have to leave those lines in the bill? And I said, Boy, it’s really, really important. And the congressman from Ohio feels strongly about it, and Mr. [Rep. Bill] Thomas feels strongly about it. And so that’s why we got HIPAA, and then, then they couldn’t legislate on it because it was too sensitive, but we put language in, and HHS wrote the rules. 

Jennings: I think it’s really important to note that in the olden days, when we started this, Congress actually gave much more explicit guidance to the executive branch as to how they implemented. HIPAA was a good example as a bridge to where we are today, which was we will do something. This is what we were saying in HIPAA. But if we fail to do so, we authorize you, executive branch, to implement the provisions of HIPAA, which is what ultimately the Clinton administration had to do. And a lot of that is because the Congress couldn’t agree on the details, as they often can’t, but they still want to be associated with the underlying policy. But anyway, it’s just another lesson of the life that we were at and where we are now. 

Kahn: And when you say, wouldn’t agree on the details, the trouble is that the poison pills, those cultural issues, frequently come into issues here. I mean abortion and other issues, which are extremely important issues, but they’re cultural issues, and people are not generally willing to compromise on those. And those are the issues that ended up holding up things like confidentiality, which Congress should have acted on. 

Rovner: Yeah, I want to get to the Affordable Care Act, but before I do, Chip, I want to talk about the strange bedfellows. Because I want … you were talking about in the context of the Clinton reform, that the stakeholders weren’t really against it. They were only against parts of it. I think I wrote in a monograph on this that everybody wanted to cut off just one finger, but, in the end, the patient bled to death. You wanted to prevent that from happening when there was the next round that became the Affordable Care Act, and you got together with Ron Pollack, who was, you know, a very liberal, also outside group. And you guys tried to put together a framework, right? 

Kahn: Well, when I went to back to the Health Insurance Association of America in 1998, Ronnie Pollack and I got together and wanted to see what we could do. I mean, in a sense, we both really agreed that we needed various kinds of coverage expansions. We started incremental. And as part of that, the Rob[ert] Wood Johnson Foundation came in with a major initiative to fund us and to fund the conversations we began, and to fund other groups coming in and joining us in a big coalition. And, frankly, we were very close on some subsidization. We had a Republican and Democratic senator right before 9/11 and then 9/11 happened, and it just … killed us. And … we got put on the back burner. And so then we went through many years of Ronnie and I doing a lot of different efforts with many other stakeholders — around either doing small-ball expansions or pushing for the ultimate — and that, ultimately, I think, at least helped fuel what happened in ’09. I mean, a lot of things led to ’09, but at least, I think, our effort laid a base of commonality across stakeholders that made ’09 very different from ’93. 

Rovner: Chris, you said that, you know, one of the things that you learned from the failed Clinton health reform is it … you’ve got to have at least some of the stakeholders inside the tent, right? … That seemed to me one of the big changes between 1993 and 2009. 

Jennings: Yes, I mean, like every story that sounds black-and-white, there’s grays in those. But yes, for sure, and I do agree that the larger insurers knew the market couldn’t — at least the individual, non-group market had to be reformed so that they didn’t … they’d make their money on avoiding sick people. They needed to have a pool of people that they could insure, and it wasn’t an irrational, expensive, immoral health care system. So I felt, and to Chip’s credit a lot, and others, they wanted to have. … And actually, the other argument that happened in 2008 and ’09, there’s a lot of different things that came together. Bipartisan Policy Center was there. There was interest in doing comprehensive reforms that were very consistent with what the Affordable Care Act ended up happening. But there was also this notion of all the stakeholders were just tired of fighting, and it was like, Let’s get something together. There’s one last point that I think people neglect to cite, and I know Chip would agree. At the time, there was a concern that a lot of the savings from health care would go to something like deficit reduction or tax cuts, but not reinvested in health care for coverage expansion. And so when, you know, if you’re a stakeholder and you’re going to contribute something to the offsets, you want to be reinvested in your system so you have paying customers, and that’s why I think the hospitals and the physicians and the insurers all came together to say, let’s figure out a way that this can work. So that at least helps paint the picture about how you could tie it together. 

Kahn: And one experience that I had was that I brought — I was then working by the early 2000s for the hospital association, the Federation of American Hospitals. And at that point, you know, obviously my members were supportive of the work I was doing with Ronnie. But there came a point, I can remember it to this day, in October 2006 we were having a meeting, and a number of the CEOs of the systems I work for came to me in a meeting and said, This isn’t good enough. There are just too many patients that we’re treating that don’t have insurance, where their finances are getting in the way of the care they need, and we got to have something comprehensive. So they moved away from, not that they didn’t support incremental changes, but they wanted to see the big picture done, and that led the Health Insurance Association — we were a small group — to develop our own plan, the health care passport. And there were other plans out there. And the increment, the very important thing about that plan and the others and the way that ’09 worked was that in the administration and in Congress, they wanted to build on what works in the system, and reform the individual market and lay in enough subsidization and expansion of Medicaid so that we could say everybody has the opportunity for coverage. Now we could say that was not that different from ’93 and ’94, but it was handled completely differently. And I think it was more sensitive to all the concerns of all those that were stakeholders, that were players. And that was the framework, but it was building on what exists with those kinds of playing with the knobs that really made the difference, that you could say everybody could have access to coverage. 

Rovner: So as we’ve kind of talked about, up to 2009 health care was pretty bipartisan. I mean, you know, there were partisan fights. There are obviously fights that Chip, you noted, that were going to be perennial, like fights over abortion. But, generally, big things that got done got done with Democratic and at least some Republican votes, or, you know, Republican … in the case of the Medicare prescription drug bill, Republican and some Democratic votes. And yet, you know, in 2009, it just suddenly became partisan in a way that it still is today. I mean, what happened? 

Kahn: Well, let me say it’s very, very important to think of the broader context and not just focus on health care for a second. A lot was changing. The Tea Party, we go on and on about how we got to where we are today, and the great divide. So there was a great political divide. There was no more getting … there was much less getting to yes in Congress. And I think that health reform, in a sense, suffered from that. And the other dilemma that health reform had, I think, which was it was successful because of the vast Democratic majorities. They didn’t need the Republicans. On the other hand, the fact that — and the Republicans wouldn’t play, so I’m not saying there was a possibility there — but the fact that it got done in a partisan fashion, you know, fit into a larger context that made it part of the divide. And, frankly, after it passed — and, obviously, hospitals were very supportive of it — there were a lot of Republicans that would never speak to me again. 

Jennings: Yeah. And Julie, I think it’s important to recall that even back in ’93-’94, around the Health Security Act, there were Republicans who wanted to do this, but — and I’m sure Chip will yell at me about this — but Speaker Gingrich was not interested in having a health care achievement signed into law by Bill Clinton. He made that very, very explicit. So I think different people will say, When did partisanship around health care really start? But I would say there was a big one. Then we had the big fight around the “Contract With America,” and from then on, even though there were significant reforms that were bipartisan, I would call them important, but incremental, you know. And Chip’s right. I don’t think you could have gotten anything close to the Affordable Care Act on a bipartisan bill. Maybe he’d disagree, but I just, I don’t think there are some Republicans — I’ll tell, I can even tell you — who would say, Oh, if you’d only tried or whatever … I think [Sen.] Max Baucus [the Finance Committee chairman] really wanted, you may recall this. He worked for a long time. He desperately wanted to have bipartisanship. I don’t think that was going …  

Rovner: Yes. And I sat in the hall during those meetings for weeks at a time. I remember. 

Jennings: Yeah, yes. You remember? I mean … and to the criticism of a lot of the Democrats, what are you holding up for? So unfortunately, there are elements of health care, and I think a lot have to do with coverage — Medicare, Medicaid, marketplace, the three M’s, if you will — that are very hard not to politicize. And unfortunately, public health has now become very politicized, too. So we’re having a smaller [unintelligible] of elements of health care that you can see bipartisanship. But … there are some, and I’m sure we were going to talk about that, but I look back and reflect about that debate, and I don’t see a possibility of where it would have worked and Barack Obama would have been able to achieve what he said he was going to achieve. 

Kahn: Well, let me say a couple of things. First, I think, to modify your history. I think that in the House … 

Jennings: Yes. 

Kahn: … Newt wasn’t speaker at the time, he was minority leader. Clearly, there was nowhere to go with Clinton Care. I mean, the Republicans just were not going to go. I think you saw something quite different in the Senate. And there were many Republicans in the Senate, probably not a majority of the conference, but a very large minority who were willing to at least try … but I think the environment completely changed over time, and by the time you got to 2009, 2010, despite some kabuki theater on the part of some Republican senators, who I won’t name, who sort of played along, they were not going to cooperate. But let me say, one of the turns in history that’s important is that you’ll remember the Democrats had 60 votes in the Senate until the end, when, unfortunately, Sen. [Ted] Kennedy died. But actually, I would argue that it was his death, in a sense, that ultimately led to health reform passing, because a conference report on health reform between the House and the Senate probably wouldn’t have gotten all the Democratic senators. I don’t think Sen. [Ben] Nelson [D-Neb.] could have done it, so you would have had a filibuster against it. But by [Kennedy] dying, the House was forced to take on, for the bulk of health reform, the Senate bill, and they passed the Senate bill. Yes, there was a reconciliation later, but it was really, that was the framework for health reform, and in a bizarre way, it was the contribution of his death and the … House having to accept the Senate bill that led to health reform really passing, you know, by the skin of its teeth, even though there were these vast majorities of Democrats in the House and Senate. 

Jennings: Yes, I think that’s a very insightful comment, and I rarely say that about Chip. [Kahn laughs.] So, no, I do all the time. It is, but Kennedy, the sacrifices Kennedy would make to become the ultimate legislator, even to go so far as to die. But I will say, I think that’s right, because there was a very significant frustration amongst the House Democrats, and they desperately wanted to have a true conference, and that would have made it very hard in the Senate. It would … have been hard to clear through reconciliation rules in the Senate. And there would have been lots of challenges, and, ultimately, this is why Nancy Pelosi gets most of the credit, and so too should Harry Reid. They brought it home in a way that probably was the only way to get it done. And subsequently, one of the problems was it probably wasn’t drafted as cleanly as we would have liked it to be. You know what I’m saying? 

Rovner: Yes, I know what you’re saying. For those who, for those of us who had to follow this sort of ins and outs of the not being able to make technical corrections to it for its entire history — which, flash-forward to today, is there any chance of ever getting back to bipartisanship on health care? 

Kahn: I don’t think on anything regarding delivery and financing that’s major is there much likelihood of consensus. Now, if you remember, not too long ago, there were bills on, you know, FDA processes and the such, and they were done in a bipartisan manner. And maybe some of those things at the edges. I think there are some hospital issues and others that still could be dealt with in a bipartisan manner. But that gets back to context. You’ve got to have the sun and the moon come together on political context that would allow some — I won’t call them marginal, but — relatively small changes to be legislated. Other than that, we’re in an environment right now where I just don’t see compromise on anything big, because the divide that we saw coming out of ’10 is still there. And if anything, it’s just deeper than ever. 

Jennings: Right, and … although I don’t think Chip would disagree with … what I’m about to say, is, there are issues that are not so much ideological in coverage: biomedical research, transparency, even physician payment reform, rural health, telemedicine, community health centers. I’m just mentioning these out loud, because you’ll see bipartisan agreements on some of those things. But in terms of real structural reform, and particularly when you’re talking about where people get coverage and how much you subsidize it, boy, is that tough. In fact, I would even argue, and this is really unbelievable to say out loud, that cost containment in some fields, which is almost always impossible, is easier than how you spend the money. Because people don’t, can’t agree on the structure by which you would reallocate the savings to make health care work. So it is a frustrating time, which is why it’s hard to make the argument against people who say, then we need to have all one party or the other party to get something big done. 

Kahn: Now, let me say I think there could be some surprises next year if the Democrats took over in the House. You know, is there some possibility that there could be a big compromise with a Trump administration in the future on drug negotiation or drug costs? So I don’t want to say that there’s nothing that can be done. And I agree with, and I think I said, with Chris that there are these issues around the edges that could be dealt with, and the ones he outlined are the ones that I would agree with. I think the one big one is there is some possibility around drugs. But I think, other than that, I don’t see the Republicans being willing to help on Medicaid. 

Jennings: And that is a cost containment as opposed to kind of a coverage, you know. And it’s sort of a one-off. It isn’t, you know, big, big reform. But I agree with Chip that there you could see Democrats in the House push something that [President Donald] Trump would endorse, that Republicans in the Senate wouldn’t like to pass but would. … They probably would want to have come up with an excuse not to. But that’s, that is a target area that could happen. Although, you know, I’m … Democrats aren’t catching, counting our chickens just yet, Chip. … We’re knocking on wood here. [knocks] 

Kahn: Yeah, let me say, if the Congress doesn’t change, in terms of who has the majorities in both House and Senate, I don’t see anything major, other than some of the things, you know, transparency and some of these other issues, getting attached to something bigger. And then you’ve got to have context, as I said, the right context to have it. But I don’t see anything big unless we get split government. I think split government could lead to some interesting things in some of these areas. But what we think of as health reform writ large, right now, it’s just politically charged. 

Rovner: We’re going to have to wrap up. But one thing that I’ve been sort of thinking about a lot is that we seem to be getting to this place that we were in in 1993 again, and in 2008 again, where everybody is unhappy with the system — that, particularly patients, even people with insurance, are unhappy with the way the system is working. Doctors are unhappy, hospitals are unhappy, insurance companies are unhappy. Is it possible that that’s going to push this big divide a little bit back together, at least in an effort to do something? I mean, clearly President Trump knows that people are unhappy with the cost of drugs, if nothing else in health care. Do you think we’re heading for another round of major health reform debate? 

Jennings: It feels like that, Julie, for sure, ’91-’92-ish, or, you know. It does not feel like in any way. … I think people are really frustrated with costs, really frustrated with complexity, really frustrated with how they think the system is not necessarily responsive. They’re pretty good at kind of defining the problems, but in terms of developing a consensus around how best to do that, which is, you know, typically what people say, I want comprehensive reform that doesn’t disrupt me, you know, which is a hard nut to crack sometimes. But … it feels like we’re seeing it. And you’re going to hear a lot about talk, but I think you’re … the big thing will happen around a ’27-’28 period, when the two open electorates for presidency come up, and … this issue will be absolutely debated. But the big, big thing probably isn’t going to happen until the next president is elected. 

Kahn: So let me say this, and I’m going to give a plug to KFF’s Business of Health With Chip Kahn, a podcast that will come sometime in April. 

Rovner: Absolutely. 

Jennings: He’s shameless. 

Kahn: We’re going to … focus on AI [artificial intelligence] for the first three or four months. And I don’t want to say it’s going to change the world. It’s going to change the world. I don’t want to say it’s going to change health care. It’s going to change health care. Is it going to solve all these problems? I don’t know, but I think many of these issues could be different five years from now because of the effect of AI, and will doctors be practicing the same way they are now? Will all these issues of thousands of people working with green eyeshades in hospitals to make sure the claims are done right, they go to insurance companies. With respect to those thousands of people, it’s going to be AI. … They’re not going to have jobs anymore, and it’s going to change a lot. Now, is it going to solve any of these problems, or is it going to raise risks and challenges we can’t even foresee? I don’t know, but I think we’re going through, about to go through, an evolutionary period, and I don’t know what it’s going to look like on the other end. 

Rovner: Well, I think that’s as good a place as any to leave it. I want to thank both of you. I could definitely go on for another hour, but we won’t. Chip Kahn, soon to be a fellow at KFF. Chris Jennings, Jennings Policy Strategies. Thank you very much.  

Kahn: Thanks a lot. 

Rovner: OK, that is this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer this week, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. We’ll be back in your feed next week with all the health news. Until then, be healthy.

Credits

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Editor

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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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Health insurance could be out of reach for many Americans in 2026.

About a million fewer people signed up for Affordable Care Act marketplace coverage this year. The Congressional Budget Office told lawmakers that more could opt out in coming years after the GOP-led Congress let expire subsidies that helped many afford a plan. Meanwhile, plan premiums jumped, and new, stricter Medicaid eligibility rules kicked in.

If you lost health insurance this year, there may be ways to see the doctor without breaking the bank. On March 4, in conversation with WAMU host Esther Ciammachilli, KFF Health News correspondent Sam Whitehead shared tips on navigating care without coverage.

Renuka Rayasam and Taylor Cook contributed reporting.

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.

USE OUR CONTENT

This story can be republished for free (details).