As the Trump administration loosens enforcement of unproven health claims, the 'medical freedom' movement is pushing to permanently roll back the health regulatory state.
This article was published on Monday, August 25, 2025 in KFF Health News.
Don't get Nathan Jones started on xylitol, the active ingredient in his chewing gum, nasal spray, and other products. He'll talk your ear off about its wondrous powers against tooth decay, as well as its potential to fight COVID, heart disease, Alzheimer's — you name it.
For now, Jones, the founder of Xlear, can't make those claims in his company's advertising. But if the lawsuit his company brought against the Federal Trade Commission succeeds, he'll likely be able to say anything he wants.
As the Trump administration loosens enforcement by the Federal Trade Commission, Department of Justice, and FDA of unproven health claims, Jones and his allies in the "medical freedom" movement are pushing to permanently roll back the health regulatory state.
For decades, the FTC has required companies to back any medical claims about their products with substantial evidence, while taking actions against hundreds of "bogus health cures," said Jessica Rich, the FTC's director of consumer protection from 2013 to 2017.
If successful, the lawsuit by Jones' company "would be a complete game changer," said Mary Engle, associate director of the FTC's advertising practices division from 2001 to 2020.
The FTC — and FDA — don't have sufficient staffing to rigorously police health claims, but Health and Human Services Secretary Robert F. Kennedy Jr.'s allies in the alternative medicine world have suggested that the agencies already go too far.
"The pharmaceutical industry has a stranglehold and monopoly in America," Jones told KFF Health News. "The consumer should have a choice in what they're doing and how they're being proactive and reactive in their healthcare."
Jones and other members of the Alliance for Natural Health USA, which includes alternative medicine practitioners, vaccine skeptics, and proponents of "natural" remedies, were elated when Kennedy became Health and Human Services secretary in February. One called it a "once-in-a-lifetime opportunity."
Kennedy had warned shortly before Trump's reelection that the FDA would face a reckoning for its "aggressive suppression" of vitamins, peptides, nutraceuticals, and other products from a supplement industry that has sought more freedom to make claims about its products.
Losing Regulatory Bite?
For decades, the FDA has had the power to recall dangerous products and check health claims, although it has nowhere near the workforce it would need to police the vast $70 billion supplement industry.
The FTC has traditionally had more teeth, successfully suing companies that make unsubstantiated claims. For example, the agency won a judgment last year against a company that advertised a supplement as "clinically shown" to improve memory.
The FTC under Trump has not announced any new enforcement actions against supplement makers (it did send consumers the proceeds of previousfraud settlements), and the administration has reversed several COVID-related FTC actions. In March, the FTC dropped a lawsuit filed in 2021 against Jones and Xlear over the marketing of its "drug-free" sinus rinse as a COVID preventive and treatment. The Department of Justice also closed a case brought on behalf of the FTC and the FDA against a company that claimed its Earth Tea could cure COVID.
In June, Jones, who says he spent $3 million fighting the FTC suit before it was dropped, sued back. The company asked a judge to forbid the FTC from requiring that health product marketers back their claims with convincing evidence, such as clinical trials — a position the FTC has maintained since 1984.
Xlear hopes the suit will be considered under last year's Supreme Court ruling known as Loper Bright, said Xlear attorney Rob Housman. That ruling gave courts more power to second-guess federal agencies' interpretation of the laws that govern their activities.
The Alliance for Natural Health joined Xlear in a separate petition in May demanding that the FTC drop its requirement for companies to provide substantial evidence backing health claims, and to withdraw 2022 guidelines that generally require companies to run a randomized clinical trial to prove their claims.
The petition was filed by Jonathan Emord, a lawyer who has successfully fought FDA and FTC regulation of supplements and unsuccessfully ran for governor of Virginia as a Republican in the 2024 primary.
Emord's petition seeks to flip the burden of proof. Instead of requiring the makers of supplements and cosmetic creams, pills, sprays, and herbals to prove their products do what they claim to do, the government would have to prove that they don't.
"If an advertiser throws caution to the wind and makes a health-related product claim without resort to any supporting evidence, the FTC is powerless" to stop it, Emord wrote in the petition. "Rather, the claim will be tested in the idea and information market free of government constraint."
Emord and the Alliance for Natural Health did not respond to repeated requests for comment.
The FTC would not comment on the lawsuit, the petition, or the issue of substantiation in general, spokesperson Juliana Gruenwald Henderson said.
Shorthanded and Mostly Hands-Off
Meanwhile, with Kennedy's administration chockablock with proponents of nontraditional health products, "there's been a downtick of enforcement," Housman said.
Since Trump took office, the FTC has lost at least a quarter of the staff in its Division of Advertising Practices, which took the original action against Xlear, said Serena Viswanathan, who retired as FTC associate director in June. The Department of Justice has reorganized its consumer protection unit, which backed the FTC in many actions, and moved some of its lawyers to immigration and other areas.
In one of the only actions it has taken against deceptive health practices under Trump, the FTC hosted a July 9 workshop titled "The Dangers of ‘Gender-Affirming Care' for Minors."
In FTC Chairman Andrew Ferguson's opening statement at that event, he excoriated the Biden administration for allowing hormonal and surgical treatments for youth experiencing gender dysphoria.
But Ferguson justified the FTC's new attack on these treatments by referring to the agency's traditional practice of pursuing companies for making false and deceptive claims. Noting the agency's past actions against "shyster snake oil salesmen" promoting fake cures, Ferguson highlighted the Biden-era FTC's position that "health claims need to be backed up by reliable scientific evidence" and an "incredibly high standard of scientific ‘substantiation.'"
Under that logic, Ferguson "has to defend against the Xlear lawsuit," Rich said.
"If anyone can just hawk health products without any basis, and customers spend money on bogus cures instead of seeking proper care, it's really a serious issue," she said.
‘Nanny State' or Not?
Ferguson's remarks reflect one of many contradictions in the administration's approach to health policy. While favoring deregulation and greater personal liberty to consume unregulated supplements, Kennedy has also pushed for stricter FDA oversight of food and drugs, while advocating for behavioral change that GOP officials derided as "nanny state" tactics when Democrats like former first lady Michelle Obama promoted doing so.
Kennedy, for example, has said he wants more randomized control trials for vaccines and drugs — a requirement rejected by medical freedom advocates like Jones.
"I like clinical data; I think it's great," Housman said. "It's not the be-all and end-all."
Kennedy has also announced plans to change a policy that allows food companies to add ingredients without a full safety review. But many supplement makers use the policy to get their products on the market without FDA review, and some are unhappy about the potential clampdown.
Banking on Xylitol
The FDA approved xylitol as a food additive in 1963 and regulates it as a cosmetic ingredient. Jones, who said his company has about 110 employees and sells to 70,000 retailers, founded Xlear 25 years ago.
Jones expresses skepticism of vaccines, believes the drug industry has a monopolistic stranglehold on healthcare, and is a "true believer" in xylitol, Housman said.
In an interview with KFF Health News, Jones said that the slightly sweet, minty-flavored substance reduces gum inflammation by blocking the adhesion of tooth-rotting Streptococcus mutans bacteria to cells in the mouth.
In Finland, where water is not fluoridated, dentists have long recommended xylitol-imbued chewing gum for children. In addition to fighting cavities and lowering periodontal disease, Jones said, xylitol could fight chronic illnesses like obesity, Alzheimer's, and heart disease, which "all have a correlation with oral hygiene."
But "the government bans us from going out and talking about what xylitol does," he said. "We cannot say xylitol can help prevent tooth decay, because xylitol is not a drug, and that's a drug claim."
As for its use against COVID, three ear, nose, and throat specialists interviewed by KFF Health News said that xylitol is good for moisturizing nasal cavities, perhaps a bit better than simple saline solution. While there's no evidence it prevents or cures COVID, xylitol, like saline nose washes, may reduce symptoms when used toward the start of any viral upper respiratory infection, said Christine Franzese, a professor of otolaryngology at the University of Missouri Medical Center and the chair of the American Academy of Otolaryngology-Head and Neck Surgery's allergy, asthma, and immunology committee.
Xylitol is poisonous to dogs, but deemed safe to humans when used at recommended doses in sprays, candies, chewing gum, and other products, according to the American Academy of Pediatric Dentistry, which also states that evidence is mixed on whether xylitol fights cavities effectively.
At higher doses, xylitol can cause diarrhea and other gastrointestinal problems, and a study funded by the National Institutes of Health and published last year found that regular use of xylitol as a sweetener could exacerbate heart disease. The quantities of xylitol consumed daily by participants in that study were far higher than what's in a few sticks of chewing gum, however.
Whether his lawsuit succeeds or not, Jones can probably expect a rosy business future.
On May 21, he and pediatric dentist Mark Cannon of Northwestern University were called to testify in the Utah Legislature in support of a pilot project to provide Xlear's gum to students and prisoners in the state as a replacement for fluoridated water, which the state banned in March.
Florida ordered fluoride removed from the state's water starting July 1, and other states are considering bans. Kennedy wants to end fluoridation nationwide, despite widespread skepticism of his belief that it poisons the brain at common dosing levels.
The bans are a boon to Xlear, Jones said. The company would provide gum for the Utah pilot at cost, he said, but if governments promote it and people learn more, "that's where we see us being able to grow."
Wary of inflation, Americans have been watching the prices of everyday items such as eggs and gasoline. A less-noticed expense should cause greater alarm: rising premiums for health insurance. They have been trending upward for years and are now rising faster than ever.
Consider that, from 2000 to 2020, egg prices fluctuated between just under $1 and about $3 a dozen; they reached $6.23 in March but then fell to $3.78 in June. Average gas prices, after seesawing between $2 and $4 a gallon for more than a decade starting in 2005, peaked at $4.93 in 2022 and recently fell back to just over $3.
Meanwhile, since 1999, health insurance premiums for people with employer-provided coverage have more than quadrupled. From 2023 to 2024 alone, they rose more than 6% for both individuals and family coverage — a steeper increase than that of wages and overall inflation.
For many people who have the kind of insurance plans created by the Affordable Care Act (because they work for small companies or insure themselves), rates have probably risen even more drastically. In this market, state regulators scrutinize insurers' proposed rate increases, but only if they exceed 15%.
And the situation is about to get worse: For 2026, ACA marketplace insurers have proposed eye-popping new prices: In New York, UnitedHealthcare has proposed a 66.4% rise. HMO Colorado has asked for an average increase of more than 33% in that state. In Washington, the average proposed increase across all insurers is 21.2%, and in Rhode Island it's 23.7%.
According to Business Group on Health, a consortium of major employers, "actual healthcare costs have grown a cumulative 50% since 2017." In a separate survey published in 2021, 87% of companies said that in the next five to 10 years, the cost of providing health insurance for their workers would become "unsustainable."
And insurers in the ACA marketplace are increasing premiums by an average of 20% for next year, according to a new analysis. Imagine if tens of millions of Americans' rent or mortgage payments were to suddenly increase by that amount.
Insurance regulators theoretically could demand that these proposed rates be lowered — and this often happens. But some states are more active than others in this regard. And all are wary that too much regulatory interference could drive insurers from their markets.
Insurers offer many explanations for their calculations, some of which are tied to recent actions by Congress and President Donald Trump. New tariffs on America's trading partners, for example, are expected to push up the cost of drugs and medical supplies.
Meanwhile, reductions in healthcare spending included in the GOP budget bill, along with the expiration of some Biden-era premium subsidies at the end of this year, will cause many people to lose their health insurance. About 16 million Americans are expected to become uninsured in 2034, in many cases because keeping insurance will become unaffordable.
Because most of these people are likely to be young and/or healthy, the "risk pool" of those remaining insured will become older and sicker — and therefore more expensive to cover.
"Ultimately, we believe the ACA market will likely be smaller and higher acuity-driven next year," Janey Kiryluik, vice president of corporate communications for Elevance Health (formerly known as Anthem), wrote in an email. She added: "Our position reflects early disciplined action."
Remember, most insurers in the United States are public, for-profit companies; as such, they tend to act in the interests of their shareholders, not the patients whose healthcare they cover.
Large employers that manage their own healthcare plans might be able to negotiate better deals for their workers. But smaller companies, for the most part, will need to accept what's on offer.
Premiums are not the only part of health insurance that's getting more expensive. Deductibles — the money that beneficiaries must spend out-of-pocket before insurance kicks in — are also rising. The average deductible for a standard ACA silver plan in 2025 was nearly $5,000, about double what it was in 2014. (For those with employer-based insurance, the average number is just under $2,000.)
A few states are trying to stem the tide by offering a state-run "public option," a basic affordable insurance plan that patients can choose. But they have struggled because a lower payment rate for workers generally means fewer participating providers and reduced access to care.
If voters paid as much attention to the price of health insurance as they do to the cost of gas and eggs, maybe elected officials would respond with more action.
The first cohort of seniors to have contended — not always enthusiastically — with a digital society has reached the age when cognitive impairment becomes more common.
This article was published on Thursday, August 21, 2025 in KFF Health News.
Wanda Woods enrolled because her father advised that typing proficiency would lead to jobs. Sure enough, the federal Environmental Protection Agency hired her as an after-school worker while she was still a junior.
Her supervisor "sat me down and put me on a machine called a word processor," Woods, now 67, recalled. "It was big and bulky and used magnetic cards to store information. I thought, ‘I kinda like this.'"
Now she is an instructor with Senior Planet in Denver, an AARP-supported effort to help older people learn and stay abreast of technology. Woods has no plans to retire. Staying involved with tech "keeps me in the know, too," she said.
Some neuroscientists researching the effects of technology on older adults are inclined to agree. The first cohort of seniors to have contended — not always enthusiastically — with a digital society has reached the age when cognitive impairment becomes more common.
Given decades of alarms about technology's threats to our brains and well-being — sometimes called "digital dementia" — one might expect to start seeing negative effects.
The opposite appears true. "Among the digital pioneer generation, use of everyday digital technology has been associated with reduced risk of cognitive impairment and dementia," said Michael Scullin, a cognitive neuroscientist at Baylor University.
It's almost akin to hearing from a nutritionist that bacon is good for you.
"It flips the script that technology is always bad," said Murali Doraiswamy, director of the Neurocognitive Disorders Program at Duke University, who was not involved with the study. "It's refreshing and provocative and poses a hypothesis that deserves further research."
Scullin and Jared Benge, a neuropsychologist at the University of Texas at Austin, were co-authors of a recent analysis investigating the effects of technology use on people over 50 (average age: 69).
They found that those who used computers, smartphones, the internet, or a mix did better on cognitive tests, with lower rates of cognitive impairment or dementia diagnoses, than those who avoided technology or used it less often.
"Normally, you see a lot of variability across studies," Scullin said. But in this analysis of 57 studies involving more than 411,000 seniors, published in Nature Human Behavior, almost 90% of the studies found that technology had a protective cognitive effect.
"There's pretty compelling data that difficulties can emerge with attention or mental health or behavioral problems" when young people are overexposed to screens and digital devices, Scullin said.
Older adults' brains are also malleable, but less so. And those who began grappling with technology in midlife had already learned "foundational abilities and skills," Scullin said.
Then, to participate in a swiftly evolving society, they had to learn a whole lot more.
Years of online brain-training experiments lasting a few weeks or months have produced varying results. Often, they improve a person's ability to perform the task in question without enhancing other skills.
"I tend to be pretty skeptical" of their benefit, said Walter Boot, a psychologist at the Center on Aging and Behavioral Research at Weill Cornell Medicine. "Cognition is really hard to change."
The new analysis, however, reflects "technology use in the wild," he said, with adults "having to adapt to a rapidly changing technological environment" over several decades. He found the study's conclusions "plausible."
Analyses like this can't determine causality. Does technology improve older people's cognition, or do people with low cognitive ability avoid technology? Is tech adoption just a proxy for enough wealth to buy a laptop?
"We still don't know if it's chicken or egg," Doraiswamy said.
Yet when Scullin and Benge accounted for health, education, socioeconomic status, and other demographic variables, they still found significantly higher cognitive ability among older digital technology users.
What might explain the apparent connection?
"These devices represent complex new challenges," Scullin said. "If you don't give up on them, if you push through the frustration, you're engaging in the same challenges that studies have shown to be cognitively beneficial."
Even handling the constant updates, the troubleshooting, and the sometimes maddening new operating systems might prove advantageous. "Having to relearn something is another positive mental challenge," he said.
Still, digital technology may also protect brain health by fostering social connections, known to help stave off cognitive decline. Or its reminders and prompts could partially compensate for memory loss, as Scullin and Benge found in a smartphone study, while apps help preserve functional abilities like shopping and banking.
Researchers have attributed the decline to a variety of factors, including reduced smoking, higher education levels, and better blood pressure treatments. Possibly, Doraiswamy said, engaging with technology has been part of the pattern.
Of course, digital technologies present risks, too. Online fraud and scams often target older adults, and while they are less apt to report fraud losses than younger people, the amounts they lose are much higher, according to the Federal Trade Commission. Disinformation poses its own hazards.
And as with users of any age, more is not necessarily better.
"If you're bingeing Netflix 10 hours a day, you may lose social connections," Doraiswamy pointed out. Technology, he noted, cannot "substitute for other brain-healthy activities" like exercising and eating sensibly.
An unanswered question: Will this supposed benefit extend to subsequent generations, digital natives more comfortable with the technology their grandparents often labored over? "The technology is not static — it still changes," Boot said. "So maybe it's not a one-time effect."
Still, the change tech has wrought "follows a pattern," he added. "A new technology gets introduced, and there's a kind of panic."
From television and video games to the latest and perhaps scariest development, artificial intelligence, "a lot of it is an overblown initial reaction," he said. "Then, over time, we see it's not so bad and may actually have benefits."
Like most people her age, Woods grew up in an analog world of paper checks and paper maps. But as she moved from one employer to another through the '80s and '90s, she progressed to IBM desktops and mastered Lotus 1-2-3 and Windows 3.1.
Along the way, her personal life turned digital, too: a home desktop when her sons needed one for school, a cellphone after she and her husband couldn't summon help for a roadside flat, a smartwatch to track her steps.
These days, Woods pays bills and shops online, uses a digital calendar, and group-texts her relatives. And she seems unafraid of AI, the most earthshaking new tech.
Last year, Woods turned to AI chatbots like Google Gemini and OpenAI's ChatGPT to plan an RV excursion to South Carolina. Now, she's using them to arrange a family cruise celebrating her 50th wedding anniversary.
The New Old Age is produced through a partnership with The New York Times.
Medicare enrollees who buy the optional Part D drug benefit may see substantial premium price hikes — potentially up to $50 a month — when they shop for next year's coverage.
Such drug plans are used by millions of people who enroll in what is called original Medicare, the classic federal government program that began in 1965 and added a drug benefit only in 2006. The drug plans are offered through private insurers, and enrollees must pay monthly premiums.
It's not known whether insurers will pursue the maximum increase allowed, as premium prices for next year won't be revealed until closer to open enrollment, which starts Oct. 15.
Increases are expected to mainly affect stand-alone Part D plans, not the drug coverage offered as part of Medicare Advantage, the private sector alternative to original Medicare. More on that later.
Policy experts say premiums are likely to go up for several reasons, including increased use of some higher-cost prescription drugs; a law that capped out-of-pocket spending for enrollees; and changes in a program aimed at stabilizing price increases that the Trump administration has continued but made less generous.
One thing is surer than ever, say many policy experts: Beneficiaries should not simply roll over their existing stand-alone Medicare drug plans.
"Everyone should shop plans in open enrollment," said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.
Here are three reasons prices would rise.
1. It's the Spending!
Every year, insurers keep an eye on what they're spending on drugs so they can build that into their premium estimates. Spending covers both the prices charged by drugmakers and volume, meaning how many people take the medications and how often.
And it's up. Spending by insurers and government programs for prescription drugs in 2024 across the market grew more than 10%, which is slightly greater than in recent years, according to a research report published in last month's issue of the American Journal of Health-System Pharmacy. Estimates are not yet available for this year's trends.
Still, in 2024, researchers found that drug prices overall decreased slightly. Spending rose because of drugs coming on the market and increased utilization, especially for pricey weight loss drugs and another category of medications that treat various autoimmune conditions, such as rheumatoid arthritis.
Such increased use is evident in Medicare. Many beneficiaries, for example, are treated for autoimmune conditions. And even though Medicare doesn't cover treatment for weight loss, many members have diabetes or other conditions that a new type of weight loss drugs can treat.
The Trump administration, according to The Washington Post, is considering a five-year pilot program in which Medicare Part D plans could voluntarily expand access to the drugs, which can cost more than $1,000 a month without insurance. Details have not yet been provided, but the pilot program would not begin in Medicare until 2027.
Another wild card for insurers is the Trump administration's tariffs on businesses that purchase products made overseas, which could boost drug prices because the U.S. imports a lot of its pharmaceuticals. Much, however, remains unknown about whether drugmakers will pass along any additional tariff costs to consumers.
So, while rising spending is one factor, it isn't the only reason next year's premium prices are expected to go up.
2. New Out-of-Pocket Caps for Consumers
Changes made to Medicare aimed at helping people with high out-of-pocket costs for expensive medications may be a bigger factor.
Here's why: Starting this year, Medicare enrollees have a limit on how much they must pay out-of-pocket for prescription drugs. It's capped at $2,000, a threshold that will rise each year to cover inflation.
Lawmakers in Congress set those changes in the Inflation Reduction Act under President Joe Biden. The law also shifted a larger share of the cost of drugs used by Medicare beneficiaries from the federal program to insurers.
That $2,000 cap is a big change from previous years, when people taking expensive drugs had a higher threshold to meet annually and were on the hook to pay 5% of the drug's cost even after meeting that amount. Those additional 5% payments ended last year under the provisions of the IRA.
Before that law passed, "people would spend $10,000 or $15,000 out-of-pocket each year just for a single drug," Dusetzina said. "The Inflation Reduction Act was necessary to make Part D proper health insurance, but there's a cost to do so."
While the cap is a big help for affected consumers, the reduced amounts paid by some beneficiaries — coupled with the cost shift to insurers — could lead plans to spread their increased expenses across all policyholders through higher premiums. A growing number of health plans have also begun to require enrollees to pay a percentage of a drug's cost, rather than a flat-dollar copay, which can lead to larger-than-expected costs at the pharmacy counter, Dusetzina said.
While consumers not currently taking high-cost specialty drugs may not see a benefit in the $2,000 cap initially, they might one day, say policy experts, who note that drugmaker prices continue to rise and that enrollees could fall ill with a condition like cancer or multiple sclerosis for which they need a very high-priced drug.
"It's important to think not just in context of those groups who hit the cap every year, but also people are paying more in premiums to protect their future selves as well," said Casey Schwarz, the senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.
The new prescription drug cap and other changes apply to both the stand-alone Part D drug plans and Medicare Advantage plans. But those Medicare Advantage plans are not expected to increase the drug portion of their premiums, partly because the private sector plans are paid more per member than what it costs taxpayers for the traditional program.
That means Advantage plans have far more money to add benefits, such as vision and dental coverage, which traditional Medicare does not include, or to use them to cushion the impact of rising spending on drug costs, thus limiting premium increases.
Those additional benefits are advertised to attract customers to Medicare Advantage, which also sometimes offers plans with minimal or no monthly premium costs. There are other differences between traditional Medicare and private sector plans. For example, Advantage members must stick to doctors and hospitals in the plan's networks, and they may face more prior authorization or other hurdles than in the traditional program.
The growing difference between premiums — fueled by the extra rebates flowing to the private sector plans — "is increasingly tilting coverage toward Medicare Advantage and making traditional Medicare plus a stand-alone PDP [prescription drug plan] unaffordable for many enrollees," said Juliette Cubanski, deputy director of the program on Medicare policy at KFF, a health information nonprofit that includes KFF Health News.
3. Trump Administration Reduced Funding Meant To Slow Premium Growth
The final factor in the premium increase equation is a program set up to slow the rise of premiums in stand-alone Part D plans.
It began under the Biden administration to offset premium increases tied to changes in the Inflation Reduction Act by temporarily injecting additional federal dollars to help insurers adjust to the new rules.
That plan sent just over $6 billion this year to Part D insurers.
And it had an effect.
The average monthly premium for a stand-alone Part D drug plan dropped 9%, from $43 last year to $39 this year, according to KFF, even when factoring in that some plans raised prices by up to $35 a month, the maximum increase allowed under the stabilization plan for this year.
In a memo released in late July, the Trump administration said it would continue the program for next year, while shaving about 40% of the funding. A government official told The Wall Street Journal that the administration felt that keeping the full funding would have mainly benefited the insurers and cost taxpayers an "enormous, excess amount."
The stabilization effort next year will send $10 a month per enrollee to Part D insurers to help keep premiums in check, down from $15 this year. Among other changes, it allows insurers to raise premiums by as much as $50 a month, up from the $35 allowed this year.
That would be a substantial increase, Cubanski noted, although it is not clear just how many insurers would pursue the full amount.
"We did see some plans this year were taking premium increases of that $35 amount in 2025, and I fully expect we will see some plans with increases up to $50 a month" next year, she said.
Another reason to take a close look at all the options once open enrollment begins.
But in his 40 years as a pediatrician in Southern California serving those too poor to afford care, including many immigrant families, Sweidan said he's never seen a drop-off in patient visits like this.
"They are scared to come to the offices. They're getting sicker and sicker," said Sweidan, who specializes in neonatology and runs five clinics in Los Angeles and Orange counties. "And when they are near collapsing, they go to the ER because they have no choice."
In the last two months, he has sent young children to the emergency room because their parents worked up the courage to call his office only after several days of high fever. He said he attended to a 14-year-old boy in the ER who was on the verge of a diabetic coma because he'd run out of insulin, his parents too frightened to venture out for a refill.
Sweidan had stopped offering telehealth visits after the covid-19 pandemic, but he and other health care providers have brought them back as ramped-up immigration enforcement drives patients without legal status — and even their U.S. citizen children — deeper into the shadows.
Patients in need of care are increasingly scared to seek it after Trump rescinded a Biden-era policy that barred immigration officials from conducting operations in "sensitive" areas such as schools, hospitals, and churches. Clinics and health plans have taken a page out of their covid playbooks, revamping tested strategies to care for patients scared to leave the house.
Sara Rosenbaum, professor emerita of health law and policy at George Washington University, said she's heard from clinic administrators and industry colleagues who have experienced a substantial drop in in-person visits among immigrant patients.
"I don't think there's a community health center in the country that is not feeling this," Rosenbaum said.
At St. John's Community Health clinics in the Los Angeles area, which serve an estimated 30,000 patients without legal status annually, virtual visits have skyrocketed from roughly 8% of appointments to about 25%, said Jim Mangia, president and chief executive officer. The organization is also registering some patients for in-home health visits, a service funded by private donors, and has trained employees how to read a warrant.
"People are not picking up their medicine," Mangia said. "They're not seeing the doctor."
Mangia said that, in the past eight weeks, federal agents have attempted to gain access to patients at a St. John's mobile clinic in Downey and pointed a gun at an employee during a raid at MacArthur Park. Last month, Immigration and Customs Enforcement contractors sat in a Southern California hospital waiting for a patient and federal prosecutors charged two health center workers they say interfered with immigration officers' attempts to arrest someone at an Ontario facility.
C.S., an immigrant from Huntington Park without legal status, said she signed up for St. John's home visit services in July because she fears going outside. The 71-year-old woman, who asked to be identified only by her initials for fear of deportation, said she has missed blood work and other lab tests this year. Too afraid to take the bus, she skipped a recent appointment with a specialist for her arthritic hands. She is also prediabetic and struggles with leg pain after a car hit her a few years ago.
"I feel so worried because if I don't get the care I need, it can get much worse," she said in Spanish, speaking about her health issues through an interpreter. A doctor at the clinic gave her a number to call in case she wants to schedule an appointment by phone.
Officials at the federal Department of Health and Human Services did not respond to questions from KFF Health News seeking comment about the impact of the raids on patients.
There's no indication the Trump administration intends to shift its strategy. Federal officials have sought to pause a judge's order temporarily restricting how they conduct raids in Southern California after immigrant advocates filed a lawsuit accusing ICE of deploying unconstitutional tactics. The 9th U.S. Circuit Court of Appeals on Aug. 1 denied the request, leaving the restraining order in place.
In July, Los Angeles County supervisors directed county agencies to explore expanding virtual appointment options after the county's director of health services noted a "huge increase" in phone and video visits. Meanwhile, state lawmakers in California are considering legislation that would restrict immigration agents' access to places such as schools and health care facilities — Colorado's governor, Democrat Jared Polis, signed a similar bill into law in May.
Immigrants and their families will likely end up using more costly care in emergency rooms as a last resort. And recently passed cuts to Medicaid are expected to further stress ERs and hospitals, said Nicole Lamoureux, president of the National Association of Free & Charitable Clinics.
"Not only are clinics trying to reach people who are retreating from care before they end up with more severe conditions, but the health care safety net is going to be strained due to an influx in patient demand," Lamoureux said.
Mitesh Popat, CEO of Venice Family Clinic, nearly 90% of whose patients are at or below the federal poverty line, said staff call patients before appointments to ask if they plan to come in person and to offer telehealth as an option if they are nervous. They also call if a patient doesn't show five minutes into their appointment and offer immediate telehealth service as an alternative. The clinic has seen a roughly 5% rise in telehealth visits over the past month, Popat said.
In the Salinas Valley, an area with a large concentration of Spanish-speaking farmworkers, Clinica de Salud del Valle de Salinas began promoting telehealth services with Spanish radio ads in January. The clinics also trained people how to use Zoom and other digital platforms at health fairs and community meetings.
CalOptima Health, which covers nearly 1 in 3 residents of Orange County and is the biggest Medi-Cal benefits administrator in the area, sent more than a quarter-million text messages to patients in July encouraging them to use telehealth rather than forgo care, said Chief Executive Officer Michael Hunn. The insurer has also set up a webpage of resources for patients seeking care by phone or home delivery of medication.
"The Latino community is facing a fear pandemic. They're quarantining just the way we all had to during the covid-19 pandemic," said Seciah Aquino, executive director of the Latino Coalition for a Healthy California, an advocacy group that promotes health access for immigrants and Latinos.
But substituting telehealth isn't a long-term solution, said Isabel Becerra, chief executive officer of the Coalition of Orange County Community Health Centers, whose members reported increases in telehealth visits as high as 40% in the past month.
"As a stopgap, it's very effective," said Becerra, whose group represents 20 clinics in Southern California. "Telehealth can only take you so far. What about when you need lab work? You can't look at a cavity through a screen."
Telehealth also brings a host of other challenges, including technical hiccups with translation services and limited computer proficiency or internet access among patients, she said.
And it's not just immigrants living in the country unlawfully who are scared to seek out care. In southeast Los Angeles County, V.M., a 59-year-old naturalized citizen, relies on her roommate to pick up her groceries and prescriptions. She asked that only her initials be used to share her story and those of her family and friends out of fear they could be targeted.
When she does venture out — to church or for her monthly appointment at a rheumatology clinic — she carries her passport and looks askance at any cars with tinted windows.
"I feel paranoid," said V.M., who came to the U.S. more than 40 years ago and is a patient of Venice Family Clinic. "Sometimes I feel scared. Sometimes I feel angry. Sometimes I feel sad."
She now sees her therapist virtually for her depression, which began 10 years ago when rheumatoid arthritis forced her to stop working. She worries about her older brother, who has high blood pressure and has stopped going to the doctor, and about a friend from the rheumatology clinic, who ices swollen hands and feet because she's missed four months of appointments in a row.
"Somebody has to wake up or people are going to start falling apart outside on the streets and they're going to die," she said.
Telemarketer scam signs victims up for fake 'jobs.'
This webcast was launched on Wednesday, August 13, 2025 in KFF Health News.
With Dan Weissmann
When a New York couple purchased a health insurance plan from a telemarketer, they thought it covered everything they wanted: doctor visits, tests, and medicine. But then came the unexpected bills for thousands of dollars, forcing them to skip crucial medical care.
In their series "Health Care Hustlers," Bloomberg reporters Zachary Mider and Zeke Faux revealed how this couple and thousands of other people signed up for health plans by unknowingly agreeing to work fake "jobs."
Mider and Faux join "An Arm and a Leg" host Dan Weissmann to peel back the surprising layers of this story, from a TV-sitcom-writer-turned-investor who masterminded the idea to the legal gray area that allows these plans to proliferate.
EKALAKA, Mont. — There was no doctor on-site when a patient arrived in early June at the emergency room in the small hospital at the intersection of two dirt roads in this town of 400 residents.
There never is.
Dahl Memorial's three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.
Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana's most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.
Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.
A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.
The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn't proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.
Placing ERs in the hands of nondoctors isn't without controversy. Some doctors and their professional associations say physicians' extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.
The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.
Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.
"It's important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible," Haddock said.
Other healthcare providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can't afford or recruit enough — or any — doctors.
"In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well," said Paul Amiott, a board member of the Society of Emergency Medicine PAs.
"I'm not practicing independently" despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.
Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn't unique to PAs — ER doctors seek similar consultations and backup.
The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.
But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.
None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.
But Sanford Health, which bills itself as "the largest rural health system in the United States," is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.
Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state's northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.
Adelman said he supports such laws only where it's feasible, like in Virginia. He said the state's emergency physicians' organization pushed for the law only after doing research that made it confident that the requirement wouldn't shutter any rural hospitals.
Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.
Adelman said when instituting staffing requirements isn't possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren't refraining just to save money.
He pointed to Vermont, where a report recommended that several of the state's hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state's troubled healthcare system.
Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.
Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.
The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.
Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.
Haddock said ACEP wouldn't want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.
Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.
She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.
She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn't enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.
Dowdy said Dahl Memorial hasn't had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there's a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.
People eating at Ekalaka's sole breakfast spot and attending appointments at the hospital's clinic all told KFF Health News that they've been happy with the care they have received from Dowdy and her co-workers.
Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who've been treated for more serious problems.
"We've got to have this facility here because this facility saves a lot of lives," Bruski said.
Amid the challenges of adulthood, one rite of passage is unique to the United States: the need to find your own health insurance by the time you turn 26.
That is the age at which the Affordable Care Act declares that young adults generally must get off their family's plan and figure out their coverage themselves.
When the ACA was voted into law in 2010, what's known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.
But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA's online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.
The erosion of the law has now created an "insurance cliff" for Americans who are turning 26 and don't have a job that provides medical coverage.
Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.
Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.
If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states.
Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines.
They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.
The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.
"The good news is that the ACA gave young people more options," said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.
"The bad news is the good stuff is hidden in a minefield of really bad options that'll leave you broke if you get sick."
Publicly funded counselors called "navigators" or "assisters" can help insurance seekers choose a plan. But those programs vary by state, and often customers don't realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.
In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.
Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.
In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.
Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he "didn't make enough to justify having health insurance" and has reluctantly gone without it.
Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents' plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.
Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother's plan until he turned 26, he said.
Now 28, he is insured through his federal job.
"The ACA was groundbreaking legislation, including the idea that every American needs health care," he said. "But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss."
Why 26?
Back in 2010, the decision to make 26 the cutoff age for staying on a parent's insurance was "kind of arbitrary," recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.
"My kids were young , and I was trying to imagine when my child would be an adult."
Before that time, children were often kicked off family plans at much younger ages, typically 18.
The Obama administration's idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn't have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.
But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.
Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.
"You're scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?'" he recalled. "It feels like it's nearly impossible to make a good choice in this scenario."
Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.
More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.
The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.
Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, "drowning" in texts and phone calls offering plans of uncertain and unregulated quality. "It never ends," said Herne, 27.
Young Invincibles, an advocacy group representing young adults, runs its own "navigator" program to help young people choose health insurance plans.
"We hear the frustration," said Martha Sanchez, the group's former director of health policy and advocacy. "Twenty-six-year-olds have had negative experiences in a process that's become really complex. Many throw up their hands."
Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a "really scary" year after he turned 26.
"Every time he got in the car, I thought, ‘What if?'" Mathis said.
The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It's a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.
But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.
"Technically, we gambled in the right direction," Mathis said. "But I don't feel like we've won."
The Affordability Problem
The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.
But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.
Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.
Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university's insurance premiums were more than $5,000 annually.
But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.
"People tell you to think ahead, but I didn't think that meant six months," she said.
When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.
She looked for a health care plan but found it hard to understand the marketplace. (She didn't know there were navigators who could help.) Now she can't afford her medicine or see her endocrinologist.
"I'm tired all the time," Hughes said. "My cycles are not regular anymore at all. When I do get one, it's debilitating." She is hoping a new job will provide insurance later this year.
Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.
Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.
The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.
Many companies, which say they can't afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.
Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.
In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.
As she left the first of those jobs, her husband's endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.
After a few months, they bought a marketplace plan, but it was expensive and "didn't cover a lot," she said.
When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn't start until the end of her first month of employment. The couple would be uninsured for a few weeks.
A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.
"I think I've done everything right," Creager said. "So why am I in a position where the health insurance available to me doesn't cover what I need, or I can barely afford my premiums, or worse, at times I don't even have it?"
Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn't schedule until after she would be off her family's insurance plan.
Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. "There's this impending terror of, ‘What am I going to do?'" she recalled.
(One day before she turned 26, her father's company agreed to keep her on his plan for six more months, if he paid higher premiums.)
The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation's authors had hoped. The "job lock" tying insurance to employment has long plagued the United States workforce.
Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.
Experts agree that the marketplaces need stronger regulation.
In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.
Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an "easy pricing" option or a "standard plan."
Most plans on the marketplaces don't meet these criteria. Federal and state regulators had long planned to cull such "noncompliant" plans, gradually — fearing that doing so too quickly would scare insurers away from participating.
But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it's far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.
There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.
If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.
MIAMI — GOP lawmakers in the 10 states that refused the Affordable Care Act's Medicaid expansion for over a decade have argued their conservative approach to growing government programs would pay off in the long run.
Instead, the Republican-passed budget law that includes many of President Donald Trump's priorities will pose at least as big a burden on patients and hospitals in the expansion holdout states as in the 40 states that have extended Medicaid coverage to more low-income adults, hospital executives and other officials warn.
For instance, Georgia, with a population of just over 11 million, will see as many people lose insurance coverage sold through ACA marketplaces as will California, with more than triple the population, according to estimates by KFF, a health information nonprofit that includes KFF Health News.
The new law imposes additional paperwork requirements on Obamacare enrollees, slashes the time they have each year to sign up, and cuts funding for navigators who help them shop for plans. Those changes, all of which will erode enrollment, are expected to have far more impact in states like Florida and Texas than in California because a higher proportion of residents in non-expansion states are enrolled in ACA plans.
The budget law, which Republicans called the "One Big Beautiful Bill," will cause sweeping changes to healthcare across the country as it trims federal spending on Medicaid by more than $1 trillion over the next decade. The program covers more than 71 million people with low incomes and disabilities. Ten million people will lose coverage over the next decade due to the law, according to the nonpartisan Congressional Budget Office.
Many of its provisions are focused on the 40 states that expanded Medicaid under the ACA, which added millions more low-income adults to the rolls. But the consequences are not confined to those states. A proposal from conservatives to cut more generous federal payments for people added to Medicaid by the ACA expansion didn't make it into the law.
"Politicians in non-expansion states should be furious about that," said Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank.
The number of people losing coverage could accelerate in non-expansion states if enhanced federal subsidies for Obamacare plans expire at the end of the year, driving up premiums as early as January and adding to the rolls of uninsured. KFF estimates as many as 2.2 million people could become uninsured just in Florida, a state where lawmakers refused to expand Medicaid and, partly as a result, now leads the nation in ACA enrollment.
For people like Francoise Cham of Miami, who has Obamacare coverage, the Republican policy changes could be life-altering.
Before she had insurance, the 62-year-old single mom said she would donate blood just to get her cholesterol checked. Once a year, she'd splurge for a wellness exam at Planned Parenthood. She expects to make about $28,000 this year and currently pays about $100 a month for an ACA plan to cover herself and her daughter, and even that strains her budget.
Cham choked up describing the "safety net" that health insurance has afforded her — and at the prospect of being unable to afford coverage if premiums spike at the end of the year.
"Obamacare has been my lifesaver," she said.
If the enhanced ACA subsidies aren't extended, "everyone will be hit hard," said Cindy Mann, a health policy expert with Manatt Health, a consulting and legal firm, and a former deputy administrator for CMS.
"But a state that hasn't expanded Medicaid will have marketplace people enrolling at lower income levels," she said. "So, a greater share of residents are reliant on the marketplace."
Though GOP lawmakers may try to cut Medicaid even more this year, for now the states that expanded Medicaid largely appear to have made a smart decision, while states that haven't are facing similar financial pressures without any upside, said health policy experts and hospital industry observers.
KFF Health News reached out to the governors of the 10 states that have not fully expanded Medicaid to see if the budget legislation made them regret that decision or made them more open to expansion. Spokespeople for Republican Gov. Henry McMaster of South Carolina and Republican Gov. Brian Kemp of Georgia did not indicate whether their states are considering Medicaid expansion.
Brandon Charochak, a spokesperson for McMaster's office, said South Carolina's Medicaid program focuses on "low-income children and families and disabled individuals," adding, "The state's Medicaid program does not anticipate a large impact on the agency's Medicaid population."
Enrollment in ACA marketplace plans nationwide has more than doubled since 2020 to 24.3 million. If enhanced subsidies expire, premiums for Obamacare coverage would rise by more than 75% on average, according to an analysis by KFF. Some insurers are already signaling they plan to charge more.
The CBO estimates that allowing enhanced subsidies to expire will increase the number of people without health insurance by 4.2 million by 2034, compared with a permanent extension. That would come on top of the coverage losses caused by Trump's budget law.
"That is problematic and scary for us," said Eric Boley, president of the Wyoming Hospital Association.
He said his state, which did not expand Medicaid, has a relatively small population and hasn't been the most attractive for insurance providers — few companies currently offer plans on the ACA exchange — and he worried any increase in the uninsured rate would "collapse the insurance market."
As the uninsured rate rises in non-expansion states and the budget law's Medicaid cuts loom, lawmakers say state funds will not backfill the loss of federal dollars, including in states that have refused to expand Medicaid.
Those states got slightly favorable treatment under the law, but it's not enough, said Grace Hoge, press secretary for Kansas Gov. Laura Kelly, a Democrat who favors Medicaid expansion but who has been rebuffed by GOP state legislators.
"Kansans' ability to access affordable healthcare will be harmed," Hoge said in an email. "Kansas, nor our rural hospitals, will not be able to make up for these cuts."
For hospital leaders in other states that have refused full Medicaid expansion, the budget law poses another test by limiting financing arrangements states leveraged to make higher Medicaid payments to doctors and hospitals.
Beginning in 2028, the law will reduce those payments by 10 percentage points each year until they are closer to what Medicare pays.
Richard Roberson, president of the Mississippi Hospital Association, said the state's use of what's called directed payments in 2023 helped raise its Medicaid reimbursements to hospitals and other health institutions from $500 million a year to $1.5 billion a year. He said higher rates helped Mississippi's rural hospitals stay open.
"That payment program has just been a lifeline," Roberson said.
The budget law includes a $50 billion fund intended to insulate rural hospitals and clinics from its changes to Medicaid and the ACA. But a KFF analysis found it would offset only about one-third of the cuts to Medicaid in rural areas.
Trump encouraged Florida, Tennessee, and Texas to continue refusing Medicaid expansion in his first term, when his administration gave them an unusual 10-year extension for financing programs known as uncompensated care pools, which generate billions of dollars to pay hospitals for treating the uninsured, said Allison Orris, director of Medicaid policy for the left-leaning think tank Center on Budget and Policy Priorities.
"Those were very clearly a decision from the first Trump administration to say, ‘You get a lot of money for an uncompensated care pool instead of expanding Medicaid,'" she said.
Those funds are not affected by Trump's new tax-and-spending law. But they do not help patients the way insurance coverage would, Orris said. "This is paying hospitals, but it's not giving people health care," she said. "It's not giving people prevention."
States such as Florida, Georgia, and Mississippi have not only turned down the additional federal funding that Medicaid expansion brings, but most of the remaining non-expansion states spend less than the national average per Medicaid enrollee, provide fewer or less generous benefits, and cover fewer categories of low-income Americans.
Mary Mayhew, president of the Florida Hospital Association, said the state's Medicaid program does not adequately cover children, older people, and people with disabilities because reimbursement rates are too low.
"Children don't have timely access to dentists," she said. "Expectant moms don't have access nearby to an OB-GYN. We've had labor and delivery units close in Florida."
She said the law will cost states more in the long run.
"The health care outcomes for the individuals we serve will deteriorate," Mayhew said. "That's going to lead to higher cost, more spending, more dependency on the emergency department."
WATERLOO, Iowa — John-Paul Sager appreciates the care he has received at Department of Veterans Affairs hospitals and clinics, but he thinks it should be easier for veterans like him to use their benefits elsewhere.
Sager, a Marine Corps and Army veteran, uses his VA coverage for non-VA treatment of back injuries stemming from his military service. But he said he sometimes must make several phone calls to obtain approval to see a local chiropractor. "It seems like it takes entirely too long," he said.
Many veterans live hours from VA facilities, or they need health services that aren't readily available from the VA. In such cases, the department is supposed to provide a referral and pay for private care. Critics say it often hesitates to do so.
Republicans controlling Congress aim to streamline the process of obtaining what is known as community care.
Two Republican senators have introduced legislation that would make it easier for rural veterans to seek care at local hospitals and clinics. The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump's first term.
The proposals would build on VA community care programs that started under Democratic President Barack Obama and were expanded in Trump's first term.
Critics worry that steering veterans to private care facilities drains federal money from the VA hospital and clinic system. But supporters say veterans shouldn't be forced to travel long distances or wait months for the treatment they could obtain at local hospitals and clinics.
"My main concern is for veterans, not for the VA," Sen. Kevin Cramer (R-N.D.) told KFF Health News. "I don't believe we have an obligation to sustain the bureaucracy."
About 9 million veterans are enrolled in the VA health system. Last year, about 3 million of them — including 1.2 million rural veterans — used their benefits to cover care at non-VA facilities, according to data provided by the department.
Cramer co-sponsored a bill that would allow veterans who live within 35 miles of a rural, "critical access" hospital to use VA benefits to cover care there or at affiliated clinics without referrals from VA staff.
Cramer, who serves on the Senate Veterans' Affairs Committee, noted his state has just one VA hospital. It's in Fargo, on the state's eastern border, which is more than 400 miles by car from parts of western North Dakota.
Many North Dakota veterans drive past multiple community hospitals to get to the VA hospital for treatment, he said. Meanwhile, many rural hospitals are desperate for more patients and income. "I kept thinking to myself, ‘This doesn't make any sense at all,'" Cramer said.
Cramer said previous laws, including the VA Mission Act, made it easier for veterans to use their benefits to cover care at community hospitals and clinics.
But he said veterans still must fill out too much paperwork and obtain approval from VA staffers to use non-VA facilities.
"We can't let the VA itself determine whether a veteran is qualified to receive local care," he said.
U.S. Rep. Mark Takano of California, who is the top Democrat on the House Veterans' Affairs Committee, said he sees the need for outside care for some veterans. But he contends Republicans are going overboard in shifting the department's money to support private health care facilities.
The VA provides specialized care that responds to veterans' needs and experiences, he argues.
"We must prevent funds from being siphoned away from veterans' hospitals and clinics, or VA will crumble," Takano said in a statement released by his office. "Veterans cannot afford for us to dismantle VA direct care in favor of shifting more care to the community."
Some veterans' advocacy groups have also expressed concerns.
Jon Retzer, deputy national legislative director for the Disabled American Veterans, said the group wants to make it easier for veterans to find care. Rural and female veterans can have a particularly tough time finding appropriate, timely services at VA hospitals and clinics, he said. But the Disabled American Veterans doesn't want to see VA facilities weakened by having too much federal money diverted to private hospitals and clinics.
Retzer said it's true that patients sometimes wait for VA care, but so do patients at many private hospitals and clinics. Most delays stem from staff shortages, he said, which afflict many health facilities. "This is a national crisis."
Retzer said the Disabled American Veterans favors continuing to require referrals from VA physicians before veterans can seek VA-financed care elsewhere. "We want to ensure that the VA is the primary provider of that care," he said.
Veterans Affairs Secretary Doug Collins has pledged to improve the community care program while maintaining the strength of the department's hospitals and clinics. The department declined a KFF Health News request to interview Collins.
Marcus Lewis, CEO of First Care Health Center, which includes a hospital in Park River, North Dakota, supports Cramer's bill. Lewis is a Navy veteran who uses the VA's community care option to pay for treatment of a back injury stemming from his military service.
Overall, Lewis said, the community care program has become easier to use. But the application process remains complicated, and participants must repeatedly obtain VA referrals for treatment of chronic issues, he said. "It's frustrating."
Park River is a 1,400-person town about 50 miles south of the Canadian border. Its 14-bed hospital offers an array of services, including surgery, cancer care, and mental health treatment. But Lewis regularly sees a VA van picking up local veterans, some of whom travel 140 miles to Fargo for care they're entitled to receive locally.
"I think a lot of folks just don't want to fight the system," he said. "They don't want to go through the extra hoops, and so they'll jump in the van, and they'll ride along."
Rep. Mike Bost (R-Ill.), chairman of the House Veterans' Affairs Committee, said veterans in some areas of the country have had more trouble than others in getting VA approval for care from private clinics and hospitals.
Bost helped gain the House's approval for Trump's request for $34.7 billion for the community care program in 2026. Although spending on the program has gone up and down in recent years, the appropriation represents an increase of about 50% from what it was in 2025 and 2022. The Senate included similar figures for next year in its version of a military spending budget that passed Aug. 1.
Bost also co-sponsored a House bill that would spell out requirements for the VA to pay for community care.
Sager hopes the new proposals make life easier for veterans. The Gulf War veteran lives in the northeastern Iowa town of Denver. He travels about 15 miles to Waterloo to see a chiropractor, who treats him for back and shoulder pain from injuries he suffered while training Saudi troops in hand-to-hand combat.
Sager, who remains active in the Army Reserve, also visits a Waterloo outpatient clinic run by the VA, where his primary care doctor practices. He appreciates the agency's mission, including its employment of many veterans. "You just feel like you're being taken care of by your own," he said.
He believes the VA can run a strong hospital and clinic system while offering alternatives for veterans who live far from those facilities or who need care the VA can't promptly provide.
The local VA doesn't offer chiropractic care, so it pays for Sager to visit the private clinic. But every few months, he needs to obtain fresh approval from the VA. That often requires several phone calls, he said.
Sager is one of about a dozen veterans who use the community care program to pay for visits at Vanderloo Chiropractic Clinic, office manager Linda Gill said.
Gill said the VA program pays about $34 for a typical visit, which is comparable to private insurance, but the paperwork is more burdensome. She said leaders of the chiropractic practice considered pulling out of the VA program but decided to put up with the hassles for a good cause. She wishes veterans didn't have to jump through so many hoops to obtain convenient care.
"After what they've done for us? Please," she said.
