Connect with us

Kaiser Health News

An Arm and a Leg: Meet the Middleman’s Middleman

Published

on

Dan Weissmann
Tue, 25 Jun 2024 09:00:00 +0000

Some people who expected their health insurance to cover some out-of-network care have been getting stuck with enormous bills.

One Kansas City, Kansas, couple paid thousands of dollars out-of-pocket and up-front for care. They expected to get a partial reimbursement from their insurer. So, they were shocked when instead they got a bill saying they owed even more than what they’d already paid.

It turns out, a little-known data firm called MultiPlan was working with their insurance company to suggest cuts to their coverage. MulitPlan says it’s helping control ballooning health care costs by keeping hospitals and providers from overbilling. But it’s often patients left paying the difference.In this episode of “An Arm and a Leg,” host Dan Weissmann breaks down this confusing world of out-of-network care with New York Times reporter Chris Hamby, who recently published an investigation into MultiPlan.

Dan Weissmann


@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

Credits

Emily Pisacreta
Producer

Claire Davenport
Producer

Adam Raymonda
Audio wizard

Ellen Weiss
Editor

Click to open the Transcript

Transcript: Meet the Middleman’s Middleman

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there! Paul and Kristin live in Kansas City with their two kids. Kristin and their daughter, the older kid– they have some complex medical issues, need to see some specialized folks. And some of those folks don’t take Kristin and Paul’s insurance. They’re “out of network,” so Kristin and Paul pay out of pocket– a lot. Maybe $20,000 a year. BUT their health insurance plan does reimburse some out-of-network care. 

o, in January 2023, Kristin called a help line connected with the insurance plan to find out how that was gonna work. 

Kristin H: They basically said, sure, easy peasy, you pay and then you get online and you click this form, you show what you paid, and then we send you a check and reimburse you. 

Dan: Kristin was on it. She built a whole spreadsheet to track every bill she paid, every reimbursement form she’d submitted. And she waited for the checks. The insurance company gave itself months just to process the claims. And when they finally sent statements, the statements seemed … weird. They were like: 

Kristin H: Here’s what you paid, and here’s your discounts, and here’s what you may owe. 

Dan: And Kristin was like … what? 

Kristin H: Because I was thinking, well, I don’t owe anything. We paid out of pocket, but then I was thinking, well, this must be the portion that they’re paying us back. But then the math didn’t add up. 

Dan: Yeah. Not at all. Kristin was expecting to get 50 percent back, like her plan said she would. But this amount wasn’t anything like 50 percent. And what’s this “discount” business? 

It took months– and a lot of digging from Paul, and ultimately a talk with a NewYork Times reporter– before Kristin and Paul understood what was going on, and why it was costing them thousands of dollars. 

What they didn’t know until that New York Times story came out was: Someone was making a multi-billion dollar business out of experiences like theirs. As that story made clear, LOTS of people who expected their insurance to cover them for expensive out-of-network care ended up on the hook for a lot more than they’d expected. 

That story introduced readers to a character who’s become kind of a TYPE on this show. Not a type of person, but a type of business: A middleman that works behind the scenes with insurance companies. So we’ve seen that dynamic with pharmacy benefit managers– the folks who decide what drugs you can get and for how much– and more recently, we looked at a company that uses an algorithm to justify kicking folks out of nursing homes. The middleman in this New York Times story was a company called MultiPlan. 

Reporter Chris Hamby found MultiPlan and insurance companies they worked with were leaving patients on the hook for huge amounts that they absolutely had not expected to pay. MultiPlan was also, along with those insurance companies, pocketing big fees. That story got some folks’ attention. A U.S. Senator has called for action from antitrust regulators. Those regulators might get interested. And we may wanna egg them on– so we’re gonna need to understand the whole scheme. Whothis middleman is– MultiPlan– and how they got themselves in the middle of 60 million people’s health insurance, by their own estimate … and how they make a lot of money. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge. So, our job on this show is to take one of the most enraging, terrifying, depressing parts of American life– and bring you a show that’s entertaining, empowering, and useful. 

And this time, I’ve got help. 

Chris Hamby: My name is Chris Hamby. I’m a reporter on the investigations desk at the New York Times. 

Dan: Yeah, and of course, Chris is the one who spent months figuring out the story of this middleman company, MultiPlan. 

Chris Hamby: I was poking around a number of areas related to health insurance, and this name just kept coming up. 

Dan: Like in lawsuits. 

Chris Hamby: And it wasn’t always terribly clear what they did exactly or how they were compensated. 

Dan: Or how doctors and patients– regular people– were affected. 

Chris Hamby: So that’s why I decided to try and figure this out, and it’s sort of an opaque space as so many areas of health care are these days. 

Dan: Yeah. In fact, in order to understand this story at all– to understand who’s doing WELL in this scenario– we’ve gotta peel back a layer. It’s something we’ve talked about here before, but not for a while, and you know, not even my mom remembers everything I’ve ever said here. 

This is about the mechanics of how most health insurance people get from their job actually works: about who actually pays medical bills when your insurance settles a claim. It’s not the insurance company. It’s actually the employer paying those bills. 

Of course, employers don’t know how to actually RUN an insurance plan. [Unless the employer is Aetna, I guess]. So they hire insurance companies to administer them. You get a card that says Cigna or Blue Cross, but your employer’s funds actually pay the medical bills, so these are called “self-funded” plans. But this is all stuff most of us are just not aware of. 

Here’s Chris Hamby: 

Chris Hamby: I hadn’t, until about a year ago, even heard of a self-funded plan. And I like to think that I’m reasonably well informed on this stuff. 

Dan: Yeah, that is putting it mildly. Chris made his name and won a Pulitzer Prize covering workplace health issues. So, just park that for a minute: self-funded plan, where the employer is the “self,” actually paying the bills, and paying the insurance company a fee. The insurance company is a middleman. 

OK, now, next layer: The middleman’s middleman. In this case, the company MultiPlan that Chris wrote about. What’s their job? So in this story, the job they’re doing– their middleman job– is to address what is admittedly kind of a tough question: If you go see somebody– a doctor, a therapist– who doesn’t take your insurance, what happens? 

Chris Hamby: How do you determine what a fair amount to pay the provider is? And by extension, how much is the patient potentially on the hook for the unpaid balance? And that has long been a contentious issue. 

Dan: Because, if they don’t take your insurance, a provider could charge … absolutely anything. So is your insurer– and again, that’s often actually your employer– supposed to pay absolutely anything? How much are they supposed to pay? Figuring that out, it’s a job. 

About 15 years ago, another middleman company doing that job got sued by the NewYork state attorney general. The state said this earlier middleman’s way of figuring out what to pay was screwing over both providers and patients. And the state’s lawsuit produced a solution. 

Chris Hamby: The insurance companies agreed to fund the creation of a nonprofit entity that was going be sort of an independent, neutral arbiter of fair prices. It was going to collect data from all the insurers and just make it publicly available. Make sure it was transparent to everyone. 

Dan: This nonprofit is called FAIR Health, and its data is actually public. It still exists. Like, you can use it yourself — you can look up the going rate for a knee replacement, a blood test, whatever. 

Chris Hamby: You can plug in your zip code, plug in your medical procedure and see an estimate of what, you know, typical out-of-network charges and in-network charges would be for these. 

Dan: It’s cool! Check it out yourself; it’s useful. And all the major insurance companies agreed to use it– to use FAIR Health’s benchmarks– to decide what to pay for out-of-network stuff. But, those agreements only committed insurance companies to using FAIR Health for … five years. They expired in 2014. 

Enter middleman companies like MultiPlan, saying to insurance companies: Hey, you COULD use FAIR Health– or you could route out-of-network bills to us: Hire us to get you an even better deal– better prices. 

Chris Hamby: And it’s important to note also that this is a time when private equity is investing in healthcare, and there are some legitimate concerns about driving up those list prices to ridiculously high levels in a lot of cases. So, there were real issues that insurers were saying that they were responding to at the time.

Dan: OK, so that’s the pitch. MultiPlan is saying to insurance companies: We’ll help you hold the line. We can save you more money than if you used FAIR Health. Well, kind of. Because here’s where we come back to the whole thing about self-funded insurance. MultiPlan isn’t saying, “We can save YOU, insurance company, more money than if you used FAIR Health.” They’re saying, “We can help you save your CLIENTS– employers who do self-funded health insurance– more money. And when you save them money, you’re gonna make money. Because you can charge them a percentage of what you’re saving them. And we’ll get a percentage too.” A percentage of the savings. On every single bill. That’s a very different deal than just using FAIR Health’s data. 

Chris Hamby: FAIR Health is not taking a percentage of the savings that they obtain. They’re just selling you their data. And the insurers typically are not charging employers a fee for using FAIR Health’s data. But if they use MultiPlan’s data, both MultiPlan and the insurer typically charge a fee. 

Dan: A percentage. In examples from Chris’s story, the insurance company gets 35 percent of those savings. 

Chris Hamby: And this has become a significant amount of money for a lot of insurance companies. Overall, UnitedHealthcare, is up to, you know, around a billion dollars per year in recent years. 

Dan: UnitedHealthcare collects like a billion dollars in fees for these services, basically, for using MultiPlan specifically? 

Chris Hamby: And they couch that by saying some other out-of-network savings programs, but yes. 

Dan: Whooh! 

Chris Hamby: One thing that the insurers say is that the employers are aware of this; they’ve signed up for it. 

Dan: That employers are hiring, say, Cigna, with MultiPlan to find savings. And employers are agreeing to the fees. 

Chris Hamby: Where it gets a little bit dicier from the employer’s perspective is when you see claims where, for instance, you end up paying the insurance company more in fees than you paid the doctor for treating your employee. 

Dan: yeah, one example from Chris’s story: An out-of-network provider wanted more than $150,000 on one bill. And after the insurance company and MultiPlan did their bit, the employer, a trucking company, ended up paying $58,000. Eight thousand for the provider, and $50,000 to the insurance company and MultiPlan. So, on the one hand, the employer maybe saved $90,000. But paying $50,000 for “cost containment?” Maybe doesn’t sound like such a bargain. 

Some employers and a union that runs a health plan have filed lawsuits looking for some of that money back. And there’s also a big irony here because MultiPlan’s pitch is, you need us because sticker prices are super-wildly high. But MultiPlan isn’t doing anything to contain the sticker prices as a systemic problem. In fact, the higher providers crank up their sticker prices, the more money MultiPlan and the insurance companies they work with can make. But then there’s a big question too, which is, what happens to the rest of that bill for the sticker price? Who pays that? That’s next … 

This episode of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News. The folks at KFF Health News are amazing journalists. Their work wins all kinds of awards, every year. We’re honored to work with them. 

So, a provider sends a bill. MultiPlan and the insurance company say, “Woah, way too much.” And then what happens? Well, it depends. Sometimes, MultiPlan negotiates with the provider. They’ve got people who do this. And those negotiators drive hard bargains. According to Chris’s story, negotiators sometimes tell providers: Here’s my offer, you’ve got a few hours to take it or leave it, and my next offer might be lower. 

Chris talked with a pediatric therapist who said an offer based on MultiPlan’s calculation was less than half of what Medicaid pays. Less than half. And Medicaid rates– they’re notoriously pretty low. Chris talked with some of MultiPlan’s negotiators too. 

Chris Hamby: It was interesting because some of the negotiators felt that they were doing their part to hold down costs and really sort of stick it to providers and hospitals that were price gouging. 

Dan: But …one told Chris she knew the offers she made– they weren’t fair. “It’s just a game,” another one said. “It’s sad.” And maybe the difference is that some of these negotiators were thinking of a big hospital charging $150,000  for something. And maybe some of them were thinking of someone like that therapist– the one who got offered less than half of Medicaid’s rate. 

And I’m not gonna get into the question of who should be doing this kind of negotiating, or what’s fair. I mean, not today, anyway. Because: in a lot of cases with MultiPlan, there’s no negotiation at all. Negotiation only happens when the employer has told the insurance company, look, protect my people. Figure out SOMETHING with the provider so they don’t go after my workers for the rest. 

But that doesn’t always happen. A lot of the time, what happens is: The provider sends a bill. The insurance company kicks in whatever it decides to … and that’s it. 

So Chris’s story opens with a woman who had surgery. With MultiPlan’s help, her insurance company decided to pay about $5,400. And she got stuck with a bill for more than $100,000. 

And then there’s Kristin and Paul in Kansas City. They paid their bills upfront and then looked to get reimbursed– kept a spreadsheet. But when their claims finally got processed, the numbers didn’t add up. Here’s what they saw: Like pretty much every insurance plan, Kristin and Paul’s had a “deductible”– an amount they had to pay out of pocket before insurance would reimburse anything. 

Kristin H: Then I started watching the deductible and you know, when I calculated my spreadsheet of how much we had paid out of pocket, and when we saw what was on like our out-of-network spend, those two weren’t matching. 

Dan: She really couldn’t figure this out. 

Kristin H: I just kind of handed over all of my spreadsheets to Paul, and so that’s when he started digging into the “your discount.” 

Dan: “Your discount…” That was this mysterious number on all the statements from the insurance company. In addition to the provider’s rate, and what insurance might pay, the statements listed, quote, “your discount.” 

Paul H: And I’m like, what is this? I don’t understand why it’s talking about a discount. We are paying cash out of pocket to the provider at their billed rate, and our insurance is saying that there’s some sort of discount. 

Dan: After a bunch of phone calls, he figured it out: The discount was … the difference between the amount on the bill and what the insurance company– with MultiPlan’s help– had decided was a “fair price.” 

Paul H: For example, an occupational therapy bill that might be $125, this third party adjuster might come back and say, essentially what the market rate for that should be is $76. And so, your discount, quote, unquote, is $49. 

Dan: Except of course, it wasn’t a discount for Kristin and Paul. They had already paid that $49, when they paid the provider upfront. Once Kristin and Paul learned what the “discount” actually meant, they started to understand who actually got the benefit– the insurer. Because … 

Kristin H: That discounted rate is actually what will be applied to your deductible. So you’re not going to hit your deductible nearly as quickly as you think. Right? Because we’ve essentially ignored half of your payment. 

Dan: This hits Kristin and Paul in two ways. 

First, it means they’re actually spending a lot more before their insurance kicks in. It also means that when their insurance does start reimbursing them a percentage of what they’ve spent, the insurance is only paying a percentage of that lower amount. Overall, it means the reimbursements Kristin and Paul get are gonna be thousands of dollars less than they’d expected. 

I mean, it took a LOT of work for Kristin and Paul to figure this out. At one point, Paul posted to Reddit asking for help– that’s where Chris Hamby found him. In Paul’s post, he noted how nobody ever even mentioned this third-party adjuster– not until he had already talked to his insurance company for what he said was “about 18 times.” Frequently on hold for 45 minutes or more. 

Kristin says once they finally figured out what was going on, they could figure out how to budget for it. There were sacrifices. She stopped seeing one of her providers as often. But finally figuring out what was going on also allowed them to live with it. 

Kristin H: The infuriating part was telling, like doing exactly what we were told to do, following the process, and then feeling like you are crazy. Like why, why doesn’t this make sense? You know? And so I think I’m fortunate that Paul just wouldn’t let it die and was gonna research until he figured it out. 

Dan: You did all of the work, you tracked it down, you identified the problem, and you, as you say, kind of resigned yourself to it. You’re like, okay, this Goliath is not– we don’t have the slingshot for this. Goliath is stomping all over our town, and we have to live in that reality. Having the knowledge, having done that work, gives you, it sounds like, an ability to have some peace. Like having tracked it down means that this sucks, but it’s not the same as living in a situation where like, now what? Like anything could happen.

Kristin H: Yeah, you feel crazy or hopeless. You know? Like I’ve done everything and this doesn’t … So there’s just the sense of like, am I missing something? You know, is there anything left for me to do? I recognize that everyone is not like this, but for me, knowledge is a gift. 

Dan: Chris Hamby says there’s rarely a way to get this kind of knowledge in advance. He says you’re unlikely to find these kinds of details in your insurance plan document. 

Chris Hamby: It typically will not say when you go out of network, we’re going to send your claim to a third party that you’ve never heard of to price it. It will just give some sort of vague language about competitive rates in your geographic area. And if you call up in advance of seeking the care to try and get an estimate, most of the time you will not get much more specifics than that. They tell you you have to just go and they’ll process the claim and you’ll see when the explanation of benefits comes through. 

Dan: Yeah, and look, I hate to get you even angrier, but Chris says the rules can change on you, without notice. 

Chris Hamby: A lot of people that I talk with also have seen no change in their insurance plan, but they’ve seen their reimbursement rates decline over time. 

Dan: Turns out, behind the scenes, their insurance made a switch from a service like FAIR Health, which looks at what’s getting paid in general, to a service like MultiPlan, which looks for the steepest possible price cuts. 

Chris Hamby: And the difference between those two amounts can be vast. So you have people who in some cases stop seeing their doctors because their costs doubled almost overnight. 

Dan: Oh god. And still. Better to know. Better that as many of us know as possible. That’s why Chris reviewed more than 50,000 pages of documents, and interviewed more than a hundred people for that story. And why lawyers for the New York Times helped get courts to agree to give him documents that had been under seal. 

Kristin and Paul– who had figured most of this out for themselves– they definitely appreciated all that work. 

Paul H: When Chris published the article that he did, it was very validating to know we’re not the only ones who are in this same boat. And there’s actually people who have had far worse experiences than ours. Like, ours kind of pale in comparison. And then immediately, like, within 24 hours to see 1,500 or 1,600 comments on the article talking about it. It’s like, okay, I might not have the stone that can slay the giant, but maybe The NewYork Times has the right sling and they might have the right stone to at least start the conversation. 

Dan: A few weeks after Chris’s article came out, U.S. Senator Amy Klobuchar sent the top federal antitrust regulators a letter: She wanted them to take a hard look at MultiPlan. 

Chris Hamby: She expressed concern about the potential for price fixing here. 

Dan: Actually, Chris says some providers have already filed lawsuits against MultiPlan based on antitrust allegations. 

Chris Hamby: The idea is that all the insurance companies outsource their pricing decisions to a common vendor. They’re essentially fixing prices via algorithm is the allegation. 

Dan: As we noted here a few episodes ago, these antitrust regulators in the Biden administration have gotten pretty feisty. [That was the episode about the cyberattack on a company called Change Healthcare. It was called “The Hack,” if you missed it. Pretty fun!] 

And I mean, those antitrust regulators have their work cut out for them. And a lot of targets. But I do want to egg them on here. I suspect you do too. Meanwhile, you’re egging US on. 

Listener 1: The first thought that went through my head was I’m going to fight this because this is absolutely ridiculous. I’ve already paid for this. 

Dan: A few weeks ago, we asked you for stories about your experiences with sneaky fees, often called facility fees. 

Listener 2: When the facility fee is twice the office visit fee, it’s just crazy. I mean, it’s a 10-minute appointment for a prescription. 

Dan: You came through, and now we’re making some calls, digging in for more details, and learning so much. We’re gonna have a sneak preview for you in a few weeks. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta and Claire Davenport– our summer intern. Welcome aboard, Claire!– and edited by Ellen Weiss. Adam Raymonda is our audio wizard. Our music is by Dave Weiner and Blue Dot Sessions. Gabrielle Healy is our managing editor for audience. Gabe Bullard is our engagement editor. Bea Bosco is our consulting director of operations. Sarah Ballama is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about healthcare in America and a core program at KFF, an independent source of health policy research, polling and journalism. Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org. Finally, thanks to everybody who supports this show financially. You can join in any time at https://armandalegshow.com/support/

Thanks for pitching in if you can, and thanks for listening.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to its newsletters. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

——————————
By: Dan Weissmann
Title: An Arm and a Leg: Meet the Middleman’s Middleman
Sourced From: kffhealthnews.org/news/podcast/meet-the-middleman-for-middlemen/
Published Date: Tue, 25 Jun 2024 09:00:00 +0000

Kaiser Health News

States Brace for Reversal of Obamacare Coverage Gains Under Trump’s Budget Bill

Published

on

kffhealthnews.org – Julie Appleby, KFF Health News – 2025-07-03 14:43:00


The tax and spending bill pushed by President Trump includes provisions that shorten ACA enrollment periods, increase paperwork, and raise premiums, threatening coverage gains from the Affordable Care Act. Particularly impacted are the 19 states running their own ACA exchanges, where automatic reenrollment would end, potentially causing 30-50% enrollment losses. Combined with the likely expiration of enhanced pandemic premium subsidies, premiums could rise 75% on average next year. Supporters cite fraud reduction, but many analysts warn these changes could push 4-6 million people out of Marketplace plans, increase the uninsured rate, and leave insurers with smaller, sicker pools and higher prices.


Shorter enrollment periods. More paperwork. Higher premiums. The sweeping tax and spending bill pushed by President Donald Trump includes provisions that would not only reshape people’s experience with the Affordable Care Act but, according to some policy analysts, also sharply undermine the gains in health insurance coverage associated with it.

The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges.

Many of those states fear that the additional red tape — especially requirements that would end automatic reenrollment — would have an outsize impact on their policyholders. That’s because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal healthcare.gov marketplace.

“The federal marketplace always had a message of, ‘Come back in and shop,’ while the state-based markets, on average, have a message of, ‘Hey, here’s what you’re going to have next year, here’s what it will cost; if you like it, you don’t have to do anything,’” said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director with the Manatt Health consulting group.

Millions — perhaps up to half of enrollees in some states — may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule from the Trump administration and the likely expiration at year’s end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year. That’s starting to happen already, based on some early state rate requests for next year, which are hitting double digits.

“We estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,” said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees this year, a record.

Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the “One Big Beautiful Bill,” could undo inroads made in the nation’s uninsured rate, which dropped by about half from the time most of the ACA’s provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data.

Premiums would rise along with the uninsured rate, because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage — and are thus less expensive — would not.

After a dramatic all-night session, House Republicans passed the bill, meeting the president’s July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration.

The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round.

In addition, automatic reenrollment, used by more than 10 million people for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently.

That’s a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era’s “lax verification requirements.”

He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers’ being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers.

In testimony to Congress on June 25, Blase wrote that “this simple step will close a massive loophole and significantly reduce improper enrollment and spending.”

States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal healthcare.gov.

The state-run marketplaces credit their additional security measures and tighter control over broker access than healthcare.gov for the relative lack of problems.

“If you look at California and the other states that have expanded their Medicaid programs, you don’t see that kind of fraud problem,” said Jessica Altman, executive director of Covered California, the state’s Obamacare marketplace. “I don’t have a single case of a consumer calling Covered California saying, ‘I was enrolled without consent.’”

Such rollovers are common with other forms of health insurance, such as job-based coverage.

“By requiring everyone to come back in and provide additional information, and the fact that they can’t get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,” said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

Federal data shows about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF.

States do check income and other eligibility information for all enrollees — including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they’ve experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period.

“We have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,” Altman said.

If flagged for mismatched data, applicants are asked for additional information. Under current law, “we have 90 days for them to have a tax credit while they submit paperwork,” Altman said.

That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information.

A white paper written for Capital Policy Analytics, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes.

While “tighter verification can curb improper enrollments,” the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, “would push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,” wrote free market economists Ike Brannon and Anthony LoSasso.

“Insurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,” they wrote.

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

USE OUR CONTENT

This story can be republished for free (details).

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post States Brace for Reversal of Obamacare Coverage Gains Under Trump’s Budget Bill appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content presents a critique of Republican-led changes to the Affordable Care Act, emphasizing potential negative impacts such as increased premiums, reduced enrollment, and the erosion of coverage gains made under the ACA. It highlights the perspective of policy analysts and state officials who express concern over these measures, while also presenting conservative viewpoints, particularly those focusing on fraud reduction. Overall, the tone and framing lean toward protecting the ACA and its expansions, which traditionally aligns with Center-Left media analysis.

Continue Reading

Kaiser Health News

Dual Threats From Trump and GOP Imperil Nursing Homes and Their Foreign-Born Workers

Published

on

kffhealthnews.org – Jordan Rau, KFF Health News – 2025-06-26 04:00:00


In Alexandria, Virginia, Rev. Donald Goodness, 92, is cared for by many foreign-born nurses like Jackline Conteh from Sierra Leone, who vigilantly manages his celiac disease needs. The long-term care industry relies heavily on immigrants, with 28% of direct care workers being foreign-born. However, President Trump’s 2024 immigration crackdown, including rescinded protections and revoked work permits for refugees, threatens staffing levels. Coupled with proposed Medicaid spending cuts, nursing homes face worsening shortages and quality challenges. Many immigrant caregivers fear deportation, risking a crisis in elder care as demand rises with America’s aging population.


In a top-rated nursing home in Alexandria, Virginia, the Rev. Donald Goodness is cared for by nurses and aides from various parts of Africa. One of them, Jackline Conteh, a naturalized citizen and nurse assistant from Sierra Leone, bathes and helps dress him most days and vigilantly intercepts any meal headed his way that contains gluten, as Goodness has celiac disease.

“We are full of people who come from other countries,” Goodness, 92, said about Goodwin House Alexandria’s staff. Without them, the retired Episcopal priest said, “I would be, and my building would be, desolate.”

The long-term health care industry is facing a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.

But in January, the Trump administration rescinded former President Joe Biden’s 2021 policy that protected health care facilities from Immigration and Customs Enforcement raids. The administration’s broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. “People may be here on a green card, and they are afraid ICE is going to show up,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.

Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid. Care for 6 in 10 residents is paid for by Medicaid, the state-federal health program for poor or disabled Americans.

“We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges,” said Eric Roberts, an associate professor of internal medicine at the University of Pennsylvania.

The industry hasn’t recovered from covid-19, which killed more than 200,000 long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors’ offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death has risen alarmingly from 17% in 2015 to 28% in 2024.

In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that would require most of the nation’s nearly 15,000 nursing homes to hire more workers.

The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.

In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency “is committed to supporting a strong, stable long-term care workforce” and “continues to work with states and providers to ensure quality care for older adults and individuals with disabilities.” In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers “need to do that by coming here the legal way” but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.

Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the best-staffed nursing homes in the country. Forty percent of the organization’s 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.

“As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization,” said Rob Liebreich, Goodwin’s president and CEO.

Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. “She was sitting outside,” Conteh, 56, recalled in an interview.

Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn’t afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.

Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.

“Nearly every one of us from Africa, we know how to care for older adults,” she said.

Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.

In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents’ skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called “small houses” and a wing for memory care, at least 72 were born abroad, Hutter said.

Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.

“I have a bad leg and I can’t stand on it very much, or I’d fall over,” he said. “She’s in there at 7:30 in the morning, and she helps me bathe.” Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.

Conteh said Goodness was withdrawn when he first arrived. “He don’t want to come out, he want to eat in his room,” she said. “He don’t want to be with the other people in the dining room, so I start making friends with him.”

She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community’s resident council and enjoys distributing the mail to other residents on his floor.

“The people that work in my building become so important to us,” Goodness said.

While Trump’s 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, including refugees who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security revoked the work permits for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.

“I’ve just spent my morning firing good, honest people because the federal government told us that we had to,” Rachel Blumberg, president of the Toby & Leon Cooperman Sinai Residences of Boca Raton, a Florida retirement community, said in a video posted on LinkedIn. “I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals.”

At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. “They’re scared,” she said. “Nobody trusts anybody.” Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.

“If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?” Conteh asked. “What will become of our old people that we’re taking care of?”

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post Dual Threats From Trump and GOP Imperil Nursing Homes and Their Foreign-Born Workers appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content primarily highlights concerns about the impact of restrictive immigration policies and Medicaid spending cuts proposed by the Trump administration and Republican lawmakers on the long-term care industry. It emphasizes the importance of immigrant workers in healthcare, the challenges that staffing shortages pose to patient care, and the potential negative effects of GOP policy proposals. The tone is critical of these policies while sympathetic toward immigrant workers and advocates for maintaining or increasing government support for healthcare funding. The framing aligns with a center-left perspective, focusing on social welfare, immigrant rights, and concern about the consequences of conservative economic and immigration policies without descending into partisan rhetoric.

Continue Reading

Kaiser Health News

California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch

Published

on

kffhealthnews.org – Sarah Kwon – 2025-06-25 04:00:00


California lawmakers are set to delay the state’s new IVF insurance coverage law, originally effective July 1, to January 2026. Governor Gavin Newsom requested the postponement to resolve coverage details like embryo storage and donor materials. The law mandates large employers’ health plans to cover infertility diagnosis and treatment, including up to three egg retrievals and unlimited embryo transfers, benefiting nine million people, including same-sex couples and single parents. The delay has caused uncertainty and frustration among patients and employers. If not delayed, enforcement begins July 1, but most employers renew contracts in January, delaying coverage start anyway. Lawmakers will vote soon.


California lawmakers are poised to delay the state’s much-ballyhooed new law mandating in vitro fertilization insurance coverage for millions, set to take effect July 1. Gov. Gavin Newsom has asked lawmakers to push the implementation date to January 2026, leaving patients, insurers, and employers in limbo.

The law, SB 729, requires state-regulated health plans offered by large employers to cover infertility diagnosis and treatment, including IVF. Nine million people will qualify for coverage under the law. Advocates have praised the law as “a major win for Californians,” especially in making same-sex couples and aspiring single parents eligible, though cost concerns limited the mandate’s breadth.

People who had been planning fertility care based on the original timeline are now “left in a holding pattern facing more uncertainty, financial strain, and emotional distress,” Alise Powell, a director at Resolve: The National Infertility Association, said in a statement.

During IVF, a patient’s eggs are retrieved, combined with sperm in a lab, and then transferred to a person’s uterus. A single cycle can total around $25,000, out of reach for many. The California law requires insurers to cover up to three egg retrievals and an unlimited number of embryo transfers.

Not everyone’s coverage would be affected by the delay. Even if the law took effect July 1, it wouldn’t require IVF coverage to start until the month an employer’s contract renews with its insurer. Rachel Arrezola, a spokesperson for the California Department of Managed Health Care, said most of the employers subject to the law renew their contracts in January, so their employees would not be affected by a delay.

She declined to provide data on the percentage of eligible contracts that renew in July or later, which would mean those enrollees wouldn’t get IVF coverage until at least a full year from now, in July 2026 or later.

The proposed new implementation date comes amid heightened national attention on fertility coverage. California is now one of 15 states with an IVF mandate, and in February, President Donald Trump signed an executive order seeking policy recommendations to expand IVF access.

It’s the second time Newsom has asked lawmakers to delay the law. When the Democratic governor signed the bill in September, he asked the legislature to consider delaying implementation by six months. The reason, Newsom said then, was to allow time to reconcile differences between the bill and a broader effort by state regulators to include IVF and other fertility services as an essential health benefit, which would require the marketplace and other individual and small-group plans to provide the coverage.

Newsom spokesperson Elana Ross said the state needs more time to provide guidance to insurers on specific services not addressed in the law to ensure adequate and uniform coverage. Arrezola said embryo storage and donor eggs and sperm were examples of services requiring more guidance.

State Sen. Caroline Menjivar, a Democrat who authored the original IVF mandate, acknowledged a delay could frustrate people yearning to expand their families, but requested patience “a little longer so we can roll this out right.”

Sean Tipton, a lobbyist for the American Society for Reproductive Medicine, contended that the few remaining questions on the mandate did not warrant a long delay.

Lawmakers appear poised to advance the delay to a vote by both houses of the legislature, likely before the end of June. If a delay is approved and signed by the governor, the law would immediately be paused. If this does not happen before July 1, Arrezola said, the Department of Managed Health Care would enforce the mandate as it exists. All plans were required to submit compliance filings to the agency by March. Arrezola was unable to explain what would happen to IVF patients whose coverage had already begun if the delay passes after July 1.

The California Association of Health Plans, which opposed the mandate, declined to comment on where implementation efforts stand, although the group agrees that insurers need more guidance, spokesperson Mary Ellen Grant said.

Kaiser Permanente, the state’s largest insurer, has already sent employers information they can provide to their employees about the new benefit, company spokesperson Kathleen Chambers said. She added that eligible members whose plans renew on or after July 1 would have IVF coverage if implementation of the law is not delayed.

Employers and some fertility care providers appear to be grappling over the uncertainty of the law’s start date. Amy Donovan, a lawyer at insurance brokerage and consulting firm Keenan & Associates, said the firm has fielded many questions from employers about the possibility of delay. Reproductive Science Center and Shady Grove Fertility, major clinics serving different areas of California, posted on their websites that the IVF mandate had been delayed until January 2026, which is not yet the case. They did not respond to requests for comment.

Some infertility patients confused over whether and when they will be covered have run out of patience. Ana Rios and her wife, who live in the Central Valley, had been trying to have a baby for six years, dipping into savings for each failed treatment. Although she was “freaking thrilled” to learn about the new law last fall, Rios could not get clarity from her employer or health plan on whether she was eligible for the coverage and when it would go into effect, she said. The couple decided to go to Mexico to pursue cheaper treatment options.

“You think you finally have a helping hand,” Rios said of learning about the law and then, later, the requested delay. “You reach out, and they take it back.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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

USE OUR CONTENT

This story can be republished for free (details).

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

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content is presented in a factual, balanced manner typical of center-left public policy reporting. It focuses on a progressive healthcare issue (mandated IVF insurance coverage) favorably highlighting benefits for diverse family structures and individuals, including same-sex couples and single parents, which often aligns with center-left values. At the same time, it includes perspectives from government officials, industry representatives, opponents, and patients, offering a nuanced view without overt ideological framing or partisan rhetoric. The emphasis on healthcare access, social equity, and patient impact situates the coverage within a center-left orientation.

Continue Reading

Trending