Boxes of the diabetes drug Ozempic rest on a pharmacy counter in Los Angeles. Drugs like Ozempic have grown in popularity to treat obesity, prompting more than a dozen states to pay for them. But with major budget pressures, several state Medicaid agencies are either stopping coverage altogether or restricting who can get access to the therapy. (Photo illustration by Mario Tama/Getty Images)

Some states are rethinking their coverage of GLP-1 drugs for weight loss as budgets tighten and Medicaid programs brace for the cuts included in President Donald Trump’s broad tax and spending law.

As of Oct. 1, 16 state Medicaid programs covered GLP-1s for obesity treatment, up from 13 last year, according to a survey of Medicaid directors by KFF, a health policy research group. But some states have announced they will discontinue coverage or restrict who can qualify for it.

Many doctors and patient advocates say the drugs will save money in the long run by reducing obesity-related diseases such as heart disease and diabetes. Many states, however, have concluded they just can’t afford them.

North Carolina Medicaid ended coverage of GLP-1s for obesity last month, citing shortfalls in state funding. California, New Hampshire and South Carolina have said they will end coverage on Jan. 1. Starting next year, Michigan Medicaid will limit coverage to people who are “morbidly obese.” Pennsylvania, Rhode Island and Wisconsin also are considering new restrictions.

In last year’s KFF survey, about half the states said they were interested in covering GLP-1s for weight loss, according to Elizabeth Williams, a senior policy manager at KFF who focuses on Medicaid. This year, most states are moving in the opposite direction.

“This likely reflects recent state budget challenges and the significant, significant costs associated with coverage,” Williams said. “After a number of years of robust revenue growth right after the pandemic, states are starting to see slowing revenues, increasing spending demands and a lot of fiscal uncertainty due in part to recent federal actions.”

In April, the Trump administration scrapped a Biden-era proposal that would have required state Medicaid programs to pay for some GLP-1s for obesity treatment. Earlier this month, Trump announced that his administration had reached agreements with the manufacturers of Wegovy and Zepbound to reduce the prices of the drugs for Medicaid, Medicare and consumers buying the drugs directly, But it’s unclear whether the deals will reduce costs for states.

Health plans for state workers also are reassessing their coverage of the drugs for obesity. North Carolina, for example, ended GLP-1 obesity coverage for state workers last year, and West Virginia canceled a 1,000-person pilot program.

GLP-1 medications, which balance blood sugar levels, have long been prescribed to patients with Type 2 diabetes and cardiovascular conditions. All state Medicaid programs, which are funded jointly by the states and the federal government, cover GLP-1s for those uses.

But the drugs also curb hunger signals and can help people lose significant amounts of weight. Medications such as Ozempic, Wegovy and Zepbound have become wildly popular for that purpose.

Between 2019 and 2023, the number of outpatient Medicaid prescriptions for select GLP-1s to treat diabetes and obesity grew from 755,300 to 3.8 million, according to KFF. During the same period, Medicaid spending on those drugs increased from $597.3 million to $3.9 billion.

A study published last year in The BMJ, the journal of the British Medical Association, found that the number of patients without diabetes who started GLP-1 treatment in the United States increased from roughly 21,000 in 2019 to 174,000 in 2023, or more than 700%.

More than 2 in 5 U.S. adults have obesity, according to the federal Centers for Disease Control and Prevention. The CDC defines obesity as having a body mass index — a calculated measure of body weight relative to height — of 30 or higher. Obesity costs the U.S. health care system almost $173 billion per year, according to the agency.

Recently, the manufacturers of some GLP-1s have lowered their prices, selling them directly to consumers for $500 or less per month. But many patients cannot afford to pay that much out of pocket.

States in a tough financial position

In North Carolina, Dr. Jennifer McCauley, a weight management physician at UNC Health, said Medicaid coverage of GLP-1s was “incredibly helpful for our patients.”

“Now they’ve stopped coverage, so those people are now going back, regaining some of the weight, because they’re unable to obtain these medications, and also are suffering the health consequences of obesity,” McCauley told Stateline.

Some critics of expansive GLP-1 coverage say it isn’t cost effective, because many patients gain back the weight they lost when they stop treatment. But McCauley said the “downstream effects of obesity are even higher.”

“There are definitely vulnerable populations that probably would not be able to obtain weight loss without these medications.”

James Werner, a spokesperson at the North Carolina Department of Health and Human Services, blamed the coverage change on the state legislature’s failure to budget enough money for Medicaid.

In an email to Stateline, Werner said coverage of GLP1s for weight loss “would be reconsidered if Medicaid is fully funded.”

Some states are trying to maintain at least some coverage of the expensive drugs by tightening the eligibility requirements for a prescription, according to Colleen Becker, a project manager at the National Conference of State Legislatures, a policy research group.

“States are really looking at how to balance access and provide that access to patients, but they’re stewards of their budgets, and they need to be good stewards of it,” Becker said.

Michigan and Pennsylvania are among the states considering such options. Meanwhile, Connecticut has decided to maintain coverage of weight-loss drugs for state employees, but to require beneficiaries to try online weight-loss counseling before they can get a prescription.

Some future possibilities

One state, North Dakota, has taken a different approach to GLP-1 coverage after legislation that would have required the state’s Medicaid program to cover the drug failed. Instead, North Dakota this year became the first state to mandate that insurers on the state’s Affordable Care Act marketplace cover the drugs for weight loss.

North Dakota Deputy Insurance Commissioner John Arnold said the insurance department calculated that the mandate wouldn’t cause insurance premiums to rise significantly.

“It’s not that anybody can walk into the doctor’s office and say, ‘Hey, I want to have this covered,’” Arnold said. “It is really for those who have a medical need for the drugs, then it would be covered.”

The insurance department had to ask the legislature for permission to make the change, according to North Dakota Republican House Speaker Robin Weisz. He said insurance carriers were concerned that it was going to be “open season for everybody who could lose 20 or 30 pounds.”

He said it will take time to see whether the policy raises insurance premiums.

“If the carriers can come in a couple years and say, ‘Wow, here’s what we’ve spent on these … we’ll take a hard look at it,” Weisz said. “But, it’s way too early to tell at this point.”

Arnold says other states may have the flexibility to consider mandating ACA insurers to cover the drugs.

“Our biggest concern was reducing those comorbidities and the long-term impact that that has on the cost of insurance in general, because more comorbidities means more claims,” Arnold said, referring to diseases and conditions associated with obesity.

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

Children are pictured at an Autism Speaks Light it Up Blue Autism Awareness Celebration at Chicago Children's Museum in April 2017. State Medicaid agencies are struggling to pay for applied behavior analysis, an intensive therapy for children with autism. (Photo by Daniel Boczarski/Getty Images for Autism Speaks)

State Medicaid agencies are struggling to pay for an intensive therapy for children with autism — and looming federal Medicaid cuts are likely to make the problem worse.

Parents of children and young adults who receive applied behavior analysis, or ABA, worry states’ cost-saving measures will make it harder for them to get vital services. About 5% of children ages 3 to 17 on public insurance have autism spectrum disorder, compared with 2% who have private insurance, according to a CDC survey.

Many families and autism therapists say ABA can help improve communication and social skills, sharpen memory and focus, and replace challenging behaviors with positive ones. ABA therapy can range from 10 to 40 hours per week in different settings, including home and school. That makes it expensive.

In 2014, the federal Centers for Medicare & Medicaid Services mandated that all state Medicaid programs cover comprehensive autism services for children. It did not explicitly require coverage of ABA, but by 2022, every state Medicaid program covered ABA.

In addition, more kids are getting diagnosed with autism as screenings increase. As a result, state spending on the service has skyrocketed. In Indiana, for example, Medicaid spending on ABA therapy grew from $21 million in 2017 to $611 million in 2023. The sharp increase has prompted Indiana, and other states, to take steps to control costs.

Meanwhile, federal auditors have begun examining states’ coverage of ABA services to ferret out fraud and abuse.

Mariel Fernandez, vice president of government affairs at the Council of Autism Service Providers, a nonprofit trade association, acknowledged that states are facing difficult choices.

“For such a costly and intensive service, the states need to explore how to best reimburse this benefit so that it’s sustainable and promotes quality,” said Fernandez, who is also a board-certified behavioral analyst. “Is [the rate] going to bankrupt Medicaid? Is it going to ensure that people are actually receiving the service?”

The Medicaid changes included in the One Big Beautiful Bill Act that President Donald Trump signed in July will increase the pressure: The law includes more than $900 billion in federal spending cuts over the next decade. Medicaid is funded jointly by the federal government and the states.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. has described autism as a rapidly growing “epidemic” in the U.S. and has made it a major focus of his tenure. Kennedy has promoted the debunked theory that there’s a link between childhood vaccines and autism.

Curbing costs

Several states this year have considered curbing ABA costs by capping therapy hours, tightening provider enrollment rules, reducing reimbursement rates or changing patient eligibility rules. A bill in New York, for example, would establish a 680-hour annual cap on ABA services.

But nowhere has the issue been more prominent than in Indiana, where Medicaid has covered ABA therapy since 2016.

Governor’s group recommends ABA usage cap, rate changes as Medicaid costs rise

Historically, Indiana Medicaid has reimbursed ABA providers for most services at a rate of 40%, regardless of what they charged.

That “created some very strange incentives for a small portion of the provider network,” said Jason McManus, president of Indiana Providers of Effective Autism Treatment (InPEAT), which represents smaller ABA providers in Indiana and larger providers that operate in Indiana and elsewhere. “You had folks who were charging exorbitant amounts for the service.”

Beginning in 2024, Indiana lowered its reimbursement rate to about $68 per hour — and received plenty of pushback.

“That did have an impact on the provider community,” McManus said. “You had a lot of folks, smaller shops, who ended up closing their doors or consolidating with other organizations. So that was disruptive.”

And that year, the HHS inspector general issued a report which found that Indiana’s Medicaid program made at least $56 million in “improper” payments to ABA therapy providers in 2019 and 2020.

The state’s rapidly rising ABA costs and the federal audit prompted Republican Gov. Mike Braun to issue an executive order earlier this year creating a working group to examine ways to cut costs without compromising quality.

The group crafted recommendations to correct the problems identified in the federal audit and put ABA coverage on a financially sustainable path. Without changes in the state’s reimbursement policies, the group concluded, Indiana’s Medicaid spending on ABA therapy would reach a projected $825 million by 2029.

This month, Braun unveiled the group’s recommendations, which include the creation of a new ABA office to increase oversight and lower reimbursement rates, which the state has not yet detailed.

ABA allows people with autism “to obtain the highest level of independence that’s possible for them,” said McManus, who served on the working group.

“But from a state perspective, I can see how, if you’re purely just looking at the cost, you would say, ‘Wow, this is a cost that has grown over time, and if absent all other contexts, this is something we need to pay attention to, because it’s unsustainable.’”

Nebraska rate cut

In Nebraska, state officials also have been looking for ways to control spiraling ABA costs: Last year, Nebraska Medicaid paid out more than $85 million for ABA therapy, a surge from $4.6 million in 2020.

In July, the state announced that it would cut its Medicaid reimbursement rates for ABA, including a 48% cut to reimbursement for direct therapy provided by a behavior technician. That brought the rate to $74.80 per hour, down from about $144 per hour. Rates for therapy by physicians or other board-certified professionals also were reduced by about 37%.

Many providers saw the cuts coming, as the state has had the highest hourly reimbursement rate in the nation.

“It would be fiscally irresponsible of the state to maintain that,” said Leila Allen, vice president of external affairs at Lighthouse Autism Center, which has ABA therapy centers in Nebraska as well as in Illinois, Indiana, Iowa, Michigan and North Carolina.

Sam Wallach, president of Attain, an ABA therapy provider that operates in Nebraska and a dozen other states and Washington, D.C., said the service is “life-changing for children and families.” He views the ABA reduction as a “correction” that will make it feasible for Nebraska Medicaid to continue to cover it.

“The previous rates were well above what most Medicaid programs pay nationally, and while that created short-term benefits, it wasn’t realistic or sustainable,” Wallach said.

But some providers are taking issue with the way Nebraska went about those cuts.

For example, the state provided only 30 days’ notice before making the change. “There were providers that within 30 days had to tell their staff, ‘We’re so sorry. We have to cut your salary by ‘x’ percent in 30 days,’” Allen said.

Nebraska also didn’t examine how much it costs to provide ABA in the state, she said. The new rate is closer to what neighboring states, such as Iowa, pay. But therapists are few and far between in sparsely populated Nebraska, and families there often have to travel long distances to reach ABA providers.

“There was no cost survey to determine what the cost should be,” said Allen. “They didn’t take into account that you do have to pay people a little bit more to be able to work as behavior analysts in Nebraska.”

Finding ABA therapists in Nebraska is particularly difficult for families with older kids. Angela Gleason, executive secretary on the board of autism advocacy organization Arc of Nebraska, has a 13-year-old son with autism. She said many companies only serve very young children, up to age 6.

“So for families like mine, it’s then hard to even find a company that will serve his age and will provide that kind of support,” she said. To be able to afford therapy, her son Teddy has Medicaid coverage as his secondary insurance. ABA therapy helps him with socializing and speaking with his speech delay.

“He needs a lot more help throughout his day than a normal 13-year-old without autism might need,” Gleason said.

North Carolina court case

In North Carolina, the cost of covering autism services, including ABA, will total an estimated $639 million in fiscal 2026, up 425% from 2022, according to the state’s Medicaid agency. About five autism providers made up roughly 41% of the state’s increase in spending in fiscal year 2023-2024, according to the state.

Effective on Oct. 1, North Carolina Medicaid cut reimbursement rates for all kinds of health care services, arguing that state legislators had not budgeted enough money to keep up with rising costs. The reductions, which ranged from 3% to 10%, included a 10% cut to the reimbursement rate for autism services, including ABA therapy.

But the families of 21 children immediately sued the state Department of Health and Human Services to halt the move, arguing that it was discriminatory because it targeted children with disabilities.

Earlier this month, the families won a preliminary injunction temporarily halting the rate cut.

But families across the state are on edge as children with autism often see multiple providers — psychologists and speech language pathologists, for example — whose rate cuts were not paused, according to Allen, of Lighthouse Autism Center.

David Laxton, director of communications for the Autism Society of North Carolina, which is also a provider, said many providers won’t be able to absorb the rate reductions and continue operating.

“At some point, the math is not going to math,” Laxton said.

“It’s very stressful for families, because right now, there’s not an end in sight,” Laxton said. “There’s agreement that this [service] is very important, but there’s not been action to bring an end to the cuts.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

In early November, the South Carolina Department of Public Health opened a pop-up mobile vaccine clinic in a library parking lot in Boiling Springs. Dozens of people in South Carolina’s Upstate region have been diagnosed with measles this fall. (Photo by Lauren Sausser/KFF Health News)

This article first appeared on KFF Health News.

BOILING SPRINGS, S.C. — Near the back corner of the local library’s parking lot, largely out of view from the main road, the South Carolina Department of Public Health opened a pop-up clinic in early November, offering free measles vaccines to adults and children.

Spartanburg County, in South Carolina’s Upstate region, has been fighting a measles outbreak since early October, with more than 50 cases identified. Health officials have encouraged people who are unvaccinated to get a shot by visiting its mobile vaccine clinic at any of its several stops throughout the county.

But on a Monday afternoon in Boiling Springs, only one person showed up.

“It’s progress. That progress is slow,” Linda Bell, the state epidemiologist with the Department of Public Health, said during a recent press briefing. “We had hoped to see a more robust uptake than that in our mobile health units.”

As South Carolina tries to contain its measles outbreak, public health officials across the nation are concerned that the highly contagious virus is making a major comeback. The federal Centers for Disease Control and Prevention has tallied more than 1,700 measles cases and 45 outbreaks in 2025. The largest started in Texas, where hundreds of people were infected and two children died.

For the first time in more than two decades, the United States is poised to lose its measles elimination status, a designation indicating that outbreaks are rare and rapidly contained.

South Carolina’s measles outbreak isn’t yet as large as those in other states, such as New Mexico, Arizona and Kansas. But it shows how a confluence of larger national trends — including historically low vaccination rates, skepticism fueled by the pandemic, misinformation and “health freedom” ideologies promoted by conservative politicians — have put some communities at risk for the reemergence of a preventable, potentially deadly virus.

“Everyone talks about it being the canary in the coal mine because it’s the most contagious infectious disease out there,” said Josh Michaud, associate director for global and public health policy at KFF, a health information nonprofit that includes KFF Health News. “The logic is indisputable that we’re likely to see more outbreaks.”

Schools and ‘small brush fires’

Spartanburg’s vaccination rate is among the lowest of South Carolina’s 46 counties. And that was true “even before COVID,” said Chris Lombardozzi, a senior vice president with the Spartanburg Regional Healthcare System.

Nearly 6,000 children in Spartanburg County schools last year — 10% of the total enrollment — either received an exemption allowing them to forgo required vaccinations or did not meet vaccine requirements, according to data published by the state.

Lombardozzi said the county’s low vaccination rate is tied to misinformation not only published on social media but also spread by “a variety of nonmedical leaders over the years.”

The pandemic made things worse. Michaud said that fear and misinformation surrounding COVID-19 vaccines “threw gasoline on the fire of people’s vaccine skepticism.” In some cases, that skepticism transferred to childhood vaccines, which historically have been less controversial, he said.

This made communities like Spartanburg County with low vaccination rates more vulnerable. “Which is why we’re seeing constant, small brush fires of measles outbreaks,” Michaud said.

In Spartanburg, the overall percentage of students with required immunizations fell from 95.1% to 90% between the 2020-21 and 2024-25 academic years. Public health officials say a minimum of 95% is required to prevent significant spread of measles.

Children who attend public and private schools in South Carolina are required to show that they’ve received some vaccinations, including the measles, mumps and rubella vaccine, but religious exemptions are relatively easy to obtain. The exemption form must be notarized, but it does not require a doctor’s note or any disclosure about the family’s religious beliefs.

The number of students in South Carolina who have been granted religious exemptions has increased dramatically over the past decade. That’s particularly true in the Upstate region, where religious exemptions have increased sixfold from a decade ago. During the 2013-14 school year, 2,044 students in the Upstate were granted a religious exemption to the vaccine requirements, according to data published by The Post and Courier. By fall 2024, that number had jumped to more than 13,000.

Some schools are more exposed than others. The beginning of the South Carolina outbreak was largely linked to one public charter school, Global Academy of South Carolina, where only 17% of the 605 students enrolled during the 2024-25 school year provided documentation showing they had received their required vaccinations, according to data published by the Department of Public Health.

No one from Global Academy responded to interview requests.

‘Health freedom’

In April, after visiting a Texas family whose daughter had died from measles, U.S. Health and Human Services Secretary Robert F. Kennedy Jr. wrote on social media that the “most effective way to prevent the spread of measles is the MMR vaccine.” He made a similar statement during an interview on “Dr. Phil” later that month.

But these endorsements stand at odds with other statements Kennedy has made that cast doubt on vaccine safety and have falsely linked vaccines with autism. The CDC, under his authority, now claims such links “have been ignored by health authorities.”

“What would I do if I could go back in time and I could avoid giving my children the vaccines that I gave them?” he said on a podcast in 2020. “I would do anything for that. I would pay anything to be able to do that.”

Throughout 2025, he has made other misleading or unsupported statements. During a congressional hearing in September, Kennedy defended his past claims that he was not anti-vaccine but affirmed his stated position that no vaccines are safe or effective.

Emily Hilliard, a spokesperson for the Department of Health and Human Services, told KFF Health News that Kennedy is “pro-safety, pro-transparency and pro-accountability.” Hilliard said HHS is working with “state and local partners in South Carolina” and in other states to provide support during the measles outbreaks.

Meanwhile, Kennedy has frequently championed the idea of health freedom, or freedom of choice, regarding vaccines, a talking point that has taken root among Republicans.

That has had a “chilling effect all the way down through state and local lawmakers,” Michaud said, making some leaders hesitant to talk about the threat that the ongoing measles outbreaks poses or the effectiveness and safety of the MMR vaccine.

Brandon Charochak, a spokesperson for South Carolina Gov. Henry McMaster, said the governor was not available to be interviewed for this article but referenced McMaster’s comment from October that measles “is a dangerous disease, but in terms of diseases, it’s not one that we should panic about.”

On a separate occasion that month, the Republican governor said he does not support vaccine mandates. “We’re not going to have mandates,” he said, “and I think we are responding properly.”

Even though the South Carolina Department of Public Health has repeatedly encouraged measles vaccines, the push has been notably quieter than the agency’s COVID-19 vaccine outreach efforts.

In 2021, for example, the agency partnered with breweries throughout the state for a campaign called “Shot and a Chaser,” which rewarded people who got a COVID-19 vaccine with a free beer or soda. By contrast, the pop-up measles vaccine clinic at the Boiling Springs Library featured no flashy signage, no freebies, and wasn’t visible from the library’s main entrance.

Edward Simmer, interim director of the Department of Public Health, would not speak to KFF Health News about the measles outbreak. During a legislative hearing in April, Republican state lawmakers voted against his permanent confirmation because of his past support for COVID-19 vaccines and masking. One lawmaker specifically criticized the agency during that hearing for the Shot and a Chaser campaign.

Public health officials in other states also have been blocked from new roles because of their COVID-19 response. In Missouri, where MMR vaccine rates have declined among kindergartners since 2020 and measles cases have been reported this year, Republican lawmakers rejected a public health director in 2022 after vaccine opponents protested his appointment.

In South Carolina, Simmer, lacking lawmakers’ confirmation, leads the public health agency in an interim capacity.

South Carolina Sen. Tom Davis of Beaufort was the only Republican on the Senate Medical Affairs Committee who voted to confirm Simmer in April. He told KFF Health News that his Republican colleagues raised valid questions about Simmer’s past support for COVID-19 vaccines.

But, Davis said, it would be “tremendously unfortunate and not beneficial from a public health perspective” if the Republican Party just took a stance against vaccines “as a matter of policy.”

The Department of Public Health had administered 44 doses of the MMR vaccine through its mobile health unit from October to mid-November. The last mobile vaccine clinic was scheduled for Nov. 24. But health officials are encouraged that patients are seeking vaccines elsewhere. The agency’s tracking system shows that providers across Spartanburg County administered more than twice as many measles vaccines in October as they did a year ago.

As of mid-November, more than 130 people remained in quarantine, most of them students at local elementary and middle schools. Cases have also been linked to a church and Greenville-Spartanburg International Airport.

“We’re reminding people that travel for the upcoming holidays increases the risk of exposures greatly,” said Bell, the state epidemiologist. “Due to that risk, we’re encouraging people to consider getting vaccinated now.”

KFF Health News correspondent Amy Maxmen contributed to this report. 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.

A medical worker pushes a stretcher through a hallway at Mount Sinai Hospital in New York City. States are passing laws to target private equity transactions of health care facilities, such as hospitals. (Photo by Spencer Platt/Getty Images)

As more private equity firms buy health care physician practices and facilities, states are pushing back on acquisitions that some critics say could potentially gut health care infrastructure. 

This year alone at least seven states, including California, Indiana, Massachusetts, Maine, New Mexico, Oregon and Washington, have enacted laws requiring more oversight over private equity acquisitions in health care. Private equity involves pooling resources from pension funds, endowments, sovereign wealth funds and wealthy individuals to buy controlling stakes in companies and boost their value — often with the goal of selling at a profit within a few years.

Private equity firms argue that their role in upgrading technology and increasing efficiency helps health care access, especially in rural and other underserved areas.

Private equity interest in health care has been around for a while, but really started to grow in the past decade, said John McDonough, a professor of public health practice at the Harvard T.H. Chan School of Public Health. Now there are private equity interests “in every imaginable iteration of medical care,” from hospitals to nursing homes, hospice care, physician practices and even veterinary care, he said. 

This year, several states have passed laws to increase oversight and transparency of private equity’s continuing acquisitions. 

Massachusetts and California enacted laws requiring more groups that were not included under previous reporting requirements, such as private equity firms, real estate investment trusts and management service organizations, to now notify the state if they make a health care acquisition and to give the attorney general more power to investigate the transactions. Indiana passed a law that gives the attorney general authority to investigate market concentration. 

Oregon passed an oversight law that not only limits how much private equity firms can buy up a health care market, but also bars private equity firms from having any control over clinical operations. The law also gives the state power to block any pending transitions that violate the law. California also enacted another law that prohibits private investors from interfering with the judgment of physicians and dentists. 

New Mexico passed a law that strengthened its 2024 Health Care Consolidation Oversight Act, which temporarily gave the state regulators more oversight over transactions. The new law makes that oversight authority permanent and more expansive, while also establishing penalties for non-compliance with reporting requirements. And Washington state passed a transparency law creating a registry of all health care entities. 

Maine passed a law to impose a one-year moratorium on all private equity or real estate investment trust purchases of hospitals. 

“The purpose of the dealmaking is to enrich the owners as quickly as possible, and then get out and move on to your next conquest,” McDonough said. “And so there’s a fundamental conflict there between duty to patients as a primary obligation and return on profits to shareholders.” 

According to researchers from the University of California, Berkeley, the number of acquisitions of physician practices rose from 816 in 2012, to 5,779 in 2021. Researchers also found that some single private equity firms captured 30-50% of specialty practices in local markets.

With limited congressional oversight on private equity actions in health care, states play a critical role in reining in predatory practices, said Michael Fenne, senior policy coordinator at the Private Equity Stakeholder Project, a watchdog group that monitors private equity activity.

“There’s not really federal law that targets private equity acquisitions in the same way [as laws] that states have been passing recently,” he said. 

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

As states continue to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills. (Photo by Anna Claire Vollers/Stateline)

As states strive to curb health insurers’ use of artificial intelligence, patients and doctors are arming themselves with AI tools to fight claims denials, prior authorizations and soaring medical bills.

Several businesses and nonprofits have launched AI-powered tools to help patients get their insurance claims paid and navigate byzantine medical bills, creating a robotic tug-of-war over who gets care and who foots the bill for it.

Sheer Health, a three-year-old company that helps patients and providers navigate health insurance and billing, now has an app that allows consumers to connect their health insurance account, upload medical bills and claims, and ask questions about deductibles, copays and covered benefits.

“You would think there would be some sort of technology that could explain in real English why I’m getting a bill for $1,500,” said cofounder Jeff Witten. The program uses both AI and humans to provide the answers for free, he said. Patients who want extra support in challenging a denied claim or dealing with out-of-network reimbursements can pay Sheer Health to handle those for them.

In North Carolina, the nonprofit Counterforce Health designed an AI assistant to help patients appeal their denied health insurance claims and fight large medical bills. The free service uses AI models to analyze a patient’s denial letter, then look through the patient’s policy and outside medical research to draft a customized appeal letter.

Other consumer-focused services use AI to catch billing errors or parse medical jargon. Some patients are even turning to AI chatbots like Grok for help.

A quarter of adults under age 30 said they used an AI chatbot at least once a month for health information or advice, according to a poll the health care research nonprofit KFF published in August 2024. But most adults said they were not confident that the health information is accurate.

State legislators on both sides of the aisle, meanwhile, are scrambling to keep pace, passing new regulations that govern how insurers, physicians and others use AI in health care. Already this year, more than a dozen states have passed laws regulating AI in health care, according to Manatt, a consulting firm.

“It doesn’t feel like a satisfying outcome to just have two robots argue back and forth over whether a patient should access a particular type of care,” said Carmel Shachar, assistant clinical professor of law and the faculty director of the Health Law and Policy Clinic at Harvard Law School.

“We don’t want to get on an AI-enabled treadmill that just speeds up.”

A black box

Health care can feel like a black box. If your doctor says you need surgery, for example, the cost depends on a dizzying number of factors, including your health insurance provider, your specific health plan, its copayment requirements, your deductible, where you live, the facility where the surgery will be performed, whether that facility and your doctor are in-network and your specific diagnosis.

Some insurers may require prior authorization before a surgery is approved. That can entail extensive medical documentation. After a surgery, the resulting bill can be difficult to parse.

Witten, of Sheer Health, said his company has seen thousands of instances of patients whose doctors recommend a certain procedure, like surgery, and then a few days before the surgery the patient learns insurance didn’t approve it.

In recent years, as more health insurance companies have turned to AI to automate claims processing and prior authorizations, the share of denied claims has risen. This year, 41% of physicians and other providers said their claims are denied more than 10% of the time, up from 30% of providers who said that three years ago, according to a September report from credit reporting company Experian.

Insurers on Affordable Care Act marketplaces denied nearly 1 in 5 in-network claims in 2023, up from 17% in 2021, and more than a third of out-of-network claims, according to the most recently available data from KFF.

Insurance giant UnitedHealth Group has come under fire in the media and from federal lawmakers for using algorithms to systematically deny care to seniors, while Humana and other insurers face lawsuits and regulatory investigations that allege they’ve used sophisticated algorithms to block or deny coverage for medical procedures.

Insurers say AI tools can improve efficiency and reduce costs by automating tasks that can involve analyzing vast amounts of data. And companies say they’re monitoring their AI to identify potential problems. A UnitedHealth representative pointed Stateline to the company’s AI Review Board, a team of clinicians, scientists and other experts that reviews its AI models for accuracy and fairness.

“Health plans are committed to responsibly using artificial intelligence to create a more seamless, real-time customer experience and to make claims management faster and more effective for patients and providers,” a spokesperson for America’s Health Insurance Plans, the national trade group representing health insurers, told Stateline.

But states are stepping up oversight.

Arizona, Maryland, Nebraska and Texas, for example, have banned insurance companies from using AI as the sole decisionmaker in prior authorization or medical necessity denials.

Dr. Arvind Venkat is an emergency room physician in the Pittsburgh area. He’s also a Democratic Pennsylvania state representative and the lead sponsor of a bipartisan bill to regulate the use of AI in health care.

He’s seen new technologies reshape health care during his 25 years in medicine, but AI feels wholly different, he said. It’s an “active player” in people’s care in a way that other technologies haven’t been.

“If we’re able to harness this technology to improve the delivery and efficiency of clinical care, that is a huge win,” said Venkat. But he’s worried about AI use without guardrails.

His legislation would force insurers and health care providers in Pennsylvania to be more transparent about how they use AI; require a human to make the final decision any time AI is used; and mandate that they show evidence of minimizing bias in their use of AI.

“In health care, where it’s so personal and the stakes are so high, we need to make sure we’re mandating in every patient’s case that we’re applying artificial intelligence in a way that looks at the individual patient,” Venkat said.

Patient supervision

Historically, consumers rarely challenge denied claims: A KFF analysis found fewer than 1% of health coverage denials are appealed. And even when they are, patients lose more than half of those appeals.

New consumer-focused AI tools could shift that dynamic by making appeals easier to file and the process easier to understand. But there are limits; without human oversight, experts say, the AI is vulnerable to mistakes.

“It can be difficult for a layperson to understand when AI is doing good work and when it is hallucinating or giving something that isn’t quite accurate,” said Shachar, of Harvard Law School.

For example, an AI tool might draft an appeals letter that a patient thinks looks impressive. But because most patients aren’t medical experts, they may not recognize if the AI misstates medical information, derailing an appeal, she said.

“The challenge is, if the patient is the one driving the process, are they going to be able to properly supervise the AI?” she said.

Earlier this year, Mathew Evins learned just 48 hours before his scheduled back surgery that his insurer wouldn’t cover it. Evins, a 68-year-old public relations executive who lives in Florida, worked with his physician to appeal, but got nowhere. He used an AI chatbot to draft a letter to his insurer, but that failed, too.

On his son’s recommendation, Evins turned to Sheer Health. He said Sheer identified a coding error in his medical records and handled communications with his insurer. The surgery was approved about three weeks later.

“It’s unfortunate that the public health system is so broken that it needs a third party to intervene on the patient’s behalf,” Evins told Stateline. But he’s grateful the technology made it possible to get life-changing surgery.

“AI in and of itself isn’t an answer,” he said. “AI, when used by a professional that understands the issues and ramifications of a particular problem, that’s a different story. Then you’ve got an effective tool.”

Most experts and lawmakers agree a human is needed to keep the robots in check.

AI has made it possible for insurance companies to rapidly assess cases and make decisions about whether to authorize surgeries or cover certain medical care. But that ability to make lightning-fast determinations should be tempered with a human, Venkat said.

“It’s why we need government regulation and why we need to make sure we mandate an individualized assessment with a human decisionmaker.”

Witten said there are situations in which AI works well, such as when it sifts through an insurance policy — which is essentially a contract between the company and the consumer — and connects the dots between the policy’s coverage and a corresponding insurance claim.

But, he said, “there are complicated cases out there AI just can’t resolve.” That’s when a human is needed to review.

“I think there’s a huge opportunity for AI to improve the patient experience and overall provider experience,” Witten said. “Where I worry is when you have insurance companies or other players using AI to completely replace customer support and human interaction.”

Furthermore, a growing body of research has found AI can reinforce bias that’s found elsewhere in medicine, discriminating against women, ethnic and racial minorities, and those with public insurance.

“The conclusions from artificial intelligence can reinforce discriminatory patterns and violate privacy in ways that we have already legislated against,” Venkat said.

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

Group Health Cooperative of South Central Wisconsin's East Side Madison clinic. (Photo by Erik Gunn/Wisconsin Examiner)

Directors of a Madison health care system will consider Thursday whether to change course in the organization’s response to a union organizing campaign.

Supporters of the union campaign at Group Health Cooperative of South Central Wisconsin put five motions before the board of directors at an in-person meeting in October — including one to voluntarily recognize the union, SEIU Wisconsin.

A statement from the co-op management Wednesday did not address whether the board will directly act on any of the motions when it meets.

“The motions are advisory to the Board of Directors concerning its instructions to management about the unionization efforts of our direct care employees,” Group Health stated. “All the Motions will be considered by the Board at the November 20th meeting. The results of those discussions will be communicated to our membership in a future statement.”

Group Health’s response to the union drive, which became public about a year ago, has produced a rift between the co-op’s management and some of its members, who have criticized the organization’s response as a betrayal of its progressive heritage.

“To me it was horrifying to learn that we had people leaving because the conditions were not tolerable,” said Ruth Brill, a Group Health member since 1979 who has supported the union organizing campaign.

According to union supporters, the five motions offered at an Oct. 11 in-person mass meeting to discuss the union organizing campaign passed unanimously. About 170 Group Health members attended that meeting, and union allies said it was the largest turnout in memory for an in-person meeting of co-op members.

Three of the five motions call on the board, the co-op management, or both:

• To report to members how much money Group Health has spent in 2024 and 2025 to pay the law firm Husch Blackwell, which has represented the co-op in connection with the union campaign.
• To voluntarily recognize SEIU Wisconsin as the representative for the professions and departments that the union first sought to represent when workers petitioned the National Labor Relations Board for a union election on Dec. 12, 2024. That motion also demands that Group Health “observe strict neutrality regarding the unionization of any of its workers.”
• To compile a report “of all meeting minutes, emails, and other communications involving Board members, administrators, and/or supervisory employees regarding union activity, from January 2024 to the present.”

The third motion also demands a report on all legal or consulting fees that Group Health has spent related to the union drive, including itemized details.

The fourth motion demands that the board and administration “faithfully follow the democratically expressed will” of the co-op members, charging that the membership has “been denied an opportunity to duly and fully exercise its role” in leading the co-op.

The fifth motion calls for a meeting by mid-January “on the democratization of GHC governance.”

“GHC says members are the most important part of our cooperative and yet the board is not listening to what the members have very clearly stated what they would like to happen,” said Dr. Nisha Rajagopalan, a family practice physician and among the union campaign’s leaders.

“If we are a cooperative that is for our members and our patients, those people showed up in the room and they voted and said exactly what they wanted, and we would like to hear the board uphold that,” said Katie Cloud, a certified medical assistant who has also been active in the union campaign.

Paul Terranova, a Group Health member for 25 years, organized a presentation to the co-op board earlier this year to make the case for unionization in the context of a nonprofit co-op. He later helped organize a slate of candidates for the board in opposition to four incumbent board members. All four of the rival candidates were elected in June.

Terranova said that board members have not communicated directly with Group Health members about the union campaign. Board discussions about the matter have been conducted in closed sessions.

The board’s consideration of the motions is “a really pivotal moment for GHC,” Terranova said, “and how they handle this is going to say a lot about whether this is still a cooperative or if it’s become just a corporate board with cooperative window dressing.”

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The U.S. Capitol building in Washington, D.C., amid fog on Tuesday, Dec. 10, 2024. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — U.S. senators began debating how to reduce health care costs for Americans during a hearing Wednesday, where experts’ varied recommendations and comments from lawmakers previewed the rocky and potentially long path ahead. 

Republicans on the Finance Committee argued the Affordable Care Act, or Obamacare, has led to a spike in health insurance costs for individuals  that shouldn’t be offset by tax credits any longer. 

Democrats urged their colleagues to extend the enhanced subsidies for at least another year to give Congress more time to address larger, more complex issues within the country’s health insurance and health care systems. 

Committee Chairman Mike Crapo, R-Idaho, said the hearing marked “the first step in building the foundation for” health care reform.

“We need both short-term and long-term solutions,” Crapo said. “In the short term, we cannot simply throw good money after bad policy. If we keep advancing a system that drives up premiums, we will make this problem even harder to solve.”

“Instead, we should set the groundwork for giving Americans more control over their health care choices,” Crapo added. “Rather than accepting the current system of giving billions of taxpayer dollars to insurers, we should consider providing financial assistance directly to consumers through health savings accounts, which are now available on the Obamacare exchanges through a provision in the One Big Beautiful Bill.”

Such tax-advantaged accounts are used to save money to pay for medical expenses and generally are used in conjunction with a high-deductible insurance plan, but an HSA “is a trust/custodial account and is not health insurance,” according to the Congressional Research Service.

The ACA, signed into law by President Barack Obama in 2010, overhauled the U.S. health care system with the intent of reducing high rates of uninsured people and ending insurance industry practices such as exclusions based on pre-existing conditions and the sale of policies with high costs and skimpy coverage. The law also expanded Medicaid and, for individual coverage, introduced the health insurance exchanges, or marketplaces, that now are at issue.

According to the health organization KFF, the number of uninsured Americans fell from about 14% to 16% in the years preceding passage of the law to a record low of 7.7% in 2023.

Pessimism about health care action

Oregon Sen. Ron Wyden, the top Democrat on the panel, rebuked Republicans for focusing on other policy areas throughout the year instead of making improvements to health care.

“Sitting on your hands has consequences,” he said. 

Wyden doesn’t see a way for Congress to extend the enhanced tax credits set to expire at the end of the year for people who get their health insurance from the ACA marketplace, despite Democrats pressing for that during the 43-day government shutdown that ended in mid-November. 

Wyden expressed support for working with Republican senators to address health insurance companies’ structure, though he said he is “skeptical” his GOP colleagues will actually approve legislation on that particular issue in the months ahead. 

“Now if they are serious about taking on the crooks that dominate big insurance, like UnitedHealthcare, I’m all in,” Wyden said. “In my view that starts with a laser focus on lower costs for consumers, going after fraud where it truly exists, and cracking down on middlemen.”

‘Very little that this Congress can do’

Douglas Holtz-Eakin, president at the center-right American Action Forum and former chief economist at the Council for Economic Advisers during the President George W. Bush administration, told the committee the structure of the Affordable Care Act poses problems. 

“As a piece of health policy, economic policy and budget policy, the ACA has always been a troubling construct,” Holtz-Eakin said, later adding there is “very little that this Congress can do to change the outlook” for 2026. 

Holtz-Eakin testified that Congress is long “overdue for a real rethinking of health care policy at the federal level” that he believes should focus on two primary areas. 

The first is to “rationalize the insurance subsidies” and the second is to address what he referred to as “high-value care,” which he said should include Medicare, the health program that covers 69 million Americans over 65 and some people with disabilities. 

“Medicare is a great budgetary threat, and so I encourage the committee and the Congress as a whole to take a hard look at that and make some progress toward better health care outcomes and better budgetary outcomes,” Holtz-Eakin said.  

Jason Levitis, senior fellow of the Health Policy Division at the left-leaning Urban Institute and a Treasury employee who led the ACA implementation at the department during the Obama administration, urged lawmakers to address the “too complicated and segmented” health insurance marketplace. 

Levitis said the best short-term option for Congress would be to extend the enhanced tax credits for ACA enrollees during 2026, despite the time crunch. 

“At this point the only feasible option is a clean extension of the existing enhancements,” Levitis said. “The marketplaces have already built that option and have been preparing for months for the possibility of an extension.” 

Former Trump adviser says ACA ‘failed’

Brian Blase, president of the Paragon Health Institute and a former special assistant to President Donald Trump at the White House National Economic Council, said bluntly that the Affordable Care Act has “failed.”

“The law entrenched an inefficient insurance-dominated health sector with massive subsidies flowing straight from the Treasury to health companies,” Blase said. 

The subsidies for ACA marketplace plans, he said, were “ill-designed and inflationary,” urging lawmakers not to extend them for another year.  

“The enrollee share of the premium is capped regardless of the total premium. When enrollees pay only a small slice of the premium or no premium at all, insurers face almost no price discipline,” Blase said. “Insurers can raise premiums knowing the taxpayers will absorb almost all of the increase.”

Blase said he believes the ACA’s regulations on health insurance companies are one of the reasons costs have spiked. 

“For example, under the medical loss ratio, insurers must spend a minimum share of premium revenue on medical claims. In other words, to increase profits, insurers must increase premiums,” Blase said. “The ACA’s essential health benefits require plans to cover the same set of services regardless of what people want or need. These rules increase premiums and wasteful spending.”

The medical loss ratio was included in the ACA in response to insurers who spent “a substantial portion” of premiums on administrative costs and profits, including executive salaries, overhead and marketing, according to the Centers for Medicare and Medicaid Services.

‘We all believe we need to reform’

Senate Majority Leader John Thune, R-S.D., told reporters separately from the hearing the debate over how to restructure health insurance to bring down costs has highlighted the “differences of opinion” among GOP lawmakers. 

“We’ve got a lot of people who have strong views, but the one thing that unites us is we all believe we need to reform, and we’ve got to do something to drive health care costs down,” Thune said. 

GOP leaders, he added, are “looking for solutions that will lower health care premiums, not increase them. And what we see today is just constant inflationary impacts from some of these policies of the past.”

Trump, who would need to support any health care overhaul bill for it to move through Congress, wrote in a social media post Tuesday that he wants lawmakers to send money straight to Americans, without detail on how that would work. 

“THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH,” Trump wrote. “THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! Congress, do not waste your time and energy on anything else. This is the only way to have great Healthcare in America!!! GET IT DONE, NOW. President DJT”

Photo by Getty Images

In an ever-changing world, it’s nice to know that some things stay the same – my annual health insurance premium increase just came through for the 20th year in a row! For 2026, my company’s small-group policy will rise roughly 10%. And believe it or not, in the world of American health care, that’s considered a modest increase.

For my own family — myself, my wife, and our four kids — our health insurance plan costs about $1,800 per month with a $12,000 annual deductible. That is about $34,000 per year. 

If your household earns around $110,000 a year, you’re actually doing extremely well: that puts you in the top 15% of earners in states like Wisconsin.

But even at that income, a $34,000 annual healthcare bill eats up 40% of your post-tax income.

Let’s put that in perspective:

• That $34,000 is almost six times what that same family pays in Medicare taxes — taxes that help cover the oldest, sickest people in the country.
• That $34,000 is more than my family spends on food, mortgage, property taxes, and utilities combined.
• And the gap between what we pay and what we use has become downright comical: I’m at Hy-Vee four times a week, but I haven’t been to a doctor in over three years.

But here’s the bigger problem: When premiums go up 7% per year — again, considered “moderate” — the magic of compound interest turns that into a doubling of price in just a decade.

At only 7% increases, by 2037, a family earning $110,000 will be paying a $45,000 annual premium for a small-group plan. Add a $15,000 deductible, and private insurance would consume 80% of their after-tax take-home pay.

No household, no matter how responsible or hard-working, can withstand that. 

We’ve been promised reform for nearly a decade. Donald Trump began talking about fixing healthcare back in 2016. By 2024, the country still had nothing more than “concepts of a plan.” And temporary patches — tweaked subsidies, tinkering with tax credits, or tossing out $2,000 checks — are not even in the neighborhood of a real solution. 

At the very least, Congress should make sure those price spikes don’t devastate families on Jan. 1, but the fact that those tax credits are needed speaks to out of control costs within the health care system. 

We are out of time for small fixes. The system doesn’t need polishing — it needs structural change. 

What we need is bold leadership and big ideas. And in my view, the fastest, most practical path forward is a public option — Medicare-for-all-who-want-it. Let individuals and small businesses buy into Medicare. If my family could get coverage for anything less than $34,000 a year, that’s an immediate savings! And we’re far from alone. That’s why I’m advocating with other small business owners, including those at the Main Street Alliance, to get it done. 

You can’t solve an economic problem with partisan politics. That’s why Rep. Derrick Van Orden must come to the table to negotiate on health care. He said he would protect rural health care earlier this year, then turned his back on folks on Western Wisconsin and voted for the ‘Big Ugly Law’. The system is broken and we need serious people to address health care in a serious way. The math has already made the case. Now we need you to have the courage to follow it. 

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Health insurance claim form. (krisanapong detraphiphat/Getty Images)

WASHINGTON — Two leading Democrats on a U.S. House panel called on the head of an agency within the U.S. Department of Labor responsible for protecting workers’ benefits to take action to address improper health insurance claim denials, in a Tuesday letter provided exclusively to States Newsroom.  

Reps. Bobby Scott of Virginia and Mark DeSaulnier of California — the respective ranking members of the House Committee on Education and Workforce and its Subcommittee on Health, Employment, Labor, and Pensions — offered three recommendations to Daniel Aronowitz. He is the assistant secretary of the DOL’s Employee Benefits Security Administration, or EBSA. 

“Improper claim denials impose substantial health and financial hardships on individuals, leading to delays in necessary treatments, worsened health outcomes, and high out-of-pocket costs,” Scott and DeSaulnier wrote.

“In far too many tragic cases, denials lead to the unnecessary deaths of people who have earned benefits through their plan, but are nonetheless denied the care that could have saved their lives,” they added. 

Improvements called for in collecting data on denials

As head of EBSA, Aronowitz is responsible for administering, regulating and enforcing Title I of the Employee Retirement Income Security Act, or ERISA, which is intended to protect participants’ and their beneficiaries’ interests when it comes to benefit plans under their employers. 

DOL estimated roughly 136 million participants and beneficiaries were covered by approximately 2.6 million ERISA-covered group health plans in 2022.  

As part of their recommendations, Scott and DeSaulnier called on Aronowitz to “implement long-delayed transparency requirements to collect data on health claim denials by insurance companies and group health plans.”

The two suggested building upon Form 5500, ERISA’s annual reporting requirement, to “improve data collection from group health plans.” 

Staffing at agency, Trump budget cuts cited

Scott and DeSaulnier also urged Aronowitz to “commit to fully enforcing the law and to ensuring that EBSA is adequately staffed to fulfill its mission,” pointing to a decline in more than a fifth of the agency’s staff under President Donald Trump’s administration. 

Trump’s fiscal 2026 budget request for DOL also called for $181 million in funding for EBSA, a $10 million proposed cut from the prior fiscal year. 

The Senate Appropriations Committee passed its annual bill to fund DOL, including EBSA, back in July and maintained funding for the program in fiscal 2026 at $191 million. 

The corresponding panel in the House also approved its bill to fund DOL in September, aligning with the administration’s request of cutting funding for EBSA by $10 million in fiscal 2026. 

The Democrats also recommended Aronowitz take steps to “improve consumers’ ability to appeal wrongfully denied health benefits.” 

They encouraged the assistant secretary to consult the Advisory Council on Employee Welfare and Pension Benefit Plans and to “reverse” DOL’s current posture regarding the council. 

Scott and DeSaulnier noted that DOL took several steps to “undermine” the council, including “delaying public release of its report, purging documents such as testimonies from consumer advocates from the Department’s website, and, to date, failing to convene the Council for any of the four statutorily-mandated meetings.” 

The department did not immediately respond to a request for comment Tuesday. 

Lt. Gov. Sara Rodriguez speaks during a Wisconsin Technology Council forum featuring Democratic and Republican hopefuls in the 2026 governor's race Nov. 6, 2025. (Photo by Baylor Spears/Wisconsin Examiner)

The longest ever federal government shutdown that ended last week revolved around a top issue for Lt. Gov. Sara Rodriguez as she campaigns to be Wisconsin’s next governor: health and health care.

A registered nurse by training and former official at the Centers for Disease Control and Prevention, Rodriguez has been deeply involved in health care policy, first in her single term as a member of the Wisconsin Assembly and then, since 2023, as the No. 2 official in the state’s executive branch.

And, she says, it motivated her to declare her intention to succeed Gov. Tony Evers after Evers decided to stand down from the 2026 election.

“One of the reasons why I wanted to run is to make sure that we have somebody in a leadership position that, No. 1, understands health care, and No. 2, really gets how unaffordable and broken it is,” Rodriguez told the Wisconsin Examiner in an interview Monday.

She also sees a shift in the federal government away from established public health principles, forcing states to take the lead on setting public health standards. In the governor’s office, she said, her professional background would equip her to tackle  those issues.

As  a state representative, Rodriguez proposed a bill in the 2021-22 legislative term to accept the expansion of Medicaid — BadgerCare in Wisconsin — through the Affordable Care Act. Expansion would allow the state to enroll people with incomes between 100% and 138% of the federal poverty guidelines in Medicaid, with the federal government paying 90% of the additional cost.

When the ACA took effect, Gov. Scott Walker was in office and refused throughout his two terms as governor to accept the federal support and expand the program.

Evers defeated Walker in 2018 and promised to accept the federal expansion, but in the lame-duck session before he was sworn in, the Republican majority in the Legislature passed a bill that Walker signed, requiring the Legislature’s approval for expansion.

Since then, repeated attempts by Democrats to expand Medicaid, including the bill Rodriguez authored four years ago, have failed with Republican majorities in both houses of the Legislature.

Another form of Medicaid expansion — covering mothers for a year after they give birth — has the support of bipartisan majorities in the Senate and the Assembly, but Assembly Speaker Robin Vos (R-Rochester) has opposed bringing it to the floor. 

“We are one of two states that have not done that — us and Arkansas,” Rodriguez said. “And I think Arkansas may be working on it. So we may be the only one left at the end of the day.”

Rodriguez’s political career started with her Assembly race in 2020, flipping a Republican seat in the Milwaukee suburbs. She followed that with her race for lieutenant governor in 2022 and now her  campaign for the Democratic nomination to run for governor in 2026.

Throughout her political life, she said, she has been supported by 314 Action, a political organizing group seeking to elect more scientists and people in science-related professions, including health care.

During the recent federal government shutdown, Democrats in the U.S. Senate insisted that any resolution to fund the government also extend federal subsidies for health insurance under the ACA. The expiration of those subsidies at the end of this year will cause health insurance premiums to double, on average, participants in the ACA marketplace. 

Ultimately, a handful of Democratic senators voted with the Republicans to advance a GOP-authored spending bill that ended the shutdown without addressing the looming health insurance cost spike.

But the issue won’t go away, Rodriguez said.

“We’re looking at a doubling of premiums,” she said. “A 60-year-old couple are looking $1,500 to $2,000 more a month to be able to pay for their health insurance. That is absolutely unaffordable for most Wisconsinites.”

The problem extends beyond just people who buy their insurance through the federal marketplace, she warned.

“The larger amount of people who are uninsured in the state, the higher our health care costs are going to get, because they’re going to wait, they’re going to delay care, they’re going to be sicker when they get into care, and it’s going to cost hospital systems more in terms of uncompensated care,” Rodriguez said.

“If people will go uninsured, it’s going to raise costs,” she added. “And continuing to talk about it, continuing to let people know how that works, is something that I’m uniquely equipped to do as a nurse, as somebody who’s worked within the health care system. And it’s one of the reasons why I’m running for governor.”

Rodriguez said she has seen the benefits that the ACA has brought in the last decade and a half.

Before it was in place, “people delayed care,” she said. “They came in sicker to my emergency department and it cost a whole lot more dollars to be able to treat them and they were out of work because they had to be treated within a hospital system as opposed to going to their regular doctor and being able to get the care that they needed and be able to take care of their diabetes, to take care of their hypertension. Those are the kind of things that the Affordable Care Act has allowed us to do.”

She said she’s heard from small business owners who were able to start a business because they could get health insurance thanks to the ACA.

“Do we need to fix it? Absolutely. Do we need to get it better? Absolutely,” Rodriguez said. “But to get rid of it is going to have devastating effects on health care in Wisconsin.”

Rodriguez said she also brings the perspective of health and health care to other policy topics.

“The medicine we give you, the procedures that we do — it’s such a tiny fraction of how healthy we are,” she said.

Food, housing and “a good-paying job to put a roof over our heads and to pay for the food we eat and to pay for the medications we’re prescribed” are health issues, too, Rodriguez said. That’s why housing affordability, for example, is part of her platform, she said. 

“Tom Tiffany in the governor’s seat [is] not going to put a priority on lowering costs for Wisconsinites,” she said.

She also predicted that, if elected, Tiffany would sign laws restricting abortion in Wisconsin — “and that is going to be extraordinarily dangerous for people.”

Rodriguez views her science background as a strong selling point. “I think we want somebody who’s going to use data and science to make decisions,” she said.

Robert F. Kennedy Jr., President Donald Trump’s secretary of the federal Department of Health and Human Services, has been “using conspiracy theories as his underlying belief system, and that hurts real people,” Rodriguez said.

She cited surging measles cases in Wisconsin and nationally and the deaths of children in some states after the federal government weakened its support for vaccination.

“That hasn’t happened in a decade, and they’re continuing to feed this anti-science rhetoric that is going to harm our kids here in Wisconsin,” Rodriguez said. “I’ve been clear, I think RFK Jr. should resign. I don’t think he’s qualified for the job that he has and he’s actually a danger to public health across the country.”

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A farmhouse sits along a gravel road near Elgin, Iowa. For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a new report. (Photo by Scott Olson/Getty Images)

For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a report released Monday.

The nonprofit Commonwealth Fund based its analysis on federal health workforce data. Its report comes just days after states applied for portions of a $50 billion rural health fund included in the broad tax and spending law President Donald Trump signed in July. Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one.

About 43 million people live in rural areas without enough primary care physicians, according to the report. Across the country, nearly all — 92% — of rural counties are considered primary care professional shortage areas, compared to 83% of nonrural counties. Forty-five percent of rural counties had five or fewer primary care doctors in 2023. Roughly 200 rural counties lacked one altogether.

Nationally, the report found there was an average of one physician per 2,881 rural residents. States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician.

Rural residents are less likely to use telehealth for primary care, largely because of limited broadband internet access. About 19% of rural respondents said they received health care from a primary care physician via telehealth over the past year, compared with the national average of 29%.

The report also took the pulse of states’ participation in national programs for rural areas, such as a federal loan repayment and scholarship program for physicians working in areas with a shortage of health care providers. In 2023, 40% of rural counties had at least one primary care clinician participating in the program — compared to 60% of nonrural counties.

While the demand for primary care physicians will surpass the supply, the study estimates that the supply of rural nurse practitioners will exceed demand over time, as nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the authors wrote.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

 

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Two of the biggest political issues of the year are immigration and health care.

In the latest Marquette Law School Poll, 75% of Republicans said they were very concerned about illegal immigration and border security while 83% of Democrats said they were very concerned about health insurance. Those were the top issues among those groups. (Among independents, 79% said they were very concerned about inflation and the cost of living, making it their top issue.)

Here’s a look at some recent fact checks of claims related to health care and immigration. 

Health care

No, Obamacare premiums aren’t doubling for 20 million Americans in 2026, but 2 to 3 million Americans would lose all enhanced subsidies and about half of them could see their premium payments double or triple.

Yes, Obamacare premiums increased three times the rate of inflation since the program started in 2014. They’re making headlines now for going up even more.

No, 6 million people have not received Obamacare health insurance without knowing it. There wasn’t evidence to back a claim by U.S. Sen. Ron Johnson, R-Wis., about the level of fraud in the program.

No, Wisconsin does not have a law on minors getting birth control without parental consent. But residents under age 18 can get birth control on their own.

Immigration

Yes, unauthorized immigrants have constitutional rights that apply to all people in the U.S. That includes a right to due process, to defend oneself in a hearing, such as in court, though not other rights, such as voting.

No, standard driver’s licenses do not prove U.S. citizenship. There’s a court battle in Wisconsin over whether voters must prove citizenship to cast a ballot.

Yes, U.S. Immigration and Customs Enforcement (ICE) is offering police departments $100,000 to cooperate in finding unauthorized immigrants. It’s for vehicle purchases.

No, tens of millions of unauthorized immigrants do not receive federal health benefits. 

Here are 8 claims related to health care and immigration … and the facts is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.

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The amount some pay for Affordable Care Act health insurance will double when enhanced subsidies expire, but there isn’t evidence the number is 20 million.

KFF, a health policy nonprofit, estimates monthly payments for Obamacare recipients will increase, on average, $1,016 – more than doubling, from $888 in 2025 to $1,904 in 2026.

That counts increases to premiums and lost subsidies.

U.S. Sen. Bernie Sanders, I-Vermont, citing KFF, made the 20 million claim. U.S. Sen. Ron Johnson, R-Wis., said Sanders was wrong.

KFF doesn’t say how many of the 24 million Obamacare enrollees will see premiums double.

But 2 to 3 million people on the high end of income eligibility would lose all enhanced subsidies. About half could see premium payments double or triple. 

Enhanced subsidies, created in 2021, expire Dec. 31. Some Obamacare enrollees will receive lower enhanced subsidies or none. Standard subsidies remain.

This fact brief is responsive to conversations such as this one.

Sources

• KFF: ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire
• U.S. Sen. Bernie Sanders: Email
• KFF: Email
• Centers for Medicare & Medicaid Services: Health Insurance Exchanges 2025 Open Enrollment Report
• The Journalist's Resource: The battle over Affordable Care Act insurance subsidies: What to know as open enrollment looms
• NBC News: What the government shutdown's end means for Obamacare subsidies
• PolitiFact: Fact-checking Democrats’ talking points about Affordable Care Act subsidies

Will 2026 Obamacare premiums double for 20 million Americans? is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.

Senate Minority Leader Chuck Schumer, D-N.Y., left, accompanied by Sen. Cory Booker, D-N.J., points to a poster depicting rising medical costs if Congress allows the Affordable Care Act tax credits to expire in December as he speaks to reporters following a Democratic policy luncheon at the U.S. Capitol on Oct. 15, 2025 in Washington, D.C. (Photo by Andrew Harnik/Getty Images)

WASHINGTON — Congress has roughly two months to find bipartisan agreement to curb rising health insurance costs if lawmakers want to avoid another government shutdown.

That herculean task would be difficult in the best circumstances, but is much more challenging after lawmakers spent the last 43 days criticizing each other instead of building the types of trust that are usually needed for large deals. Democrats maintained they wanted to address skyrocketing premiums for individual health care plans, while Republicans insisted those talks had to occur when the government was open.

At the same time, congressional leaders will try to wrap up work on the nine full-year government funding bills that were supposed to become law before Oct. 1 and weren’t included in the package that reopened the government. 

Congress must pass all of those bills or another stopgap measure before the new Jan. 30 deadline, regardless of how well or disastrous talks on a health care bill turn out. 

The two-track negotiations will push party leaders to compromise on issues they’d rather not, especially as next year’s November midterm elections inch closer. 

Early signs were not good.

House Speaker Mike Johnson said during a Wednesday night press conference the enhanced Affordable Care Act tax credits set to expire at the end of the year are a “boondoggle” and that “Republicans would demand a lot of reforms” before agreeing to extend those in any way. 

“We currently have 433 members of the House of Representatives. There’s a lot of opinions in this building. And on our side, certainly, a lot of opinions on how to fix health care and make it more affordable. I have to allow that process to play out,” Johnson, R-La., said. 

While Senate Majority Leader John Thune, R-S.D., made a commitment to hold a vote on a health care bill before the end of December to conclude the shutdown, Johnson has avoided giving a timeline for when he would bring any similar legislation to the floor. 

President Donald Trump, aside from throwing insults at Democrats, largely stayed on the sidelines of the shutdown fight, though he suggested the funds used for the tax credits should in some way go directly to individuals instead of large insurance companies.

Pessimism over progress

The shutdown highlighted the stark differences Republicans and Democrats hold on health care as prices for insurance continue to spike, forcing millions of Americans to choose between taking care of themselves and breaking their budgets, States Newsroom found in interviews with members of Congress. 

GOP leaders held together throughout the funding lapse and didn’t negotiate on the expiring ACA marketplace tax credits, or anything else. 

Now that it’s over, Republicans will need to put something forward.

Connecticut Rep. Rosa DeLauro, the top Democrat on the House Appropriations Committee, said her sense is that Congress will “probably be in the same place on January 30th that we are now.”

“We have two parties here, two sides,” DeLauro said. “In the past … we’ve had serious negotiation back and forth, and that’s what we need to do, and that’s not happening.”

While Republicans have unified control of government, major legislation needs the support of at least 60 senators to advance in that chamber. Republicans hold 53 seats at the moment, meaning at least some Democrats must support a bill for it to pass. 

DeLauro did not rule out another shutdown, saying Democrats plan to take the next few months “one day at a time,” while closely watching what Republicans are willing to do on the nine full-year appropriations bills and health care costs. 

Maryland Democratic Rep. Steny Hoyer, former House majority leader and a senior member of the Appropriations Committee, said Republican leaders keeping that chamber in recess for nearly two months leading up to and during the shutdown significantly delayed work on the full-year government funding bills. 

Hoyer said that scheduling decision was a clear “indication they’re not interested in solving the problem.”

“If they were, they would have had members here working on appropriation bills,” Hoyer said. “And the only way you’re going to ultimately solve this problem is to pass appropriation bills.”

Hoyer said the real question facing Congress now isn’t whether there is time to work out agreement on the remaining nine government spending bills, but whether there’s a will to make the types of compromises needed. 

Untangling spending bills

The spending package that reopened the government included three of the dozen full-year bills, funding the Agriculture Department, Food and Drug Administration, Legislative Branch, military construction projects and Department of Veterans Affairs.

The remaining appropriations bills will be considerably tougher to resolve, especially because the House and Senate have yet to agree on how much they want to spend across the thousands of programs. Trump proposed major cutbacks in multiple programs in his budget request earlier this year that Democrats have strongly resisted.

The Defense, Homeland Security, Labor-HHS-Education and State-Foreign Operations bills will be some of the more difficult to settle. 

Congress could always lean on another stopgap spending bill to keep funding relatively flat for the departments and agencies not covered by a full-year bill before Jan. 30. But lawmakers will need bipartisan support to advance in the Senate.

Washington Democratic Rep. Pramila Jayapal, former chair of the Congressional Progressive Caucus, said Republicans don’t seem to grasp how much Americans are struggling with the cost of living, including for health insurance and health care. 

“My constituents are already telling me that they’re making that choice between having health insurance or having a house to live in, and they’re going to choose the house,” Jayapal said. 

Whether or not a partial government shutdown begins in early 2026 will likely depend on whether Republican lawmakers from swing districts force bipartisanship on a health care bill. 

“I really don’t know,” Jayapal said. “I think it depends on these vulnerable House Republicans, who are not going to be able to go back to their constituents without telling them that they’ve done something on health care.”

Political juice and a backbone

Democratic Rep. Melanie Stansbury of New Mexico said she wouldn’t be surprised if Congress is unable to strike a deal on government funding and winds up in a partial shutdown by February. 

“Do I think that the Republicans have the political juice to get … the rest of their appropriation bills across the finish line and a health care deal? No,” Stansbury said. 

She added that she hopes a handful of Republicans decide to join Democrats on the discharge petition bill that would force a floor vote on a bill to extend the ACA marketplace subsidies for three years. 

“We gotta find a few brave Republicans who still have a backbone and some guts to stand up to this administration and actually care for their constituents,” Stansbury said. 

But any bipartisan deal to extend those health care tax credits seems fraught, as House Minority Leader Hakeem Jeffries slammed Republicans as having “zero credibility on this issue.”

He pointed to Republicans trying several times to repeal the Affordable Care Act, including their last attempt in 2017, when GOP Sens. Lisa Murkowski of Alaska, Susan Collins of Maine and the late John McCain of Arizona crossed party lines to vote against repealing the 2010 law.

“There’s no evidence that they’re serious about extending the Affordable Care Act tax credits,” Jeffries, of New York, said. “Republicans have zero interest in fixing the health care crisis that they’ve created.”

‘No point in taking 41 days to cave’

When Democrats controlled both chambers, temporary health care subsidies were originally passed as part of the COVID-19-era American Rescue Plan in 2021 for two years. 

With Democrats still controlling both chambers, lawmakers approved the Inflation Reduction Act, the 2022 signature climate policy bill from the Biden administration, that extended those health care subsidies for three years, expiring at the end of December 2025.

The outcome of the just concluded shutdown is shaping some House Democrats’ views.

Virginia Democratic Rep. Bobby Scott said if there is a new shutdown come February, Senate Democrats will have to decide whether they’re going to “cave again, or at least engage in negotiations.” 

“When the (Senate) Democrats say: ‘Our strategy wasn’t working,’ it wasn’t working because they assume you’re going to cave, which you just proved,” Scott told States Newsroom. “Their strategy worked — trying to get them to negotiate and talk to you doesn’t because they know you’re going to cave.”

Scott said “there’s no point in taking 41 days to cave,” pointing to the eight members of the Senate Democratic Caucus who broke ranks to advance and later approve the package to reopen the government. 

“Why don’t you just cave right at the beginning, on February 2nd?” he said. “If the Republican strategy is: ‘We’re not going to negotiate at all because you’re going to cave,’ you have to show them that you’re not going to cave, then you can have a discussion.”

Scott said the same health care issues will still exist if nothing happens between now and the package’s Jan. 30 government funding deadline.  

“By then, we’ll know that several million people don’t have health insurance, we’ll know that rural hospitals are beginning to suffer,” Scott said. 

Delaware Democratic Rep. Sarah McBride said that “from today through November (2026) and after, we will continue to be talking about health care, to be fighting for health care.”

“I think what you’ve seen over the last several months, you will continue to see from us through November and then, God willing, once we’re in a majority, we’ll do all that we can to reverse these cuts and restore care and expand access to it,” she said. 

Sen. Tammy Baldwin (D-Wisconsin) speaks Wednesday about the effort to extend enhanced Affordable Care Act insurance premium tax credits that will expire at the end of 2025. Nancy Peske, left, and Julia Harris-Robinson, center also joined the press conference. (Photo by Erik Gunn/Wisconsin Examiner)

With the loss of enhanced subsidies for the health insurance she has bought on the federal marketplace HealthCare.gov, Nancy Peske’s health plan will cost $1,163.50 a month in 2026.

That’s more than three times what she paid this year — $372 a month, Peske said Wednesday.

But if there’s one thing she wants everyone to know, it’s this: The higher prices for health insurance aren’t just something that she and other people who buy their coverage on the federal marketplace are facing.

Long before the ACA, Peske learned about “the premium death spiral,” she said.

“The more you raise the price, the more people drop out of the pool. This means you have to raise the price, which means more people drop out of the pool. And it goes on and on and on,” Peske said.

“It’s not just my health insurance that’s going to go up. It’s everybody’s — right?” she said. “We’re all in this together.”

Peske was one of two people who have relied on HealthCare.gov, created as part of the Affordable Care Act, who spoke Wednesday at a press conference in Milwaukee with Sen. Tammy Baldwin (D-Wisconsin).

Baldwin called the press conference  to draw attention anew to the skyrocketing cost of health insurance — and to the failure of Congress to address it in the stopgap spending bill that passed the U.S. Senate Monday, the U.S. House Wednesday evening and was signed by President Donald Trump.

“This is a health and wellness issue,” Baldwin said. “This is an affordability and cost-of-living issue, and this is a quality of life and dignity issue. And it touches every single one of us right now.”

A success amid ‘a broken system’

Health care in the U.S. is “a broken system that prioritizes profits over patients,” Baldwin said. Despite that, she said, the 2010 Affordable Care Act was an important advance for expanding health care access.

She said that was improved by enhanced federal subsidies enacted in 2021 to offset the cost of health insurance for people who must buy their own policies on the federal HealthCare.gov marketplace that was created by the ACA — making insurance more affordable and drawing record numbers of people to the marketplace to get health coverage.

The enhanced subsidies expire at the end of 2025, however, and until this week a Republican stopgap spending bill that passed the U.S. House in September stalled in the U.S. Senate as Democrats pushed unsuccessfully to extend the subsidies.  

“That is what is at the center of the government shutdown and debate in Washington, D.C.,” Baldwin said. “We know the impact of taking away these tax breaks. For 275,000 Wisconsinites, their health care [insurance] costs will double, triple or even more. For 30,000 Wisconsinites, they predict the price will be too high, and that those Wisconsinites will go without insurance altogether.”

A handful of Democratic Senators changed their votes Monday to advance the spending bill in return for a promise of a future vote on the subsidies, with the House taking up the revised bill Wednesday. Baldwin didn’t join them.

“I said the entire time that a handshake deal with my Republican colleagues to reopen the government and no real action to lower health care costs was simply not good enough,” said Baldwin of her vote against the bill.

She also forced an amendment to extend the tax credits for a year — a compromise, she said, because she wants them extended permanently, but one she offered “to avoid catastrophe for families across Wisconsin and give folks breathing room while we negotiate longer-term solutions.”

The amendment failed on a party-line vote.

“Every single Republican voted no on my amendment,” Baldwin said. “They chose to send a clear, unmistakable message that they are OK with jacking up health care costs on 22 million Americans.”

Early retirement, then sticker shock

HealthCare.gov user Erica Topps also joined Baldwin’s news conference. Topps took early retirement in April and bought a health insurance policy through the federal marketplace for herself and her college-age daughter that started in June.

At the marketplace open enrollment for 2026 that started Nov. 1, that plan’s premium increased by $1,200 a month and the deductible went from $6,700 per person to $10,600 per person, Topps told reporters She found another plan via the marketplace and is enrolling, but she’s concerned about the future beyond that.

“Part of my plan is to go back to work” so she can get health insurance, Topps told the Wisconsin Examiner, because it will be 10 years before she can qualify for Medicare.

Before taking early retirement, “I did my due diligence,” she said. “I feel like the rug was pulled out from under me.”

Peske is a freelance writer, editor and consultant. She is also a cancer survivor, whose diagnosis two years ago was covered thanks to her HealthCare.gov policy. Going without health insurance is unthinkable, but at the age of 63, she must wait another two years before she can go on Medicare, she said.

Peske told the Wisconsin Examiner that she will scrape together the money to afford her new premium. “I’ll not put a dime into my underfunded retirement account,” she said. She expects to “tighten the belt” on household expenses, “and I will probably cut into my savings.”

Freelancers and small businesses account for 40% of the U.S. economy, Peske told reporters.

“Do you want everyone to go out of business?” she asked. “Should I just do what so many people do and get a much lower paying job at a company? Because I’m desperate for health care. I don’t think that’s the solution. I think you want to keep people like me in business, generating money, adding to the economy, and being able to live, to not die of cancer.”

Seeking inroads with GOP lawmakers

Baldwin said she has been talking with Republicans about finding common ground in increased transparency in the health care system, from insurance companies, pharmacy benefit managers and providers.

In addition, she told the Wisconsin Examiner after the press conference, she continues to have conversations with GOP Senate colleagues who have expressed interest in continuing the subsidies to avert the sharp hike in premiums.

None of them were willing to break ranks and vote for her amendment this week, however.

“Those discussions were happening informally, in quiet, not in the public spotlight,” Baldwin said. “But they were afraid to vote on something that they, probably, some of them want, because Donald Trump said you can’t talk about this before the government reopens.”

Baldwin said that the next step will be for the Democrats to settle on the bill that Republican Senate Majority Leader John Thune has promised they could bring to the upper chamber for a vote.

As much as she favors a permanent extension of the enhanced credits, if the Democrats go that route, “we know it will go down, and it will be on a pretty much a partisan vote,” Baldwin said.

“I want results, so that probably dictates towards supporting something that conceivably does respond to some of the concerns Republicans have raised,” she said. “I’d like to pick the path most reasonably likely to succeed on behalf of the people who sent me to Washington to fight for them.”

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Blister packs of hormone replacement therapy medication. (Getty photos)

WASHINGTON — The U.S. Food and Drug Administration announced Monday it plans to remove warnings from hormone replacement therapy drugs that can be used to address symptoms of menopause, saying the statements are no longer needed. 

The black box warning, the strongest caution possible from the FDA, was added in the early 2000s after a study from the Women’s Health Initiative showed an uptick in rates of blood clots, breast cancer, heart attacks and strokes for women who used certain types of hormone replacement therapy. 

FDA Commissioner Marty Makary said during a press conference the change for estrogen-related products “is based on a robust review of the latest scientific evidence.”

Makary rebuked the medical establishment for not putting enough effort into researching women’s health conditions, including menopause. 

“A male-dominated medical profession, let’s be honest, has minimized the symptoms of menopause, and as a result, women’s health issues have not received the attention that they deserve. More than 80% of women have notable severe symptoms lasting up to eight years. How could the medical establishment get it so wrong for so long?” Makary said. “Women deserve the same rigorous sciences as is used for men.”

Study criticized

Department of Health and Human Services Advanced Research Projects Agency for Health Director Alicia Jackson said the black box warning on estrogen was based on “the flawed, overgeneralized and misinterpreted WHI study.” 

Jackson said menopause leads to a series of complicated and often painful experiences for women, including “sleepless nights, derailed careers, painful sex, broken bones and a loss of wellbeing.”

Jackson explained that when the level of estrogen drops throughout and after menopause, “a cascade of disease and aging begins.”

“A preponderance of data now shows that estrogen, when started early, acts as a protective shield for the brain, lowering risks of memory loss, mental health decline and neurodegenerative disease, even Alzheimer’s,” Jackson said.  

Makary said women should talk with their doctors and can request their estrogen levels be monitored as they approach the age where menopause typically begins and throughout that years-long process. 

He said that sometimes doctors can prescribe microdosing for hormone replacement therapy, followed by a half-dose and eventually a full dose as a woman’s estrogen levels decrease over time. 

Makary didn’t say how many of the companies that produce hormone replacement therapies plan to remove the black box warning but said he expects nearly all will do so. 

“Companies are, generally speaking, very excited when the FDA tells them they can remove a scary warning on your product,” he said. 

Review by panel

The FDA’s process for removing the black box warning requirement, Makary said, began with an expert panel earlier this year. The FDA’s subject-matter experts then conducted a “comprehensive review of the literature” and recommended the agency remove the requirement, which Makary accepted. 

The scientists who were part of the expert panel, he said, have written an article that will be published in the Journal of the American Medical Association.

President of the American College of Obstetricians & Gynecologists Steven J. Fleischman wrote in a statement that he “commends the HHS leadership for improving the lives of perimenopausal women by making the estrogen products they need more accessible to them.”

“The modifications to certain warning labels for estrogen products are years in the making, reflecting the dedicated advocacy of physicians and patients across the country,” Fleischman wrote. “The updated labels will better allow patients and clinicians to engage in a shared decision-making process, without an unnecessary barrier, when it comes to treatment of menopausal symptoms. ACOG has long advised clinicians to counsel patients based on an individual’s unique risk factors and treatment goals; this announcement does not change ACOG’s guidance on estrogen therapy.”

Deysi Camacho shops at the Feeding South Florida food pantry on Oct. 27, 2025 in Pembroke Park, Florida. Feeding South Florida was preparing for a possible surge in demand as SNAP benefits were delayed and reduced due to the government shutdown. (Photo by Joe Raedle/Getty Images)

WASHINGTON —  Senate Democrats left their Thursday caucus lunch tight-lipped as an agreement to end the government shutdown, now the longest in U.S. history at 37 days, remained elusive.

Republicans have floated a deal that includes the reinstatement of federal workers laid off by President Donald Trump, but no votes were scheduled on a spending bill as of late Thursday afternoon. There was some speculation senators could work through the weekend.

The chair of the Senate Appropriations Committee, GOP Sen. Susan Collins of Maine, said negotiations are still underway. But she said as part of a deal, she supported the rehiring of the thousands of federal workers the Trump administration fired in its Reductions in Force, or RIFs, during the government shutdown that began Oct. 1.

“Those who were RIF’d during the shutdown should be recalled,” she said. “We’re still negotiating that language.”

Emboldened by this week’s Election Day victories, where Democrats swept major local and state races, Senate Democrats are seeking to use that momentum as leverage to get Republicans to also agree to a health care deal to end the government shutdown.

While Democrats have pushed to extend tax credits for health care, Senate Majority Leader John Thune told reporters Thursday that the best he can offer is a vote on extending those subsidies, which expire this year. 

The coming expiration has resulted in millions of people who buy their health insurance through the Affordable Care Act Marketplace receiving notices of a drastic spike in premium costs.

“I can’t speak for the House, and obviously I can’t guarantee an outcome here, and they know that,” Thune, a South Dakota Republican, said. “I think the clear path forward here, with regard to the ACA issue, is they get a vote, and we open up the government, and we head down to the White House and sit down with the president and talk about it.”

Democrats that represent states with a high population of federal employees, such as Sen. Tim Kaine of Virginia, are also seeking to strike a deal on RIFs. A federal judge blocked those Reductions in Force last month.

Kaine told reporters Wednesday that those negotiations are occurring with the White House.

“It is an item that is being discussed with the president, with the White House,” Kaine said.

The progressive wing of the Democratic Party has stressed that unless there is a commitment from House Speaker Mike Johnson and President Donald Trump to extend health care tax credits, Democrats should not agree to pass a stopgap spending bill to reopen the government. 

In session next week?

Senators are still scheduled to leave Capitol Hill late Thursday and be out next week on recess for the Veterans Day holiday.

But a couple Senate Republicans said late Thursday afternoon that lawmakers might stay in Washington, D.C. into Friday or later.

“I think they’re trying to work towards a vote tomorrow, maybe through the weekend. I’m pro-through the weekend,” Sen. Thom Tillis, R-N.C., said in an interview following a GOP lunch meeting.

Sen. John Kennedy, R-La., likened the situation to a “goat rodeo,” which is a hyperbolic phrase to refer to a disaster.

“We’re probably going to have a vote tomorrow, and then we will get on, and then we will know where we are, and we’ll know whether the Democrats are serious or not,” Kennedy said, adding that he was unsure exactly what they were voting on.

Democrats quiet about any deal

Following their Thursday caucus lunch, Democrats did not seem closer to an internal agreement on how to move forward with resolving the government shutdown as they left their huddle. 

Senate Minority Leader Chuck Schumer said Democrats had a “very good, productive meeting.”

One of the top negotiators for Democrats on finding a deal, New Hampshire Sen. Jeanne Shaheen, declined to comment.

Pennsylvania Democratic Sen. John Fetterman threw his hands up as he left the room.

“I don’t know how productive it was,” Fetterman, who has voted with Republicans to move legislation to reopen the government, said. 

Some Democrats said they were unified, such as New Jersey Sen. Andy Kim, Michigan’s Gary Peters and Connecticut’s Chris Murphy, a top appropriator. 

Peters did not specify what issue Democrats were unified on. 

“I don’t want to get into that, but it was an encouraging caucus (meeting) because there’s a great deal of unity as we came out,” he said.

Revised stopgap?

Additionally, a new continuing resolution, or CR, is needed, as the stopgap funding measure would have funded the government until Nov. 21, now just two weeks away. 

The House, which Johnson has kept in recess since September, would also need to be called back to pass a new version of a CR.

As the government shutdown continues, Transportation Secretary Sean Duffy warned this week that if funding is not restored, flights will need to be reduced by 10% in some air spaces due to a shortage of air traffic controllers, who have worked without pay for weeks.

The government shutdown has led to millions of federal workers furloughed or required to work without pay and has created uncertainty for vulnerable people who rely on food assistance and  heating services, as well as stoppages in vital child development and nutrition programs. 

In an effort to force Democrats to vote to reopen the government, the Trump administration has tried to withhold Supplemental Nutrition Assistance Program, or SNAP, benefits for 42 million people, until a court ordered the U.S. Department of Agriculture to release those benefits. 

Frustrated with the government shutdown, Trump has also tried to pressure Republicans into doing away with the Senate’s filibuster, which requires a 60-vote threshold, but Thune has resisted those calls. 

Progressives: ‘Do not cave’

Johnson, a Louisiana Republican, said during a Thursday press conference that he’s “not promising anyone anything” when it comes to a House vote on extending health care tax subsidies.  

Johnson criticized Senate Democrats for wanting a guarantee that the House would also take a vote on extending the ACA taxes.

“That’s ridiculous,” he said. 

House progressives said they have one message for Senate Democrats: “Do not cave,” as Rep. Pramila Jayapal put it during a Thursday morning press conference outside the U.S. House.

“Any deal must secure the extension of the ACA tax credits and ensure health care for the American people with agreement from the House, the Senate and the White House, full stop. We have the momentum,” the Washington state Democrat said.

Rep. Chrissy Houlahan, D-Pa., who publicly confronted Johnson during a press conference Wednesday, said, “We require a deal that actually addresses the health care crisis, not that promises to think about addressing it down the road in two weeks, with concepts of a plan.”

“Sadly, at this point in time, even I say it’s impossible to trust our Republican colleagues to honor their promises and their obligations,” Houlahan said.

April Verette, president of the labor union SEIU, which represents roughly 2 million members, spoke alongside Jayapal and Houlahan and praised Democrats as “courageous.”

“We are determined to say ‘Stick with this fight’ because righteousness, morality is on our side,” Verette said.

Patients have their blood pressure checked and other vitals taken at an intake triage at a Remote Area Medical mobile dental and medical clinic on Oct. 07, 2023 in Grundy, Virginia. (Photo by Spencer Platt/Getty Images)

WASHINGTON — All 50 states have applied for the $50 billion Rural Health Transformation Program in Republicans’ “big, beautiful” law, the Centers for Medicare and Medicaid Services said Thursday.

States had from Sept. 15 through Wednesday to apply for the program, which was authorized under the mega tax and spending cut package passed by Republicans and signed into law by President Donald Trump. The fund is intended to offset the budget impacts on rural areas due to sweeping Medicaid cuts. 

However, the temporary fund could only offset a little more than one-third of the package’s estimated $137 billion cut to federal Medicaid spending in rural areas over the next decade, according to the nonpartisan health research organization KFF.

Administrator of the Centers for Medicare and Medicaid Services Dr. Mehmet Oz said the program “moves us from a system that has too often failed rural America to one built on dignity, prevention, and sustainability” in a Thursday statement alongside the announcement. 

Oz said “every state with an approved application will receive funding so it can design what works best for its communities — and CMS will be there providing support every step of the way.”

Each state was asked to “design a plan for transforming its rural health care system” and outline in proposals how they “intend to expand access, enhance quality, and improve outcomes for patients through sustainable, state-driven innovation.” 

The program allocates $25 billion equally to approved states between fiscal years 2026 and 2030. CMS said states meeting the baseline criteria will then “undergo a rigorous, data-driven merit review” for the remaining half of the funds. 

In September, when announcing the application opening, CMS said the remaining half of funds would be administered to approved states based on “individual state metrics and applications that reflect the greatest potential for and scale of impact on the health of rural communities.” 

CMS said approved awardees will be notified by Dec. 31. 

Senate Minority Leader Chuck Schumer, D-N.Y., speaks to reporters during a news conference on Nov. 5, 2025 on Capitol Hill in Washington, D.C. (Photo by Tom Brenner/Getty Images)

WASHINGTON — Following major Democratic wins in local and state elections across the country on Election Day, top Democratic congressional leaders pushed for a meeting with the president to end the federal government shutdown, which on Wednesday became the longest in U.S. history at day 36.

“The election results ought to send a much-needed bolt of lightning to Donald Trump that he should meet with us to end this crisis, his shutdown,” Senate Minority Leader Chuck Schumer said on the Senate floor Wednesday. “It’s time to hold a bipartisan meeting. The takeaway from last night was simply unmistakable.” 

Schumer and House Minority Leader Hakeem Jeffries, both New York Democrats, sent a Wednesday letter to President Donald Trump, calling for a bipartisan meeting at the White House to end the government shutdown and to address the spike in individual health care premiums.

“Last night, Republicans felt political repercussions,” Schumer said after Tuesday’s Election Day wins for Democrats. They included passage of a redistricting measure in California to offset partisan gerrymandering by GOP states, governorships in New Jersey and Virginia and local races across the country.

For more than a month, Democrats have voted against approving the House-passed GOP stopgap spending measure over concerns that health care tax subsidies will expire at the end of the year. As open enrollment begins, people who buy their health insurance through the Affordable Care Act Marketplace are seeing a drastic increase in premium costs. 

Sanders pushes back on dealmaking

Schumer did not detail what kind of deal Democrats would accept, but said any negotiation “must address the health care needs of the American people.”

However, independent Sen. Bernie Sanders of Vermont said that Democrats should not accept any agreement with the GOP unless there is a commitment from House Speaker Mike Johnson and the president to pass legislation to extend those tax credits.

“Bottom line is, we need to be successful in protecting the health care of the American people, and if it’s just a piece of legislation that passes the Senate … so what? Where does it go? Then it becomes just a meaningless gesture,” Sanders said. 

Republicans have maintained that they will only have a discussion on health care after Democrats agree to resume government funding. 

This week, the Senate failed for the 14th time to pass a stopgap spending measure that would fund the government until Nov. 21. 

Lawmakers have acknowledged that a new stopgap spending bill will need to be extended past the Nov. 21 deadline, but have not come to an agreement on a new deadline.

Thune plays down Democratic victories

Senate Majority Leader John Thune told reporters Wednesday that he was skeptical the government shutdown played into major wins for Democrats across the country. 

“The shutdown doesn’t benefit anyone,” he said.

The South Dakota Republican noted the shutdown may have played a role in suburban Virginia, where a large share of federal workers live and are furloughed due to the government shutdown.

“In Northern Virginia, that has a lot of federal workers, so it certainly could have been a factor in the elections,” Thune said. “But I think it’s hard to draw conclusions.”

But Thune said he’s focused on ending the government shutdown, and hopes progress can continue to be made before senators are scheduled to be out next week for recess due to the Veterans Day holiday. 

Transportation Secretary Sean Duffy this week warned that if the shutdown continues into next week, it could lead to certain airspace needing to be closed due to a shortage of air traffic controllers who have continued to work amid the shutdown.

Trump, in a social media post, blamed two factors for Republicans not performing well on Tuesday: his absence from the ballot, and the government shutdown.

“I think if you read the pollsters, the shutdown was a big factor, negative for the Republicans, and that was a big factor, and they say that I wasn’t on the ballot was the biggest factor,” Trump said during a Wednesday press conference.

Withholding SNAP benefits

As the government shutdown has continued, the Trump administration has tried to get Senate Democrats to agree to the stopgap spending measure by directing the U.S. Department of Agriculture to not tap into its contingency fund to provide food assistance to 42 million people.

Two federal courts found that the Trump administration acted unlawfully in holding back those Supplemental Nutrition Assistance Program, or SNAP, benefits, and USDA agreed that it would partially release SNAP benefits. 

Trump earlier this week wrote on his social media platform that SNAP benefits would only be released when Democrats vote to reopen the government, a move that would likely violate the two court orders.

“SNAP BENEFITS, which increased by Billions and Billions of Dollars (MANY FOLD!) during Crooked Joe Biden’s disastrous term in office (Due to the fact that they were haphazardly ‘handed’ to anyone for the asking, as opposed to just those in need, which is the purpose of SNAP!), will be given only when the Radical Left Democrats open up government, which they can easily do, and not before!,” he wrote.

However, White House press secretary Karoline Leavitt seemed to walk back that statement on Tuesday, arguing that the president’s social media post did not refer to the court order, but to future SNAP payments.

“The president doesn’t want to tap into this (contingency) fund in the future and that’s what he was referring to,” Leavitt said.

Volunteers with the Capital Area Food Bank distribute items to furloughed federal workers in partnership with No Limits Outreach Ministries in Hyattsville, Maryland, on Oct. 28, 2025. (Photo by Ashley Murray/States Newsroom)

This report has been updated.

WASHINGTON — The U.S. Senate Tuesday failed for the 14th time to advance a stopgap spending bill to fund the government, as the ongoing shutdown hit 35 days and is now tied with the shutdown of 2018-2019 as the longest ever.

The 54-44 vote was nearly identical to the previous 13 votes, as Republicans and Democrats remained unwilling to change positions. The legislation extending funding to Nov. 21 needed at least 60 votes to advance, per the Senate’s legislative filibuster. 

Even though the upper chamber has been unable to pass a stopgap spending measure for more than a month, Senate Majority Leader John Thune, R-S.D., told reporters Tuesday that he believes senators are “making progress.” 

He floated keeping the Senate in session next week. The chamber is scheduled to be in recess for the Veterans Day holiday. 

“We’ll think through that as the week progresses, but I guess my hope would be we’ll make some progress,” he said.

Thune added that any stopgap spending bill will need to be extended past Nov. 21, “because we’re almost up against the November deadline right now.”

Duffy warns of flight ‘chaos’ due to staff shortages

Transportation Secretary Sean Duffy warned during a Tuesday press conference at the Department of Transportation that if the government shutdown continues into next week, it would lead to “chaos” and certain airspace would need to be closed due to a shortage of air traffic controllers who have continued to work amid the shutdown.

House Speaker Mike Johnson, R-La., said at a separate press conference at the Capitol that he would bring the House back to vote on a stopgap spending measure if the Senate extends the funding date.

“If the Senate passes something, of course we’ll come back,” Johnson said. “We’re running out of (the) clock.”

Johnson said he is “not a fan” of extending the bill to December and would prefer a January deadline. 

He said extending a stopgap funding bill “into January makes sense, but we got to, obviously, build consensus around that.” 

Senators at odds

On Tuesday’s Senate vote, Nevada Sen. Catherine Cortez Masto and Pennsylvania Sen. John Fetterman, both Democrats, and Maine independent Sen. Angus King voted with Republicans to advance the legislation. Kentucky GOP Sen. Rand Paul voted no.

Senate Democrats have refused to support the House-passed GOP measure over concerns about the expiration of health care tax subsidies. As open enrollment begins, people who buy their health insurance through the Affordable Care Act Marketplace are seeing a drastic spike in premium costs. 

Republicans have maintained that any negotiations on health care must occur after Democrats agree to fund the government. 

The Trump administration has also tried to pressure Democrats to accept the House stopgap spending measure by instructing the U.S. Department of Agriculture to not tap into its contingency fund to provide critical food assistance to 42 million Americans. 

SNAP fight

Two federal courts have found the Trump administration acted unlawfully in holding back those benefits, and on Monday USDA announced it would partially release Supplemental Nutrition Assistance Program, or SNAP, benefits. 

However, President Donald Trump Tuesday morning wrote on his social media platform that SNAP benefits would only be released when Democrats vote to reopen the government, a move that would likely violate the two court orders.

“SNAP BENEFITS, which increased by Billions and Billions of Dollars (MANY FOLD!) during Crooked Joe Biden’s disastrous term in office (Due to the fact that they were haphazardly ‘handed’ to anyone for the asking, as opposed to just those in need, which is the purpose of SNAP!), will be given only when the Radical Left Democrats open up government, which they can easily do, and not before!,” he wrote.

White House press secretary Karoline Leavitt said during a Tuesday briefing that the president’s social media post did not refer to the court order, but was referring to future SNAP payments.

“The president doesn’t want to tap into this (contingency) fund in the future and that’s what he was referring to,” she said.

‘Republican health care crisis’ 

House Minority Leader Hakeem Jeffries of New York stood firm in his party’s demands over extending health care tax credits in order to back a stopgap spending bill during a Tuesday press conference at the Capitol.

“We want to reopen the government — we want to find a bipartisan path forward toward enacting a spending agreement that actually makes life better for the American people, that lowers costs for the American people, as opposed to the Trump economy where things are getting more expensive by the day,” Jeffries said. 

“And, of course, we have to decisively address the Republican health care crisis that is crushing the American people all across the land.” 

He noted that Republicans’ refusal to extend the enhanced Affordable Care Act tax credits would result in “tens of millions of Americans experiencing dramatically increased premiums, co-pays and deductibles.” 

An analysis by KFF shows that those enrollees in the Affordable Care Act marketplace who currently receive a tax credit are likely to see their monthly premium payments more than double by about 114% on average.

Senate Minority Leader Chuck Schumer said the spike in health care premiums will cause some people to choose to forgo health care insurance.

“It’s a five-alarm health care emergency,” Schumer said. 

Johnson’s January CR rationale 

Meanwhile, Johnson said at his press conference that “a lot of people around here have PTSD about Christmas omnibus spending bills,” when speaking out against a December extension of the stopgap spending bill. 

GOP leaders have sought to do away with the practice of bundling at the end of the year the final versions of the dozen annual government funding bills into what’s known as an omnibus package. 

“We don’t want to do that. It gets too close, and we don’t want to have that risk,” Johnson said. “We’re not doing that.” 

However, it’s unclear how long the new stopgap spending bill will extend. Thune, during a Tuesday press conference, said a year-long continuing resolution, or CR, was not on the table. 

“There’s a conversation around what that next deadline would be,” Thune said, adding that there is not an agreement yet.