The administration of President Donald Trump has used claims of widespread wrongdoing to justify investigations, suspensions of billions of dollars in payments to states, and the cancellation of Affordable Care Act health coverage for hundreds of thousands of people.

has opened a broader political fight over the extent of fraud and the administration’s response to it. Republicans say they’re safeguarding taxpayer dollars by going after bad actors. Democrats contend the administration has relied on insufficient evidence to target blue states and cut programs Republicans have long tried to shrink. Meanwhile, Trump’s pardons of executives convicted of healthcare fraud, administration moves to weaken some protections against abuses, and a high-profile error by Trump regulators stand in contrast with the administration’s proclaimed fraud-fighting goals.

The dispute is becoming a talking point for both parties leading up to the November election.

Republican candidates are trying to win voters’ confidence by emphasizing their efforts to halt what they say is the misuse of taxpayer dollars in federal health programs.

“Going after fraud gives Republicans a healthcare message when they would otherwise just be defending cuts to Medicaid and the Affordable Care Act,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes ³Ô¹Ï²»´òìÈ. The approach, he said, helps “blunt” those attacks.

Democrats, however, traditionally have an advantage on healthcare in general, with are with such issues. Now Democrats are portraying Republicans’ fraud crackdown as a cover for the GOP’s weakening of safety net programs. But the GOP messaging could resonate at the ballot box.

About 44% of voters — and 54% of Republican voters — say fraud in government programs is “extremely important” for candidates to talk about, conducted in mid-September, suggesting the fraud focus might be connecting with the GOP base. Such fraud is also the top issue rural Republican voters want candidates to talk about, based on a by KFF and the Associated Press.

It’s an issue that is hardly new, and government watchdogs have repeatedly documented fraud by health providers and brokers, as well as improper enrollment in government health programs. A report by the in March warned that the “sheer amount of payments in the Medicare program creates significant fraud risks.” And in a , GAO investigators were able to get subsidized insurance for fake ACA enrollees.

What has changed is the prominence the issue now occupies in national politics.

Administration’s Fraud Targets

Trump administration authorities have this year charged hundreds of people, , in alleged billing schemes. It has announced and increased scrutiny of enrollment in federal programs, withholding in federal Medicaid payments over claims of lax oversight — with what Democrats say is a laser focus on blue states despite a lack of evidence.

The administration’s more expansive claims about fraud — and the actions it has taken in response — have generated fierce political clashes.

Most recently, the Centers for Medicare & Medicaid Services canceled ACA enrollments covering 760,000 people. While Democrats have questioned the methods that found them to be fraudulent, federal officials said they included nonexistent consumers whose applications were submitted by brokers or agents who can earn commissions from insurers.

CMS Administrator Mehmet Oz that the cancellations included people who had coverage through the ACA but hadn’t used it. He also said some had no Social Security numbers, calling that evidence of problems.

“About 35% of current people on the Obamacare system — 35%, more than a third — had never used the program. They haven’t bought a prescription medication. They haven’t seen a doctor. That just is not possible,” Oz said. “So we know there is fraud.”

Democrats and some health policy analysts challenge that conclusion. They say that younger and healthier people are much less likely to use their insurance and that not using their coverage doesn’t mean they were improperly enrolled. Critics also say the absence of Social Security numbers doesn’t necessarily establish fraud; for example, newborns can be added to their parents’ plans before receiving a number.

“This is yet another attempt by the Trump administration to kick hundreds of thousands of vulnerable Americans off their healthcare,” on the social media site X. “Millions are already struggling to access healthcare—and this is their plan?”

There are political risks for the GOP as well. The disenrollment of alleged phantom accounts is likely to ensnare legitimate consumers, say health analysts and ACA advocates, leading to a potential backlash against Republicans if scores of people lose coverage just before the midterm elections.

States that tend to deliver for GOP candidates will be hit especially hard, they say, because ACA enrollees are concentrated in those states. The 4.5 million people in Florida and 4.1 million in Texas who have marketplace coverage account for nearly 40% of the country’s ACA enrollment, according to .

Conservative health policy advisers say the administration took multiple steps to avoid canceling legitimate coverage, including attempts to contact consumers and requirements that additional criteria be met before coverage was terminated.

“Those criticizing the action either don’t understand it or see some political advantage in mischaracterizing it,” said Brian Blase, president of Paragon Health Institute and a former Trump health policy adviser.

Democrats, meanwhile, highlight inconsistencies in the administration’s broader anti-fraud campaign.

They note that the Department of Health and Human Services last year of insurance brokers and agents who had been suspended in 2024 by the Biden administration for suspected fraud or abuse. The Trump administration also laid off from involved in regional oversight of the ACA marketplace.

On Oct. 3, to pass legislation with mandatory prison terms for defrauding Medicare and Medicaid, eliminating probation as an option.

But Trump has also pardoned health industry executives convicted of major fraud schemes, including people who are connected to his political allies or who spent heavily on lobbying on their behalf. The pardons included a sentenced to three years in prison for a nearly $40 million tax scheme and, in Trump’s first term, convicted for Medicaid fraud.

Trump’s pardons in 2021 of executives who profited from massive public healthcare fraud spurred criticism from the National Health Care Anti-Fraud Association. Critics now say the administration is portraying cuts to Medicare and Medicaid as necessary for weeding out waste, fraud, and abuse while exonerating criminals who have engaged in some of the biggest schemes in federal health programs.

Blue State Allegations

HHS has raised concerns about Medicaid fraud and program integrity in several states, and the administration has deferred or threatened to cut federal Medicaid funding while disputes are investigated.

Democrats say the administration is itself engaging in fraud by using unsubstantiated allegations of abuse to politically target blue states.

One of the most striking clashes occurred in New York.

Federal officials launched an investigation of the state’s Medicaid program after claiming that personal care services — including help with bathing, dressing, and meal preparation — had been provided to more than 5 million people, which would have amounted to roughly three-quarters of the state’s Medicaid population — an almost impossibly large proportion.

“It is time for New York to come clean about its Medicaid program,” CMS’ Oz .

CMS its calculations were wrong. The agency said that it had misunderstood the state’s billing codes and that the actual number of beneficiaries who received the services was closer to 450,000. The administration continued its scrutiny of the New York program, however, and later suspended millions of dollars in federal funding for the state’s Medicaid fraud unit, wasn’t producing enough indictments.

The administration also withheld about from California, citing concerns about program integrity and oversight of some home medical services. State officials deny the allegations, saying has grown because of factors such as higher wages for home health aides and an increase the number of older people receiving care.

The White House announced plans to in federal funds from Minnesota, claiming the state had failed to protect its Medicaid program from abuse. State officials have and gone to court to challenge the decision.

Vice President JD Vance, who chairs Trump’s Task Force to Eliminate Fraud, and other administration officials announced the state deferrals at the White House, giving what traditionally would have been technical disputes between state and federal health officials a much higher political profile. Vance’s office did not respond to ³Ô¹Ï²»´òìÈ questions about the administration’s anti-fraud activities related to healthcare.

“I’ve never seen anything like this,” said , a Georgetown University research professor and a senior adviser at CMS during the Obama administration. “It’s a deferral, not a finding of fraud. This is being elevated by political decision-makers.”

Republican candidates have pounced on the investigations and allegations. In Minnesota, Republican gubernatorial candidate , who is speaker of the Minnesota House, released claiming that her Democratic opponent, U.S. Sen. Amy Klobuchar, “has never done anything to stop the fraud here in Minnesota.” Klobuchar has said that as governor she would “launch a top-to-bottom audit of state government to root out fraud.”

In New York, , a Democrat whose office runs the Medicaid fraud unit, criticized the decision to withhold funds and said weakening the operation would benefit criminals. Her Republican challenger in the November election, , has cited the Trump administration’s claims , telling Fox News Digital that James is “totally failing to prosecute Medicaid fraud.”

The administration says its actions are necessary because fraud diverts taxpayer money from people who legitimately qualify for government programs.

“The fraud doesn’t just steal money — it steals our trust,” Oz said in August on .

Democrats and healthcare advocates say the White House’s anti-fraud crusade is being used by Republicans to distract from criticisms over its to Medicaid, the ACA, and other federal health programs.

Republican-backed legislation enacted last year is projected to reduce federal Medicaid spending by hundreds of billions of dollars over a decade.

Congressional Republicans also declined to extend enhanced ACA premium subsidies that expired , increasing premium costs for many people who buy insurance through the marketplaces. Enrollment has since declined by millions.

Overall, the combined effect of GOP-led changes will result in more uninsured people by 2034, according to an analysis by the Congressional Budget Office.

Those changes have given Democrats an opening to campaign on protecting healthcare coverage and affordability while Republicans seek to shift some of the debate toward fraud and government spending.

“It’s really a way to distract and reframe the cuts in a different way, to say it’s part of an anti-fraud effort,” said Anthony Wright, executive director of Families USA, an advocacy group focused on expanding health coverage. “Fighting fraud shouldn’t result in people losing coverage.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Not-So-Great Healthcare

Why doesn’t world-class medicine produce world-class health?

Hayat Norimine’s reporting gets at something that has bothered me for a long time about American healthcare (Priced Out: “As Health Insurance Costs Soar, Healthcare Workers Also Feel the Pinch,” Sept. 22).

We are very proud of U.S. medicine, and we should be. We are at the forefront of new treatments, our clinician workforce is unmatched, and we deploy technologies that seemed impossible just a few years ago. Yet we are in the middle of the pack compared with other countries, in terms of healthy lifespan and many markers of quality care.

At the same time, the cost of accessing care has become outrageously high. When clinicians stop getting health insurance for themselves and their families, you know something is deeply broken.

What good is our health system if most people cannot afford to use it?

One family in Norimine’s story went without insurance when their premiums climbed. Another person kept her coverage but waited weeks to see a doctor because of a $10,000 deductible. These are different problems, but both expose the distance between the care we can provide and the care people can actually access.

Insurance is supposed to help people get the care they need to stay healthy, not just when they are at death’s door. Yet the way insurance is designed can discourage someone from seeing a clinician early, filling a prescription, or following up before a problem gets worse. A clinician may say, “This is what you should do next,” while a person’s coverage gives them a reason to wait or decline.

That tension is not an accident. It is how the system was built. Doctors design care. Insurers design coverage. The two are put together in separate rooms by different teams, measured on different things, then handed to the same person as if they were one plan. No physician would design a $10,000 deductible; it just blocks people from investing in prevention and getting care early. But no physician was in the room when that threshold was set.

Making coverage affordable is essential. So is asking what that coverage enables people to do. If better health is the goal, the people responsible for a person’s health need a hand in shaping what their coverage pays for and when. Design coverage and care together, and it gets easier for people to get the care we know works while avoiding waste.

— Clay Johnston; Austin, Texas

On Dementia, Violence, and Sedation

Reading “Drugs Are Widely Used To Sedate Dementia Patients. Her Sons Wanted To Keep Her Off Them” (Sept. 30) inspired me to share my own experience.

My husband died of dementia about two years ago at age 86. It was not an easy journey. Dementia made him agitated for the same reason it does to others: People with dementia cannot tolerate being told “no.”

So when I had to tell him to stop driving, he became violent. I was told by an eldercare specialist that if my husband remained at home, he might kill me. So it was off to a memory care center, a really good and really expensive one. And he became violent and agitated there because he couldn’t come home, which was what he wanted, and which I could not safely handle. I was also aware that if he couldn’t make it at the memory care center, there was virtually no other place that would take him.

So did I say yes to medication? I did indeed. Even with the antipsychotic, my husband would become out of control. He often tried to “abscond,” as they say in memory-care speak. I also paid through the nose for one-on-one care, which kept him sort of safe. But one night, he fell in the bathroom and broke his hip. A hip replacement was suggested. He was suffering, he had absolutely no quality of life, and I turned the offer down. He was transferred to palliative care and died peacefully about five days later.

There is no solution to this problem that I can see other than medical aid in dying, which he probably would have refused. Me — I will not refuse. My current terror is that I might do this to my remaining family.

— Nora Staffanell; Monroe, New York

The issue is appropriate treatment, not simply drug avoidance.

Jordan Rau’s report rightly highlights the danger of using sedating medications simply to make people with dementia easier to manage. But inappropriate chemical restraint should not be confused with medically appropriate treatment of serious neuropsychiatric symptoms.

Psychosis, agitation, and aggression are distinct. Before prescribing medication, clinicians should identify the target symptom and look for reversible contributors such as pain, infection, medication effects, constipation, sleep disruption, sensory impairment, fear, environmental overstimulation, or the way personal care is being delivered.

Nonpharmacological, person-centered interventions should generally come first. The American Psychiatric Association recommends antipsychotics, outside of emergencies, only when agitation or psychosis is severe, dangerous, or causes substantial distress and after nonpharmacologic approaches have been assessed. When used, treatment should begin at a low dose and aim for the minimum effective dose.

However, nonpharmacological measures do not always suffice. In 2026, the APA reaffirmed that antipsychotics can benefit some older adults with behavioral and psychological symptoms of dementia when used judiciously within a comprehensive treatment plan. Brexpiprazole, for example, received FDA approval in 2023 for agitation associated with Alzheimer’s dementia.

These drugs carry real risks, including increased mortality, sedation, orthostasis, extrapyramidal symptoms, cerebrovascular events, and falls. But untreated severe agitation or aggression also carries risks: distress, injury, emergency transfers, hospitalization, caregiver breakdown, and loss of placement.

The responsible question is therefore not whether antipsychotics are dangerous, but whether, for a particular patient and target symptom, likely benefits outweigh risks after reversible causes and nonpharmacological measures have been addressed.

Good dementia care means neither reflexive prescribing nor reflexive withholding. It means careful diagnosis, person-centered care, informed risk-benefit discussion, lowest effective dosing, close monitoring, and periodic attempts to reduce or discontinue medication when appropriate.

— James Ellison; Philadelphia

Decoding ER Bills

Autumn Daniels was billed $410 for an emergency room visit in which no clinician evaluated her (Bill of the Month: “She Left After Waiting Hours in the Emergency Room. The ER Billed Her Anyway,” Sept. 29). She received registration, vital signs, and a single question, then sat in the waiting room for four hours and left.

Carle Health billed CPT code 99281, an evaluation and management service. The American Medical Association’s CPT guidelines, quoted in your article, state that triage alone is not an evaluation and management service and cannot be reported with that code. Carle’s own email confirms the problem by defining “care” to include registration and nursing assessment. That’s triage under another name.

Billing for a service that was not performed is the most important reason insurers deny hospital claims, and it’s what physicians are trained to recognize as fraud. Daniels’ insurer denied the claim under “against medical advice,” a label that cannot apply to a patient no clinician ever saw. The right response is a written refusal to pay, addressed to the hospital, stating that the billed service was never rendered.

I spent 20 years in clinical medicine and over a decade as a health insurance medical director reviewing exactly this question. Daniels should owe nothing.

— Virgie Bright Ellington; New Rochelle, New York

This article goes much deeper than simply exploring lack of treatment in the emergency room. It’s about callous treatment, which is unacceptable on many levels. The ER provided poor care and wasn’t busy, but because the unseen patient was only feeling unwell and not bleeding from every orifice, she wasn’t taken seriously as a priority, so she left. Yet despite not being seen by a doctor, a miscellaneous bill — over $400 — was submitted for payment.

What is pain anyway — feeling uncomfortable? Pain is people dying from triggers in the body. Therefore, treating people like a business by these corporate hospitals is extremely concerning. A person feeling ill, receiving no treatment after four hours of waiting, then leaving the ER with a chronic headache  â€” which could be anything from a brain injury, an upcoming stroke, or a hemorrhage — should not be charged. And certainly a miscellaneous code should not have been applied for the pleasure of pain, waiting, and the five minutes it took to take her temperature.

No, the insurance company should not pay, and it should also let the hospital know that it will be booted from the network for false claims — spending less-than-adequate time with a patient and then submitting bills.

Laws need to be mandated, and advocates must demand optimum care, with healthcare providers abiding by the Hippocratic oath.

People are not stick figures to be treated carelessly and then charged fully. Every time a baseless claim is submitted by the hospital to the insurance company, there’s a trickle-down effect, and rates go up.

It’s akin to being charged for walking on the sidewalk outside a grocery store, checking the fruit stands, getting help from the outside clerk, and then being charged by the store — despite not making a purchase.

Bad service serves no one and will backfire on the provider in the end. How many times do we have to check management at the door for not understanding that very concept? Far too often. We need to show that medical disregard and abuse are not tolerated. It’s essential to pursue change at the federal and state level. Why? Because, ultimately, hospitals are taking advantage of people. They’ve forgotten why they exist.

— Tiff Gadison; Sacramento, California

Living Under the Government’s Thumb

It’s not a good feeling to know that the government has the upper hand and pulls the strings (Health Hub: “Sticker Shock at the Doctor’s Office Could Motivate Midterm Voters,” Sept. 18). Here it is, 2026, and this single mother still struggles — but even more so with talks of cuts and funding to programs I and so many others depend on.

I was interviewed back in November 2018 about an absurd medical bill I received and was expected to pay, even though I have Medicare and Medicaid. Jay Hancock wrote my story, which aired on All Things Considered (Bill of the Month: “Chronically Ill, Traumatically Billed: The $123,000 Medicine for MS,” Nov. 28, 2018). It also appeared on CBS Mornings with Gayle King.

Things definitely haven’t gotten any better for me. I worry about not only my health insurance and my medication but the fact I am on permanent disability. The state of the nation under the current administration is pretty frightening. My Social Security/SSI is my only means of getting by. I receive EBT (electronic benefits transfer for food assistance), and I have a family to feed. I live in government-subsidized housing, based on my income. So pretty much my whole life is controlled by the actions of folks who probably have zero clue how it is to live on a fixed income and with a chronic health condition, one in which stress exacerbates the symptoms, as well as being a single parent.

Don’t even mention being able to afford the price of gas; my car will sit more than go now. I have to pick and choose when to run errands, usually on a day I already have a scheduled appointment. That not only causes me lots of anxiety, but the fatigue is relentless! This is a very stressful, unnerving way to live.

— Shereese Hickson; Niles, Ohio

Uniting for Good

I’m writing on behalf of students with the American Lung Cancer Screening Initiative (ALCSI). Our team recently came across Noam N. Levey’s Common Ground article “‘Cancer Doesn’t Care’: Citizen Lobbyists Unite To Push Past Washington’s Ugly Politics” (Oct. 21, 2025), and its message about cancer bringing people together across political divides strongly resonated with our team.

I wanted to share a recent development in California that reflects a similar idea. A lung cancer screening awareness bill that began as an idea from a small group of California college students was signed into law by Gov. Gavin Newsom on Sept. 28, after receiving support from legislators of both parties.

As students passionate about lung cancer screening awareness, our team began exploring legislative action to improve screening rates. In March 2025, we developed the initial proposal that ultimately became California SB 1124 and continued advocating for the bill throughout the legislative process until it was signed into law.

Lung cancer is the leading cause of cancer-related death in the United States. Screening can catch the disease at an earlier, more treatable stage, but many people eligible for lung cancer screening don’t know they qualify or that screening is available to them. SB 1124 addresses that gap by requiring tobacco retailers across California to post signage about lung cancer screening at the point of sale, reaching people where they already are rather than relying on them to seek out the information. Considering that California has historically been one of the states with the lowest lung cancer screening rates, this action is crucial.

The bill was introduced by Sen. Bob Archuleta (D–Pico Rivera). Through grassroots outreach, students involved with this bill initiative helped build a coalition of support from organizations across California and the country, including the California Academy of Family Physicians, the American College of Surgeons, and the NAACP California Hawai‘i State Conference, among dozens of others.

Our experience really echoed what stood out to us in Levey’s article: that cancer can bring together people who may disagree on plenty of other issues. We also hope our experience shows that young people can have a meaningful voice in that process and contribute to bringing people together around a shared public health goal.

— Elaine Dong; Los Angeles

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

Not all of those kicked off were fraudulently enrolled, ³Ô¹Ï²»´òìÈ has learned. Insurance industry sources said the Centers for Medicare & Medicaid Services has reinstated a small number of people whose coverage should not have been canceled. More could follow in the coming weeks if enrollees discover they are uninsured when they go to use their coverage.

Still, the sweep was long overdue, say supporters such as Brian Blase, whose Paragon Health Institute has of the cited by those who allege in the ACA. But other policy experts question how many legitimate consumers were caught in the dragnet, perhaps because they failed to open a letter from their insurer or answer a phone call.

Questions continue to swirl, even as a second phase of the anti-fraud effort is underway. An additional 419,000 sign-ups are being scrutinized. Insurers must let CMS know how many of those enrollees don’t respond to outreach efforts by “around mid-to-late November, after the midterm elections,” said David Merritt, senior vice president of external affairs at the Blue Cross Blue Shield Association.

He confirmed that some BCBS members are among those who have been reinstated. He also said that CMS has an expedited review process for those who discover they have been improperly disenrolled.

Overall, however, the administration is providing few details about the cancellations, such as how robust the outreach was to those it targeted, how long it takes for people to get reinstated after discovering their coverage was wrongly canceled, and how many such cancellations have been reversed.

“It may be true that some of those enrollments were not authorized, but it can be equally true that people got lost in the shuffle and have a valid enrollment. Without more information, it’s almost impossible to tell,” said , a director of the Center for Health Policy and the Law at Georgetown Law. “That they are not being very transparent is telling too,” she said of the administration.

The enrollment cut comes as part of a larger Republican strategy to focus on fraud in government programs, including and , which resonates with GOP voters.

At an Oct. 14 press conference, Health and Human Services Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz touted the removal this year of subsidies for with duplicate Medicare, Medicaid, or Children’s Health Insurance Program coverage, citing not fraud but a failure to look for concurrent enrollments or continued coverage for dead people. They credited an by the Trump administration to restore more frequent data matching checks than were done under the prior administration.

Unauthorized sign-ups by rogue insurance agents seeking commissions and other potential impropriety in the ACA marketplace — applicants’ providing incorrect income estimates, for example — has been a concern for several years, with much debate over the magnitude of the problem.

Even so, how the recent move to cancel the 760,000 enrollments will play out politically is uncertain. with gas prices as a top concern for voters. It is likely that many removed from the ACA are in red states, such as Texas, Florida, Louisiana, and Mississippi. Those areas in ACA enrollment from 2020 to 2025, driven in part by now-expired enhanced subsidies put in place during Joe Biden’s presidency. Additionally, the cancellations target only enrollees in states that use , the federal ACA marketplace. The fully running their own marketplaces generally have programs, such as multifactor authentication, and have reported few or none of the kinds of unauthorized sign-ups plaguing the federal marketplace.

“To the extent there is a reaction depends on whether the government got it wrong, whether people try to get care and then find out their coverage is no longer active,” said Adrianna McIntyre, assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health.

How It Played Out

According to information the agency provided to ³Ô¹Ï²»´òìÈ, CMS in June selected for further review nearly 1.2 million enrollments that had all of what it deemed four warning signs for fraud:

• The application included no Social Security number or immigration document number.
• A broker was involved in the sign-up process.
• The plan had no monthly premium payment.
• The enrollee had had no contact with their insurer and no claims filed.

Then, as first reported by ³Ô¹Ï²»´òìÈ, CMS sent lists of those ACA accounts to specific insurers, instructing the carriers to review them and use at least two methods of contact — such as a phone call and a letter — to try to reach the enrollees. Policyholders were given 30 days to respond to the insurers’ outreach and provide the missing information. CMS disenrolled those who didn’t respond.

Johnny Wallin, chief operating officer of Texas-based Marketplace Insurance Exchange, which helps clients in about 35 states enroll in coverage, said insurers reached out to his organization for help contacting people on the CMS lists, prompting “an all-hands-on-deck” effort by agents to reach clients, some of whom were vacationing overseas.

“Getting them to answer the phone isn’t easy,” he noted, although he suspects his agents had a better chance of getting a reply than an insurer because their clients are familiar with their phone numbers. Still, they could not reach about 60 of them.

Additionally, his team has been asked by insurers to help contact those targeted in the second phase of CMS’ review. A recent case involved a client who needed to upload his new green card after his previous one expired, but language barriers meant that he had to take time off work to come in for agents to help with the process.

CMS would not provide a list of the insurers it contacted, but publicly available documents show that New York-based Oscar Health was one.

In an August earnings call with analysts and investors, CEO Mark Bertolini said the company was reviewing the files and that “there are a number of cases ” with people on the list. In other words, the company reached enrollees CMS had targeted over fraud concerns.

He did not specify how many it had reached. The company declined to comment for this article because it is in a voluntary “quiet period,” when publicly traded companies limit disclosing information before the release of an earnings report.

Still, in with the Securities and Exchange Commission, Oscar Health estimated that 250,000 to 300,000 of its members might be disenrolled because of the CMS effort. Nationally, the company had about 3 million members in the second quarter and reported strong profits.

A Smaller Patient Pool

Overall ACA enrollment has , falling by nearly 3 million in the first few months of the year, due in large part to the expiration at the end of last year of the enhanced subsidies. The Trump administration has also taken some credit, saying its focus on weeding out improper enrollments and other changes, such as eliminating a special year-round low-income enrollment period, led to the decline.

CMS has also suspended some brokers for improper activity and barred new brokers from enrolling clients in ACA insurance on the federal exchange during the upcoming open enrollment period.

CMS did not respond to requests for data on the reasons it canceled enrollments. What percentage of enrollees were deemed ineligible due to incorrect income reporting or because they had other health coverage, such as through their jobs? How many because their ACA applications lacked immigration documents or Social Security numbers?

“Currently, there is no additional data to share,” the agency’s press office said.

But people outside the administration have been vocal.

“This was clearly phantom enrollees,” said Paragon’s Blase. He thinks more than 99% of the cancellations are of zero-premium coverage that people were signed up for by rogue call centers without their knowledge, or for people who don’t exist at all.

Blase said the carriers had a big incentive to get hold of the enrollees because they would lose the subsidies they were being paid if the plans were canceled.

And for any people unfairly caught up, Blase and Trump administration officials say all they have to do to be reinstated is call the marketplace and provide their Social Security number or other missing information.

“Everyone has the political incentive for that process to be that easy,” Blase said. “We’re a month before the election.”

But, as prior reporting has shown, it isn’t always a quick process to get an ACA plan canceled or reinstated following an unauthorized sign-up or switch, even when a consumer discovers it themselves and reaches out to the marketplace.

Brokers and policy analysts note that some of the factors used to question enrollments — such as a plan’s having no claims filed in a year — are not that unusual because many people don’t visit a doctor or hospital in a given year.

Insurers “want those healthy people in the insurance pool to help bring down the rates,” said Ronnell Nolan, president and CEO of Health Agents for America, a trade group for health insurance agents. “We’re against fraud, and CMS has allowed a lot of fraud to happen. But we don’t want people who just didn’t go to the doctor to be canceled.”

And even with the outreach required by CMS, not everyone answers phone calls from unknown numbers or opens their mail or emails.

A found an average “open rate” on emails of 28.6%.

Policy experts also note that, while lack of a Social Security number on an ACA application could indicate a fake enrollee, it might also be an oversight, or the number might not be required, like for a child if the who is not seeking coverage for the child.

“There will be legitimate people who don’t have a claim or don’t respond to an inquiry from an insurer,” said , a senior fellow at the Brookings Institution. “If the goal is to target fraudulent enrollment, what CMS did is better than tossing people at random, but is likely to miss the mark.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

But Democratic strongholds across the country — including Oregon, California, , and — have more ambitious goals: single-payer, universal healthcare systems.

No state is closer to that goal than Oregon. A panel created by the state legislature in 2023 is slated to send lawmakers its proposal for a universal health plan by Dec. 1. The nine-person seeks to establish, starting in 2032, medical, vision, dental, and mental health benefits for every state resident from cradle to grave — with no premiums, deductibles, or copayments. Lawmakers could vote on a plan during the 2027 legislative session or refer it to voters as a ballot measure in 2028.

If approved, the state would be the first in the U.S. to implement what’s called a single-payer health coverage system. It could serve as a model for other states — and potentially the nation.

Proponents of the proposal argue that the public supports universal healthcare more than ever as healthcare spending and complexity grow. patients often delay care due to out-of-pocket costs. And medical debt remains a in the nation.

States have often served as laboratories to test health policies later implemented nationally. The Affordable Care Act was modeled after Massachusetts’ attempt to achieve universal health insurance coverage, once single-payer efforts there stalled. And Canada’s universal healthcare system began with a provincial plan in Saskatchewan.

“In the short to medium term, there is no chance that ‘Medicare for All’ can be passed at the national level,” said , a University of North Carolina health policy professor. “That’s where the states come in. A state like Oregon provides a more hospitable political environment and a more realistic path to single-payer reform.”

But advocates of the plan expect a significant fight from healthcare behemoths, including large hospital systems, seeking to sour public opinion on making such widespread changes. are health insurers. The industry’s deep pockets have helped derail myriad universal healthcare efforts at the federal and state levels.

In 2011, the Vermont Legislature voted to implement a universal healthcare plan but, three years later, Democratic Gov. Peter Shumlin, who had campaigned on the promise of single-payer, pulled the plug, citing “potential economic disruption.”

States that took the issue directly to voters have fared no better. Ballot measures in in 2016, in 2002, and in 1994 all failed by large margins.

“The aspirations of progressive reformers usually run smack into sobering political realities,” Oberlander said. “Translating a slogan into a legislative and political reality is a daunting task.”

Redirected Healthcare Dollars

Oregon’s proposal seeks to maintain the current level of spending on healthcare by government, business, and consumers with new corporate and personal taxes to replace insurance premiums and other out-of-pocket costs. Those would be combined with federal and state spending to create a single fund from which all hospitals, doctors, and other practitioners would be paid.

Board members said savings from cutting red tape, reducing fraud, and negotiating drug costs should allow the state to provide better benefits to more people.

In , the board estimated that a 30-year-old making $55,000 and purchasing a benchmark silver-level plan through the Affordable Care Act now pays $5,478 a year for insurance premiums in Oregon, but instead could pay $2,331 in taxes under the proposed plan.

Someone making $55,000 a year with coverage through their employer now pays $3,063 in premiums and out-of-pocket costs. Under the draft plan, that person could pay nothing for health services and could see any doctor in the state.

Currently, many employers pay much of the health insurance costs for their workers. The plan seeks to maintain those contributions by establishing a corporate payroll tax for companies whose payrolls exceed $500,000. Their employees could receive a partial tax credit for the taxes their employers pay. As a result, 31% to 60% of Oregonians wouldn’t pay anything for health benefits.

More affluent people, however, could end up paying more than they do now. The exact numbers would depend on how lawmakers set tax rates and payment thresholds.

“What we are proposing is something very different,” said , executive director of the Oregon board. “Everyone contributes based on the amount that they are able to contribute and not based on utilization.”

Messaging Challenge Lies Ahead

The plan’s backers will try to convince hospitals and health systems that they would benefit from reducing red tape and eliminating unpaid bills. Currently, hospitals to bill dozens of public and private health plans, each with its own coverage and billing rules. A single plan covering everyone in the state could streamline the process, saving billions.

Rural hospitals could gain financial stability. They now often struggle to stay afloat because they typically have higher rates of patients who are uninsured or on Medicaid, with its often low reimbursement rates.

Hospitals aren’t so sure.

“The universal health plan proposal preserves much of the broken, fragmented status quo and adds new taxes and complexity that Oregonians can’t afford,” said Becky Hultberg, president and CEO of the . “With federal policy changes looming, we are entering a period of tremendous upheaval. This proposal could destabilize a system that is already struggling.”

Under the proposal, doctors and other practitioners would be paid somewhere between what Medicare pays on the low end and what private insurance pays on the high end. Although total payments to doctors would remain unchanged, rates would be negotiated with physician groups to shift more money into primary care and less into specialty services.

But it is unclear whether doctors would agree that more patient time, fewer administrative hurdles, and no more unpaid bills would be worth a payment structure that could cause specialists to lose out.

“There’s always winners and losers in designing something like this, and so how to distribute those is the hardest part,” said , an associate health policy professor at Pacific University who is slated to join the Oregon board in January. “But the second-hardest part is, I think, messaging this.”

Courtni Dresser, vice president of government relations for the , said her physicians group shares many of the board’s goals in improving access to care and reducing administrative burdens. But the group has yet to declare its support or opposition to the effort.

Health insurers haven’t formally weighed in on Oregon’s proposal either, but a single-payer system would, in essence, close off Oregon to any private healthcare plans.

“We expect insurance companies to put every ounce of money they can against this idea because our system is broken and they profit from it,” said Collin Stackhouse, communications coordinator for , a consumer group advocating for universal healthcare.

, a former insurance company executive who now works to expose industry influence, said he expects health plans to hammer the Oregon proposal with claims of high taxes, loss of choice, and the specter of “socialized medicine.”

“Most people go year to year without testing the limits of their health insurance policy,” Potter said. “And so, they’re easily scared into thinking that something valuable will be taken away from them, and that they will have something that’s inferior in its place.”

Health insurers argue their health plans help shield consumers from the full impact of rising healthcare costs.

“Americans consistently report strong satisfaction with their health coverage, including more than 180 million covered through work and 36 million who choose Medicare Advantage,” said Chris Bond, a spokesperson for the health insurance . “Policy solutions are needed to rein in the ever-higher prices charged by hospitals and drugmakers and make care more affordable for everyone.”

Federal Approval Needed

It’s unclear whether Oregon could secure federal approval to redirect Medicare and Medicaid dollars into its universal plan. Backers of the proposal do not expect the Trump administration to be receptive but say it will be years before approval is needed and hope the 2028 presidential election ushers in a more supportive administration. If federal waivers are not secured, Oregon could proceed in stages, starting with the non-Medicare population.

In California, Democratic candidates for governor are not debating whether to implement single-payer but how. New York lawmakers are debating a single-payer bill called the . And in Washington, state legislators have created a commission to design a universal healthcare plan.

The Oregon board has had regular contact with teams working on single-payer proposals in California and Washington, sharing approaches and looking for ways to collaborate, McDonell said.

, an Oregon family physician and a member of Physicians for a National Health Program, said he could envision the other West Coast states joining Oregon in implementing single-payer, much as California, Washington, and Hawai‘i have in to counter changes in federal vaccine recommendations.

“If our four states could do it,” he said, “that would be the momentum we would need to get it nationally.”

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³Ô¹Ï²»´òìÈ contributor Erin Rode discussed California prison heat protections on KVPR’s Central Valley Daily on Sept. 24.

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• Read Rode’s “California Eyes Prison Heat Protections That Fall Short of Workplace Standards.”

³Ô¹Ï²»´òìÈ chief Washington correspondent Julie Rovner discussed the removal of more than 750,000 people from Affordable Care Act coverage over fraud claims on WBUR’s Here & Now on Sept. 23. Rovner also discussed “Medicare for All” on WNYC’s The Brian Lehrer Show on Sept. 22.

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³Ô¹Ï²»´òìÈ senior correspondent Stephanie Armour discussed health secretary Robert F. Kennedy Jr.’s comments to an anti-vaccine group that he founded and the surgeon general nominee’s contradictory comments in her confirmation hearing on WBUR’s Here & Now on Sept. 18.

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Céline Gounder, ³Ô¹Ï²»´òìÈ’ editor-at-large for public health, discussed Kennedy’s comments on CBS News 24/7 on Sept. 17.

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This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

When the Durhams began their practice at the end of 2023 — he as a primary care physician and she as a pharmacist who handles the billing — the couple bought coverage for themselves and their two kids on the Affordable Care Act marketplace. But they said their monthly premiums for a similar health plan for this year rose several hundred dollars to nearly $1,600.

They decided to pay out-of-pocket for their medical expenses instead, leaning on $50,000 they had set aside in a health savings account over several years.

“It’s nerve-racking,” said Joshua Durham, 47. “It just takes, you know, one little accident, and then you got a big fat bill.”

The healthcare industry traditionally has more of its workforce on medical insurance than many other fields. Nationwide, 7% of all healthcare workers were uninsured in 2024, compared with 11% of all adults under 65, according to a KFF analysis of the most recent American Community Survey data. And doctors were especially unlikely to forgo health insurance, with just 2% uninsured.

But even healthcare workers are feeling the pinch as each year, with employers expecting that costs will jump an for 2027.

The Republican-led Congress also opted last year Affordable Care Act marketplace credits enacted during the covid pandemic. While subsidies remain in place for people with low incomes, the pandemic-era credits helped , especially those working in small businesses such as independent medical practices. Nearly half of marketplace enrollees worked for small businesses or were self-employed in 2024; some of the most common occupations included chiropractic care and dentistry.

Jack Dillon, executive director of the , which represents 4,000 physician-led practices, said premium increases have become untenable for small businesses, whether employers seek coverage through the marketplace or directly from insurers.

“The cost has become so astronomical,” Dillon said. “You’re looking at it and saying, ‘What’s the value?’”

As health insurance continues to become less affordable, Dillon said, more healthcare employers may seek alternatives to their standard coverage, such as providing higher hourly wages or providing only minimal plans.

The number of people without insurance in the U.S. is expected to increase by roughly over 10 years because of the expiration of the expanded ACA subsidies and resulting from President Donald Trump’s signature One Big Beautiful Bill Act, according to the Congressional Budget Office.

Healthier people are the most likely to opt out of insurance. That leaves insurance covering a smaller pool of people who tend to be sicker and need more expensive care. So insurers raise prices to cover the remaining enrollees, which fuels even higher premium costs.

‘Healthcare Is a Business’

Samantha LeGault, a nurse practitioner at a health clinic in Boise, said her employer-offered plan’s premium payment rose from $700 to $1,500 a month this year to insure herself, her husband, and four of their kids. LeGault has Crohn’s disease and two of their daughters also have medical conditions, so she said her family has no choice but to continue to pay for that health coverage.

But she decided to skip dental insurance to save money, and she prioritizes dental visits for her children over herself.

She had already struggled to set aside retirement savings and had switched her children from a private school they liked to public school to cut down on costs. Then the new health insurance costs tightened her budget even more. She estimated that about one-fifth of her income now goes toward her monthly premium payments.

“I know how the clinics work, that I am an expensive patient,” LeGault said. “At the end of the day, healthcare is a business in the United States.”

The Durhams have three other employees in their practice. Two of them receive health insurance through their spouses, Ashley Durham said. The Durhams said they pay $420 monthly toward their physician assistant’s premiums.

As a primary care physician, Joshua Durham said he doesn’t need regular doctor visits, because he can diagnose and treat himself — and, if needed, the rest of his family, though he acknowledged that’s frowned upon. The American Medical Association’s generally discourages doctors from treating themselves or relatives but makes exceptions for emergency situations or short-term, minor problems. Ashley Durham said she’s filled prescriptions for her family.

, a bioethicist and professor emeritus at New York University’s Grossman School of Medicine, said that as more people are “turning toward relatives because they can’t access or easily see a regular doctor,” it may make sense to revisit that aspect of the code of ethics.

Out-of-Pocket Expenses

Healthcare workers with less advanced medical certifications than the Durhams often don’t have the option of treating themselves or family members — or don’t have savings to fall back on for healthcare expenses. And many healthcare professionals, such as Jill Kordick, a 64-year-old retired healthcare executive in Norwalk, Iowa, aren’t willing to go without the safety net of insurance.

In her work, Kordick saw hospitalizations become financially devastating for patients, so she said she would never opt out of health insurance — even for just the 16 months before she’d become eligible for Medicare at age 65.

Last year, she qualified for the enhanced Affordable Care Act tax credits, allowing her to pay $75 a month for health coverage. Her premiums rose to $800 a month this year when those subsidies expired.

Because she has a $10,000 deductible, she put off going to the doctor for weeks when she had a sinus infection this year, until it ultimately evolved into an ear infection. She said she regularly rethinks, and sometimes returns, nonessential groceries in her shopping cart. And she keeps her house’s thermostat at 80 degrees in the summer to cut down on air conditioning costs.

Kordick said healthcare is a universal struggle in this country, regardless of how familiar patients are with the industry. “It’s disheartening that it’s as broken and fragmented as it is,” she said.

The Durhams have seen the impact of unaffordable healthcare on their patients. They said they try to lend some leeway to patients when they can — a luxury they have, operating their own practice. In one case, Ashley Durham said, she wrote off $1,160 in bills for a single father whose son didn’t have health insurance rather than send their bills to a collection agency.

“It’s hard, because as a human I want to help them out,” she said. “At the same time, we need revenue for our office.”

Joshua Durham is more nervous about going uninsured than his wife. As a child, he witnessed his parents struggling to pay medical bills for their family of nine in south-central Idaho. Durham recalled that his dad, who was a carpenter, helped build a surgeon’s house to pay for an operation.

Today, Durham also sometimes exchanges work for care. He said he gets free eye exams from an uninsured optometrist and offers him free primary care.

He worries about a worst-case scenario: a car crash, a sports injury, a serious diagnosis.

“Do I have pancreatic cancer today?” Durham said wryly.

So far, the couple has paid around $9,000 total for expenses out of their health savings account this year, including physical therapy to help with the thoracic outlet syndrome that affects Durham’s neck and shoulder, mental health appointments, and contact lenses. The expenses were higher than the Durhams anticipated. But it was still less than what their monthly premiums would have cost them.

Their decision has paid off, Joshua Durham said. At least for now.

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact ³Ô¹Ï²»´òìÈ and share your story.

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Court papers indicate a settlement in the case against the Department of Labor , although the parameters of any such deal are unknown.

It would come amid premium surges on Affordable Care Act marketplaces that have led millions to drop coverage this year. The Trump administration has also been sharply focused on expanding access to alternative coverage, such that avoid ACA rules on preexisting conditions and benefit requirements.

“Depending on what happens with the settlement, this could be an even bigger expansion,” said , director of the Center for Health Policy and the Law at the Georgetown University Law Center. “People are worried that it is the opening salvo into promoting junk plans that don’t meet the ACA requirements.”

The plaintiff, Data Marketing Partnership, against the Department of Labor in 2019, during the first Trump administration. It wants official recognition as an employer so it can continue to allow its limited partners to buy into a type of job-based health insurance that doesn’t have to comply with state insurance rules or offer coverage as robust as required under the ACA.

But to grasp the claim, one also has to understand how the coverage works.

A consumer shopping for health insurance may come across information online or from a marketer about this concept, sometimes called “limited partnership” coverage. The pitch? Buy insurance offered through Data Marketing Partnership and handled by LP Management Services. To qualify, the consumer must download an app that tracks their internet searches. The company could then sell that data.

Some potential consumers may be turned off by the thought of their internet searches being tracked, but others may find it appealing because it allows them to become a limited partner eligible to buy into the company’s employee health insurance plans. But can these partners be considered employees?

The court’s answer has potential implications for regulators and consumers. Some health policy and market experts warn that a green light could lead to a proliferation of aggressively marketed and potentially questionable insurance with limited recourse for consumers because the plans would be exempt from state oversight.

“If this took off, you logically could see the rise of a whole bunch of what, functionally, would be unregulated insurance companies,” said , who was the principal deputy assistant secretary of the Department of Labor’s Employee Benefits Security Administration during Joe Biden’s presidency and now runs his own consulting outfit.

No one knows if the department is going to change its long-running stance defending the case. But any settlement could add more uncertainty to insurance markets.

Already insurers are requesting double-digit increases in ACA premiums again next year, partly because declining enrollment often means that the healthiest policyholders are leaving. That trend could accelerate in coming years as more people are drawn into alternatives such as limited-partnership policies.

States Act as Federal Case Plays Out

The Department of Labor defended the case throughout the first Trump administration and the Biden era, issuing a sharply worded in early 2020 stating that people who simply download software to “capture data as they browse the Internet” are not “employees or bona fide partners.”

A district court judge in Texas, the ACA unconstitutional in a decision ultimately rejected by the Supreme Court, called the advisory opinion “” in a 2020 ruling in favor of the data marketer. The U.S. Court of Appeals for the largely upheld the lower court’s decision but ordered it whether someone who downloads software is either a “working owner” or a “bona fide partner.”

The employer-employee relationship is at the heart of the case because of a designed to help large, self-insured employers offer retirement and health benefits to workers without having to meet varying rules from multiple states.

That law — the Employee Retirement Income Security Act — allows such plans to avoid most rules set by the states, which generally regulate most other types of insurance and assist consumers who report problems with their policies. As self-insured employer plans, the policies also don’t have to comply with some ACA rules, such as the 10 broad categories of “essential health benefits.”

“If the case goes the wrong way, it could impact consumers or hamstring the states,” said Marie Grant, Maryland’s insurance commissioner.

Arguments over what constitutes an employer plan are not new, and other organizations have tried offering such coverage. Some states have taken action against purveyors of limited-partner policies.

Maryland in 2024 , The Vitamin Patch, for offering limited-partnership insurance after investigating complaints and determining it was not licensed to sell coverage in the state.

Washington in 2021 to stop offering its plans in the state and fined it $25,000.

and in 2024 warned consumers about this type of coverage.

“These plans do not provide comprehensive medical coverage and can leave consumers with large, unpaid medical bills,” according to Connecticut’s notice.

Maine’s announcement noted that entities offering these types of health insurance included The Vitamin Patch as well as Affiliated Workers Alliance, Consumer Data Partners, Employers Business Alliance, Socios Buenos, and Strategic Limited Partners.

State insurance commissioners in the Department of Labor case citing their concerns about losing the ability to enforce consumer protections.

“This is not a Republican-Democrat thing,” Khawar said. “It’s really a story about state authority, the way such authority would be significantly undermined in insurance markets.”

What’s the Risk?

Still, these limited-partnership plans are viewed by proponents as a needed additional choice for consumers, at potentially lower cost than ACA plans.

When the case was filed, attorneys general , for example, urged the Department of Labor to back Data Marketing’s request to designate its limited partners as employees. That would provide an option for people who “earn too much to qualify” for ACA subsidies and be an interim solution until the ACA could be repealed and replaced, they wrote. They argued that states would retain some regulatory authority and added that the Department of Labor, which oversees self-insured employer plans, could set requirements to “encourage” stable companies to enter the market.

Critics, the attorneys general wrote, might fear that ACA alternatives will draw away younger or healthier people, thus affecting those who remain, but they argued that had already happened.

Data Marketing’s attorneys emailed ³Ô¹Ï²»´òìÈ that they could not provide a comment for this article because the case is in active litigation. Neither the White House nor the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, responded to questions from ³Ô¹Ï²»´òìÈ about whether the Department of Labor has changed its stance and how the administration views limited-partnership health plans.

In court filings, however, Data Marketing said that without an employer designation, it would have to end the insurance coverage, affecting about 50,000 policyholders. That would also hurt its ability to generate revenue, it argued, because offering insurance is “a significant attractor” to get people to join its partnership and let it access their electronic data.

, who helped oversee ACA implementation in the Biden administration and is now a managing director at consultancy Manatt Health, had a different take. “The only reason why these sorts of products exist is because they aren’t beholden to consumer protection rules of the ACA and can essentially make money by attracting good risk, people who are healthy,” she said.

Maryland’s Grant echoed this warning, saying that proliferation of such plans could lead to even higher premiums in the ACA markets, if those who remain are older or sicker than those who leave.

Nineteen patient advocacy groups to the Department of Labor Aug. 11 urging it to continue its defense in the case, warning that a settlement that says such arrangements create an employer-employee relationship could “significantly” undermine “both state regulatory authority and decades of bipartisan efforts to promote stable, well-functioning health insurance markets.” Some of those groups in support of the department in 2021.

Days after the August letter, U.S. Rep. Bobby Scott (D-Va.), the ranking member of the House education and workforce committee, warned the department against increasing the availability of “questionable employment relationships” and the insurance they offer.

He cited reports of call centers’ misleading consumers “who think they are enrolling in comprehensive health insurance but instead sign up for junk coverage under the guise of creating an employment relationship with what the consumer believed to be a traditional health insurer.”

This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .

“Maybe this is my sign to try the full-time music thing,” Morgan recalled thinking. “Step one in that was: Get health insurance again.”

Austin bills itself as “the Live Music Capital of the World,” but it for the artists who provide the city with its cultural cachet — and help drive its tourism revenue.

Morgan has supported himself by patching together gigs with a number of bands. To help pay for health insurance, he turned to a local nonprofit, the , or HAAM.

“That’s part of being able to make this whole thing work,” Morgan said.

HAAM subsidizes the monthly insurance premiums of local musicians who purchase plans through the Affordable Care Act marketplace. To fund the roughly $4 million program, it works with Central Health, a public agency that provides healthcare resources for low-income residents of Austin and surrounding Travis County. Many of the performing artists pay $0 toward monthly premiums.

After more than a decade, including through the coronavirus pandemic, the assistance program has become an established and reliable financial support for Austin’s musician community.

This year, after Congress failed to extend pandemic-era subsidies, premiums skyrocketed for many ACA plans. A recent report found that 5 million people nationwide had . HAAM helped blunt the impact for its members. It has emerged as a potential model for other cities hoping to make healthcare more affordable for key populations and industries.

A Growing Idea

Texas had the among states, with 19% of people age 64 and under uninsured, as of 2024.

Even before the launch of the ACA marketplace in 2014, HAAM had spent a decade connecting musicians with free and low-cost care at clinics and hospitals in and around Austin. But roughly 85% of HAAM members remained uninsured, leaving them exposed when traveling to gigs in other cities and states.

“When the Affordable Care Act came out, and we knew it was here to stay, it really made sense for us to start getting our musicians fully insured,” said , HAAM’s chief strategy officer.

Similar nonprofits in other U.S. cities with strong live music cultures, such as , , and , help musicians get medical care. With the advent of the ACA, some of these organizations began helping musicians navigate the sometimes complex enrollment process for the online marketplaces, though they stopped short of pitching in on premiums.

But the team at HAAM recognized that without direct support to help pay premiums, many of their members would still struggle to retain coverage.

“When you think about the average HAAM member making about $30,000 a year, there’s no way that they would be able to spend a third of their income on healthcare,” Blair said.

The organization’s membership has grown by 77% to more than 3,300 people since HAAM began offering premium assistance, and more than 90% of members are now insured.

To help subsidize costs for members, HAAM partnered with Central Health, which is Travis County’s public hospital district — a type of health agency in Texas charged with using tax dollars to fund safety net healthcare for low-income residents. Central Health also operates the nonprofit , which offers marketplace insurance to Travis County residents.

To qualify, HAAM members must enroll in one of Sendero’s silver-level, or benchmark, plans. If their income is between one and two times the federal poverty level, Central Health pays the balance of their monthly premium after federal tax credits are applied. For members who fall above that income range, HAAM offers a more limited subsidy, covering 50% of their premium balances.

In 2017, HAAM helped set up a similar program in Denton, a college town north of Dallas that has served as a , from Meat Loaf to Norah Jones.

The Denton Music and Arts Collaborative works differently: It connects members with an independent insurance agent who helps them find the best health plan for their needs. The nonprofit then offers members a monthly subsidy of $100.

The subsidies are a way of keeping Denton’s culture of jazz and “weird art rock” alive, said the collaborative’s president, Jennifer Kapinos.

“More and more people were maybe graduating college and leaving and going to find better opportunities in other places,” Kapinos said. “People who had lived here a long time suddenly were finding it harder and harder to afford to be here.”

In Austin, other sectors have been watching HAAM’s work. In 2025, , a nonprofit that advocates for restaurant workers, launched a small pilot program with Central Health to help local food workers enroll in Sendero plans and cover their premiums.

Kit Abney Spelce, vice president of operations for Central Health, said partnering with an advocacy group focused on a particular workforce is key because simply announcing “free insurance for you” doesn’t mean people will sign up.

“We are very much dependent on our partner entity to go out and connect with the community, to have that relationship and that trust,” she said.

Navigating Federal Headwinds

Though premium payments often increase year over year, the 2026 plan year was particularly expensive, .

Citing medical and pharmacy costs, Sendero by an average of 16% for its enrollees. At the same time, Congress allowed the pandemic-era enhanced premium tax credits to expire, reducing the federal subsidies that many marketplace customers relied on.

“Our premiums for our members went up 60% from one year to the next,” Blair said.

HAAM stepped up its fundraising into 2026, but it wasn’t enough to cover everyone who requested assistance. They had to turn away hundreds of qualified people. Still, they were able to buffer existing members, said Spelce with Central Health.

“We’re going to make sure their monthly premium is paid every month,” she said.

A Viable, if Limited, Model

Beyond the eligible musicians they turned away in 2026, another population remains out of HAAM’s coverage reach for premium assistance: Austin’s poorest residents.

Under the ACA, the marketplace plans that HAAM helps subsidize are for low- and middle-income earners, but the people with the very lowest incomes — below 100% of the federal poverty level, set at — are supposed to be covered by expanded Medicaid.

But Texas is one of 10 states that chose not to expand Medicaid after the ACA became law, so many of the poorest Texans remain uncovered.

With no federal subsidies available for that group, HAAM and Central Health have tried to develop separate solutions for this subpopulation. Central Health has its , an alternative to health insurance that gives low-income, uninsured people access to a network of local care providers. HAAM has also with primary care providers to serve its uninsured members — but Blair acknowledges it’s not an equivalent benefit to what Medicaid expansion would offer.

“It’s not a very sustainable solution, especially when there’s a really good alternative,” Blair said.

This article is from a partnership that includes , , and ³Ô¹Ï²»´òìÈ.

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It’s an achievement the former congressman and former U.S. secretary of Health and Human Services as he campaigns for California governor against Republican Steve Hilton, a former Fox News commentator.

But should Becerra cruise to victory in November, as , he will face what may be the steepest decline in health insurance coverage in a generation, one that will land especially hard in his home state.

By 2030, the number of uninsured Californians under 65 is expected to from 2.4 million to 4.6 million, as recently enacted state and federal cuts to Medicaid and ACA marketplaces begin to historic gains in health coverage, according to a May analysis by the University of California-Berkeley Labor Center. The anticipated rise in the uninsured population could have broad implications for hospital systems, insurers, and the economy.

In February, Miranda Dietz, the labor center’s healthcare program director, told legislators the changes could end up costing California , mostly in the healthcare industry.

Hospital executives have begun reporting , and experts warn health plans will raise premiums further as they’re left with enrollees who are, on average, sicker and more expensive to cover.

“It’s triage,” said , executive director of Covered California, the nation’s largest state-run health insurance marketplace. “That’s what the next governor is walking into.”

California achieved one of the most in the nation, largely credited to the state’s robust adoption of the ACA. If tapped to lead the wealthy, progressive state, Becerra would wrestle with how uninsured Californians get care and who pays as the Trump administration shrinks a federal safety net he once oversaw.

Becerra has some experience pushing back against Washington, D.C. As California attorney general, he many provisions of the Affordable Care Act, including access to birth control.

Becerra said he would issue an to keep those affected by federal cuts insured. But he has not detailed how the state would backfill in federal funding California stands to lose annually.

At a policy forum hosted by Politico last month, would not lose health coverage despite federal cutbacks, saying he would push the industry to eliminate waste from “attorneys, accountants, pencil pushers” that cost consumers billions.

“I’m going to ask them to help me extract some of that waste and put it into healthcare, which helps us cover the cost of keeping Californians insured,” he said.

His opponent, Hilton, is trying to appeal to , despite receiving the president’s endorsement, and has stumped on cutting off coverage for Californians without legal status, which is paid for with state funds. Hilton has vowed to use those savings to , calling it an immediate antidote to high costs.

“We all understand that the healthcare system is a mess and needs major reform,” Hilton said in an interview. “The quickest thing we can do on healthcare costs is actually to tax people less.”

Left Behind?

In 2010, Becerra was part of U.S. House Speaker Nancy Pelosi’s leadership team and helped whip up votes to pass the law. He also had a hand in crafting it, though his attempt to include a government-backed coverage option failed.

A decade later, when lawmakers considered him for the nation’s top healthcare job, Becerra said his primary mission would be to carry out President Joe Biden’s vision to expand access and cut costs under the Affordable Care Act.

Before the ACA, some — roughly 1 in 6 — were uninsured. Within a few years of the law’s , its expansion of Medicaid eligibility and financial aid to lower-income marketplace enrollees helped slash the U.S. uninsured rate by nearly half.

Millions more gained coverage during the covid-19 pandemic after Becerra implemented a and administered generous but temporary tax credits that put the cost of Obamacare plans .

As Biden’s health secretary, Becerra launched aggressive public awareness campaigns, , and distributed hundreds of millions in grants to pay consumer assistants, also , to help enrollees wade through paperwork.

“One of the common things we would hear from him as a leader was, ‘Who’s being left behind?’” said Benjamin Sommers, a Harvard health policy professor who was a under Becerra.

Under Biden and Becerra, the percentage of people with health insurance reached a historic high of 92%, or 310 million Americans having health coverage in 2024.

Republican Response

But conservatives said those policies by attracting fraudulent and wasteful coverage. In response, the second Trump administration has and toughened income reporting.

“It’s simple and easy to say, well, the numbers are up so the program must be working,” said , a senior research fellow at the Heritage Foundation, a conservative think tank. “My argument would be that’s the wrong metric.”

Last summer, the GOP-led Congress passed Trump’s One Big Beautiful Bill Act, which for those who need it most while . Altogether, the law is expected to cut Medicaid spending by over a decade.

Congress also allowed enhanced for Obamacare plans to expire last year, spiking premium payments for middle-income Americans and driving down enrollment by this year.

“We are now witnessing almost a wholesale reversal of pretty much all those policies” that helped cover millions more Americans, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

For Eric Maciel, the $800 monthly cost of a Covered California plan is too much. To avoid injury, the 28-year-old stays home more and rarely plays pickup soccer at the park — the other players, he added, can get pretty rough.

“That’s another car note,” Maciel said. “I’d be left with nothing.”

Health economists say Maciel is the type of customer insurers need to stabilize their risk pools: young, healthy, and less costly.

Hilton criticized state leaders for passing a revised provider tax he asserts will send premiums soaring and said he wants to inject more competition into California’s health insurance market — but he offered no specific ideas.

Playing Defense

Higher-than-expected state costs coupled with federal cuts have prompted California to retreat on healthcare coverage. Federal funds of the state’s budget and , the state’s Medicaid program.

Gov. Gavin Newsom has frozen enrollment for immigrants without legal status, enacted monthly premiums for some, and federal assistance for legal immigrants such as asylees and refugees.

Newsom and Democratic lawmakers agreed to until July 2027, leaving the next governor to weigh further rollbacks against increased taxes. Becerra, a California native born to Mexican immigrants, , on November’s ballot. Last month, he said he supported legislative efforts to penalize large corporations whose workers rely on Medi-Cal, arguing that taxpayers are subsidizing employers’ low wages and paltry benefits.

County governments, which are legally required to provide healthcare to uninsured residents too poor to afford care, are lobbying lawmakers for funding to treat what they describe as a fresh deluge of patients who need free care.

“It’s a pretty big cliff if all this stuff goes into effect,” said Dietz, the labor center’s healthcare program director. “And there’s a choice whether to make it less bad and maintain coverage for folks.”

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Céline Gounder, ³Ô¹Ï²»´òìÈ’ editor-at-large for public health, discussed fatal measles cases on CBS News 24/7’s Mornings on Aug. 26. Gounder fact-checked Centers for Medicare & Medicaid Services Administrator Mehmet Oz’s comments about vaccines and drug prices on CBS News 24/7’s The Daily Report on Aug. 24. She also discussed food recalls this summer on CBS News 24/7’s The Takeout With Major Garrett on Aug. 24.

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³Ô¹Ï²»´òìÈ chief Washington correspondent Julie Rovner discussed kindergarten vaccination rates on WNYC’s The Brian Lehrer Show on Aug. 25.

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³Ô¹Ï²»´òìÈ contributor Mark Kreidler discussed the use of artificial intelligence for Medicaid reenrollment on KVPR’s Central Valley Daily on Aug. 24.

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• Read Kreidler’s “AI Is Being Used To Boost Medicaid Enrollment, but Not Without Concerns.”

³Ô¹Ï²»´òìÈ senior correspondent Julie Appleby discussed the state of the Affordable Care Act on Vox’s Today, Explained podcast on Aug. 24.

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³Ô¹Ï²»´òìÈ Georgia correspondent Briah Lumpkins discussed the importance of healthcare policy in upcoming elections on WUGA’s The Georgia Health Report on Aug. 21.

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This article first appeared on ³Ô¹Ï²»´òìÈ and is republished here under a .