Nurse practitioner Carol Biocic treats a Marine Corps veteran at a podiatry clinic for veterans in 2023 in Chicago. New professional student loan caps might make it more difficult for people to pursue advanced nursing degrees. (Photo by Scott Olson/Getty Images)

Zoe Clarke became a hospital registered nurse two and a half years ago, following in the footsteps of her mother and grandmother.

Clarke, an ICU nurse in Asheville, North Carolina, wants to get her master’s degree to become a nurse practitioner or a certified registered nurse anesthetist — occupations in high demand — and eventually work toward a doctoral degree.

But new borrowing limits on federal student loans may hinder her from reaching that goal.

A provision in the federal One Big Beautiful Bill Act, the tax and spending law enacted this summer, overhauls the federal student loan program for graduate students in an effort to simplify the loan process and discourage colleges from raising tuition.

To comply with the new law, the U.S. Department of Education recently issued a draft rule that would impose limits on how much graduate students can borrow — up to $20,500 per year and $100,000 in total for most students, but up to $50,000 a year and $200,000 in total for students in a new “professional” category. The category includes people studying to be medical doctors, dentists, veterinarians, pharmacists and lawyers.

Students pursuing advanced nursing degrees, however, are not included in the professional category.

Advanced practice nurses, hospital associations and other health groups say the rule will make it unaffordable for many nurses to advance their careers — disproportionately affecting communities, especially rural ones, that rely on them amid physician shortages.

Advanced nurses can provide primary care, deliver babies as nurse midwives and anesthetize surgery patients where there aren’t enough physicians to go around. They can also write some prescriptions. Advanced practice nurses also serve as college faculty in community colleges and nursing schools.

The U.S. Bureau of Labor Statistics estimates the nation will employ an additional 134,000 nurse practitioners, nurse midwives and nurse anesthetists in the next decade, 35% more than there are now. In high demand, nurse practitioners are one of the fastest-growing occupations in the nation, the bureau says.

“We depend heavily on nurse practitioners,” said Sandy Reding, a president of the California Nurses Association and vice president of National Nurses United. “But if they don’t have access to getting further education, we’re not going to see additional nurse practitioners come into the field.”

Tuition, combined with living expenses, can far exceed $50,000 a year for many post-bachelor’s nursing programs.

“Potentially, this could devastate a whole generation of nurses getting their advanced practice degrees,” Clarke said.

Some education advocates fear that losing a pipeline of advanced nursing practitioners to serve as college faculty also could lead to fewer registered and advanced nurses and other caregivers with two- and four-year degrees, because there would be fewer people to teach them.

Many advanced-degree nursing faculty are retiring. Nursing schools reported more than 2,100 full-time faculty vacancies in 2022, according to the American Nurses Association — leading to roughly 80,000 students being turned away.

States are already grappling with workforce shortfalls caused by exhausting work conditions that have led many nurses to burn out and leave the field, or leave bedside care to teach, nurses told Stateline.

In response to an uproar from nursing associations and others in health care, the Department of Education released a rebuttal last week defending its proposal, saying it is not a “value judgement about the importance of programs.”

It also said it may make changes in response to public comments. The new limits would take effect July 1, 2026.

Rural and underserved communities

Advanced practice registered nurses, known as APRNs, fill gaps in rural communities where there aren’t enough clinicians. For example, nurses needed for surgeries — nurse anesthetists, or CRNAs — make up 80% of anesthesia providers in rural counties. About a fifth of APRNs nationwide worked in rural areas in 2022, according to one survey of more than 18,800 APRNs.

“The nurse practitioners, APRNs, are a needed lifeline to help fill those gaps,” said Heidi Lucas, executive director of the Missouri Rural Health Association and former director of the state’s nurses association. “Putting barriers in the way to keep [nurses] from getting degrees — that’s just going to exacerbate the problems that we already have.”

She said Missouri will be short about 2,000 physicians next year.

The new rule cutting options for federal student loans would only worsen staffing shortages amid tenuous rural hospital budgets, said state-level observers. Hospitals already are grappling with millions of dollars in looming Medicaid cuts over the next 10 years, said Rich Rasmussen, president of the Oklahoma Hospital Association.

Nurse practitioners often serve as primary care providers, writing prescriptions and managing patient care. About 80% of them see Medicaid and Medicare patients, according to the American Association of Nurse Practitioners, citing federal data from the Centers for Medicare and Medicaid Services.

The proposal to deny advanced practice nurse practitioners the more generous loan options ignores the nation’s needs, said nurse practitioner Valerie Fuller, president of the association.

“At a time when America needs more health care providers, we can’t afford to put more obstacles in place for nurse practitioner students who want to go on and further their education and take care of the patients that need care,” said Fuller, former president of the Maine Nurse Practitioner Association. “We know it’s going to harm our workforce.”

‘Clipping the wings’

Rasmussen, of the Oklahoma Hospital Association, said he is concerned about the effect the rule will have on the pipeline for certified nurse midwives and the state’s already dwindling rural maternal health care options.

“We are clipping the wings of rural [obstetrics] to be able to blossom in our state if we’re going to put these types of restrictions on the borrowing capability of nurses who want to pursue obstetrical services in nursing as well,” he said. He added that the rules will force nurses to seek private sector loans — which don’t qualify for federal loan forgiveness programs that encourage clinicians to come work in rural areas.

Teshieka Curtis-Pugh, executive director of the South Carolina Nurses Association, is also concerned about nurse midwives. South Carolina is expected to see a shortage of 3,200 physicians by 2030.

“We also live in a state that has very poor maternal outcomes, especially for women of color. So think about, how does that impact them?” she said. “That means we don’t get the certified nurse midwives who are masters prepared, some of them are doctorally prepared, who are able to fill that gap for birth in that area.”

Diversity and opportunity for students from marginalized groups could also take a hit, said Curtis-Pugh, a registered nurse with a master’s of science in nursing. And for those going back to school while juggling parenting, federal loan dollars can help beyond tuition, she noted.

“They help that mom be able to supplement child care for their child, so that they can have child care while they go to school,” she said. “There’s tuition, there’s books, there’s keeping the lights on. They’re feeding the family they’re getting to and from.”

The exclusion from the higher, “professional” category of student loan options is especially galling after nurses’ work during the COVID-19 pandemic, said Reding, of National Nurses United.

“We were all heroes in 2020. Now, what are we?” Reding asked. “It’s a slap in the face to the nurses that go to work every day doing our very best to care for our patients, even under very adverse conditions and even facing deadly viruses.”

Clarke, the registered nurse considering a post-bachelor’s degree, said nurses’ pandemic-era devotion influenced her own career path.

“When I saw the nurses and the health care workers really working hard for their communities and sacrificing a lot, I was really inspired by that,” Clarke said. “And that’s why I went to school.”

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

 

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As a practicing OB-GYN in Wisconsin, I see firsthand how many of my patients rely on contraception to protect their health, manage painful conditions, and plan their futures. When a woman sits across from me in the exam room, she’s not thinking about politics. She’s thinking about how to survive her work day without severe cramps, how to manage her bleeding so she can attend class without mishap, or how to avoid threatening her life with another high-risk pregnancy. 

These situations are only a few of the reasons why the news about abandoned U.S.–funded contraceptives overseas is so alarming. This action blatantly reflects the same disregard for women’s health that now shapes national policy. And that disregard lands directly on women’s bodies. 

Under the Trump administration, the U.S. government ordered the destruction of nearly $10 million worth of U.S.–funded contraceptives, based on the false claim that birth control is an “abortifacient.” This claim is absolutely nonsensical. Contraception doesn’t end a pregnancy — it prevents one. Unfortunately, ideology, and not medicine, guided that decision, leaving lifesaving, taxpayer‑funded medicine stalled in warehouses instead of reaching women who need it. 

The full picture is even more disturbing. Several days ago, a new report found that the Trump administration left 20 of 24 U.S.–funded contraceptive shipments to waste away in Belgian warehouses. These were fully paid-for, taxpayer-funded supplies — IUDs, implants, pills, and other reproductive health essentials — intended for women in 13 countries. This is simply appalling. 

And if you think that kind of extremism stops at the water’s edge, think again. 

Back home, I see the fallout of the same ideology driving national attacks on contraception and women. 

Already, there are over 300,000 women of reproductive age in Wisconsin in need of contraception, and attacks are making this gap even worse. 

And these gaps carry real health risks, because contraception does more than prevent pregnancy — it treats endometriosis, PCOS, severe bleeding and anemia, and it reduces the risk of reproductive cancers. 

Rural clinics that once offered contraception and family-planning visits have declined in number, a trend worsened by federal policy shifts that weaken the reproductive-health safety net and leave too many women without reliable nearby options for care.

And now, with health-insurance costs already skyrocketing for many families — and monthly bills set to jump even higher if those tax credits expire — the ACA’s no-cost contraception guarantee slips further out of reach. Road block after road block after road block. 

Fortunately, Wisconsin has leaders who understand the stakes. 

Sen. Tammy Baldwin’s leadership on the “Right to Contraception Act” reflects a truth every OB‑GYN knows: contraception saves lives. Contraception reduces maternal deaths, prevents unintended pregnancies, treats reproductive-health conditions, and empowers women to build stable lives. Baldwin fights to protect contraception — what Wisconsin women rely on every day — not because it’s politically convenient, but because she understands it’s a medical necessity. 

U.S. Rep. Mark Pocan co-sponsored the “Saving Lives and Taxpayer Dollars Act” — legislation designed to stop exactly what we’re seeing in Belgium. The bill requires that U.S.–funded food and medical supplies – like the contraception sitting in Brussels at this moment – reach the people they were purchased for, instead of being left to rot or destroyed for ideological reasons. In Washington, where too many have decided contraception is a cultural wedge rather than essential health care, Pocan’s voice matters. 

The women I see in my exam room aren’t looking for a political fight. They’re looking for care that lets them stay healthy, stay safe, and stay in control of their lives — something contraception makes possible every day. 

Jeopardizing contraception — whether through wasteful negligence abroad or political interference here at home — is harmful, cruel and simply unjust. 

We in Wisconsin cannot afford to look the other way. We need leaders who will defend the right to contraception, not undermine it. 

The stakes are simple: either we protect access to basic health care, or we allow ideology to decide who gets care — and who doesn’t. 

For the women in my clinic — and for women everywhere — contraception is essential care that strengthens their health and safeguards their freedom.

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Wisconsin State Capitol (Wisconsin Examiner photo)

Gov. Tony Evers vetoed nine bills Friday including a Republican bill that would have barred local and state funds from being used for immigrants without legal status.

Wisconsin already doesn’t allow immigrants without legal status to access BadgerCare, which Evers noted in his veto message. Republicans lawmakers acknowledged that fact as they advocated for AB 308, saying the bill was intended to block future use of health care benefits by immigrants. The bill would have prohibited state, county, village, long-term care district and federal funds from being used to subsidize, reimburse or provide compensation for any health care services for a person not lawfully in the U.S.

“As this bill’s Republican co-author in the Wisconsin State Assembly plainly stated in the public hearing on this proposal, ‘Wisconsin currently doesn’t allow undocumented immigrants to enroll in BadgerCare,’” Evers wrote in his veto message. 

“I object to Republican lawmakers passing legislation they acknowledge is unnecessary to prevent problems they admit do not exist, all for the sake of trying to push polarizing political rhetoric,” Evers added. 

Evers said the bill was “more about being inflammatory, stoking fear, and sowing division than it was about accomplishing any significant policy outcome or being prudent stewards of taxpayer dollars.” 

U.S. Rep. Tom Tiffany, one of two Republican candidates for governor, criticized the veto in a statement, saying Evers was putting the interests of “illegal aliens” ahead of Wisconsin taxpayers and sought to tie Evers’ action to next year’s high-profile gubernatorial election. Evers is not running for reelection, and there is a crowded Democratic field that is still taking shape.

“If Democrats take the governor’s office in 2026, you can count on them to hand out driver’s licenses, in-state tuition and taxpayer-funded health care to illegal aliens. I will not let that happen,” Tiffany said.

No new cigar bars

Evers also vetoed a bill that would have allowed for more tobacco bars in Wisconsin. 

Wisconsin first enacted its smoke-free air law in 2010 — prohibiting smoking cigars, cigarettes, pipes and other products in public spaces. The law included an exclusion for cigar bars that were in existence before June 4, 2009.

AB 211 would have allowed for more exemptions for tobacco bars if they came into existence on or after June 4, 2009 provided that they allowed only the smoking of cigars and pipes and were not part of a retail food establishment.

Evers, a former smoker and an esophageal cancer survivor, said he objected due to the harm that the bill could have on Wisconsinites public health.

“Secondhand smoke, a known carcinogen, causes serious health problems and is responsible for thousands of deaths on an annual basis,” Evers stated. He said the state’s smoke-free air law was “a critically important step forward for keeping kids, families, and communities healthier and safer, improving public health and, most importantly, saving thousands of lives… I cannot in good conscience reverse course on that important step for public health, safety, and well-being by restoring indoor smoking in certain public spaces.”

Bill to ban guaranteed income

Evers also vetoed AB 165, which would have banned local governments from using tax money to create guaranteed income programs without a work or training requirement. 

Evers wrote in his veto message that he objects to lawmakers’ “continued efforts to arbitrarily restrict and preempt local governments across our state.” He said they should instead focus on finding ways to support local communities and ensure they have the resources they need to “meet basic and unique needs alike.”

Building code delay

Evers vetoed AB 450, which would have put off the effective date of Wisconsin’s updated commercial building code until April 1, 2026, saying he objected to “further unnecessary delay in implementing new building standards that will benefit Wisconsin communities.” 

The new building codes were originally blocked by lawmakers on the Joint Committee on the Review of Administrative Rules for years, but they were reinstated this year by the the Department of Safety and Professional Services (DSPS) after a state Supreme Court decision. Justices ruled in July that state laws allowing the Legislature to block executive branch administrative rules indefinitely were unconstitutional.

The current effective date for the building codes is Nov. 1, 2025.

Republican lawmakers claimed the delay to next year was needed to provide clarity to builders who had been planning projects under the previous code. 

Evers wrote in his veto message that the bill would do the opposite. 

“This bill would not only create confusion for developers with current building projects under review but would also further delay the implementation of new safety and energy efficiency standards that have been already widely adopted,” Evers said. “The department has and will continue to work with building professionals throughout the state to ensure proper understanding and compliance with the new building commercial code.” 

Education bills rejected

A handful of Republican education-related bills were rejected by Evers. 

Currently, teacher preparation programs are required to have a full semester of student teaching during the school year. SB 424 would have allowed for programs to use student teaching during a summer session as an alternative to a full school-year semester.

Lawmakers had said the bill would help with recruitment by allowing for more flexibility to students seeking to become teachers. However, Evers said that the bill would potentially reduce the rigor of the current training that students are required to have, especially given that summer sessions can be shorter than a typical school term and may not allow students to experience the same opportunities available during the school year such as parent-teacher conferences.

“Reducing training, qualifications, experience, and work ages are not real solutions for solving Wisconsin’s generational workforce shortages,” Evers said in his veto message. “Wisconsin’s challenges recruiting, training, and retaining exceptional educators will not be aided by making education professionals less trained, less qualified, and less experienced — nor will our kids.”

Evers also vetoed AB 166, which would have required UW system institutions, technical colleges and private nonprofit colleges to report cost and student outcome data and required the information be provided to high school juniors and seniors in academic and career planning services. 

Evers said in his veto message that he didn’t want to burden the state’s higher education institutions with more administrative requirements, especially without “necessary resources.” He noted that the UW system says that the requirements in the bill “overlap substantially” with existing information that is already available. 

The University of Wisconsin system keeps a public dashboard with some of the information that the bill would have required, including for financial aid, retention and graduation, and time and credits to degree.

Evers also vetoed SB 10, which would have mandated that Wisconsin public school districts provide military recruiters with access to common areas in high schools and access during the school day and during school-sanctioned events. He said that while he supports the troops, he doesn’t support lawmakers’ attempts to “usurp” local control of decisions on when and where military recruiters are given access to schools. 

Bill that would have eliminated requirement for Elections Commission appeal

Voters currently can file a complaint to the Wisconsin Election Commission if they allege an election official serving the voter’s jurisdiction has failed to comply with certain election laws or has abused his or her discretion with respect to the administration of such election laws. A voter who doesn’t agree with a WEC decision can appeal to a court, though currently courts are only allowed to take up an appeal if voters have suffered an injury to a legally recognized interest as a result. That requirement was established in a 2025 state Supreme Court decision.

SB 270 would have eliminated that requirement, and Evers said he objected because it “would open the floodgates to frivolous lawsuits that not only burden our courts, but our election systems as well.” 

Penalties for those who falsely claim a service animal

AB 366, which would have allowed housing providers to require documentation for service animals and created penalties for misrepresentation of an animal. Evers said he objects to “the creation of unnecessary barriers for individuals with legitimate disability-related needs.”

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Members of a key CDC advisory committee, known as the Advisory Committee on Immunization Practices, met in Atlanta on Dec. 4. Maya Homan/Georgia Recorder

ATLANTA — A Centers for Disease Control and Prevention committee voted to eliminate a recommendation that all newborn babies receive a vaccine against hepatitis B, ending a policy that has been in place since 1991 to protect Americans against an incurable liver disease that can lead to cirrhosis, cancer and liver failure. 

The current three-dose series for hepatitis B includes one vaccine administered to infants within 24 hours of birth, and subsequent booster shots given one month and six months after the initial dose. The universal vaccination policy is credited with a 99% drop in serious infections among American children between 1990 and 2019.

In its updated guidelines, the agency will continue to recommend that babies born to mothers who test positive for hepatitis B receive a vaccine at birth. However, in all other cases, the decision will be left to “individual-based decision-making,” a change that experts say will lead to an increase in chronic hepatitis B infections. The new recommendation also suggests that parents delay the first dose of the vaccine until at least two months after birth.

Friday’s decision comes after an 8-3 vote from a key CDC advisory committee, known as the Advisory Committee on Immunization Practices, which is charged with setting national guidelines around which people should be vaccinated against a wide range of preventable diseases and when those vaccines should be administered. The recommendations play a key role in determining which vaccines insurance companies are willing to cover and how accessible those immunizations are to the public.

The two-day meeting included several presentations from prominent anti-vaccine activists, including Aaron Siri, a vaccine injury lawyer who has previously represented U.S. Health Secretary Robert F. Kennedy Jr. and reportedly helped him vet health officials for President Donald Trump’s administration. At least two of them — Cynthia Nevison, a climate researcher who has ties to anti-vaccine groups, and Mark Blaxill, a former consultant and author — were recently hired by the CDC.

Retsef Levi, an ACIP member and professor of operations management at the Massachusetts Institute of Technology, called the updated recommendation a “very positive change in policy,” arguing that blanket vaccine recommendations force newborns to serve as “a safety net for adults’ mistakes.”

But Dr. Cody Meissner, another member of the committee who also serves as a professor of pediatrics and medicine at Dartmouth College, argued that the vaccines play a crucial role in protecting infants from the disease, and said there was no valid scientific evidence to support the changes implemented by the panel.

“Thoughtful inquiry is always commendable,” he told the committee. “But that inquiry should not be confused with baseless skepticism, which is what I think we’re encountering here.”

Sandra Fryhofer, a doctor and liaison for the American Medical Association, also criticized the move, arguing that implementing guidelines based on the mother’s hepatitis status will leave babies vulnerable to developing the disease from other sources, such as infected relatives. According to CDC data, roughly half of people with hepatitis B do not know they are infected.

“Are we going to test every patient that has access to or touches that baby?” she asked the committee Thursday. “I mean, that’s not something that’s really doable.”

The updated recommendation for the hepatitis B vaccine mirrors COVID-19 vaccine guidelines passed by the same panel in September, which place new emphasis on the risks of immunizations, though the CDC’s own data shows that the vaccines are safe and effective for most people. 

A second vote, which passed 6-4, encourages parents to discuss using serology testing, a type of blood test that measures antibodies to gauge how well a patient’s immune system has responded to a disease, before allowing their children to receive additional doses of the hepatitis B vaccine.

The changed recommendations will not prevent doctors from administering hepatitis B vaccines to newborns, but critics say they could create additional hurdles for families and healthcare providers.

“Adding excessive or ambiguous language around shared decision-making for routine vaccines muddies the waters, creates a false sense of scientific uncertainty and places unnecessary burden on clinicians and families,” said Dr. Natasha Bagdasarian, who was representing the Association of State and Territorial Health Officials.

Children enrolled in Medicaid or the Vaccines for Children program, which provides free immunizations to children who are uninsured or underinsured, will continue to be eligible for hepatitis B vaccines at birth under the new recommendations, according to program liaisons.

Federal fallout

As with the new COVID-19 vaccine recommendations, the updated hepatitis B guidelines will not take effect until being officially signed off by the acting CDC Director, Jim O’Neill.

But amid shifting federal guidance on public health policies, a growing number of state and federal officials are developing their own policies rather than relying on the agency’s guidelines. In a Dec. 3 letter sent ahead of ACIP’s meeting, more than 30 members of Congress urged O’Neill to maintain the existing recommendations, regardless of what the advisory committee decided.

“There is no data to support delaying the first immunization to one-month, four years, or 12 years of age,” the letter states.

U.S. Sen. Bill Cassidy, a Louisiana Republican who heads the Senate Health, Education, Labor and Pensions Committee, also called for O’Neill to forgo signing the updated recommendations.

“As a liver doctor who has treated patients with hepatitis B for decades, this change to the vaccine schedule is a mistake,” he wrote in a social media post after the vote. “The hepatitis B vaccine is safe and effective. The birth dose is a recommendation, NOT a mandate.”

Cassidy, a doctor, cast the deciding vote to confirm Kennedy as health secretary on the condition that Kennedy “maintain the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices without changes.” Kennedy later backtracked on that promise, firing all 17 previous members of the committee and replacing them with a slate of hand-picked appointees, many of whom are seen as vaccine skeptics.

In a Thursday social media post, Cassidy criticized the committee for its plans to hear testimony from Siri, the vaccine injury lawyer.

“The ACIP is totally discredited,” he added. “They are not protecting children.”

Older men play cards in a park in New York City's Chinatown in 2024. Medicare, the public health insurance for older Americans, is piloting a new prior authorization program powered by artificial intelligence that some physicians fear will result in more denials and delays in medical care for patients. (Photo by Spencer Platt/Getty Images)

A Medicare pilot program will allow private companies to use artificial intelligence to review older Americans’ requests for certain medical care — and will reward the companies when they deny it.

In January, the federal Centers for Medicare & Medicaid Services will launch the Wasteful and Inappropriate Services Reduction (WISeR) Model to test AI-powered prior authorizations on certain health services for Medicare patients in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. The program is scheduled to last through 2031.

The program effectively inserts one of private insurance’s most unpopular features — prior authorization — into traditional Medicare, the federal health insurance program for people 65 and older and those with certain disabilities. Prior authorization is the process by which patients and doctors must ask health insurers to approve medical procedures or drugs before proceeding.

Adults over 65 generally have two options for health insurance: traditional Medicare and Medicare Advantage. Both types of Medicare are funded with public dollars, but Medicare Advantage plans are contracted through private insurance companies. Medicare Advantage plans tend to cost less out of pocket, but patients enrolled in them often must seek prior authorization for care.

AI-powered prior authorization in Medicare Advantage and private insurance has attracted intense criticism, legislative action by state and federal lawmakers, federal investigations and class-action lawsuits. It’s been linked to bad health outcomes. Dozens of states have passed legislation in recent years to regulate the practice.

In June, the Trump administration even extracted a pledge from major health insurers to streamline and reduce prior authorization.

“Americans shouldn’t have to negotiate with their insurer to get the care they need,” U.S. Health and Human Services Secretary Robert F. Kennedy Jr. said in a June statement announcing the pledge. “Pitting patients and their doctors against massive companies was not good for anyone.”

Four days after the pledge was announced, the administration rolled out the new WISeR program, scheduled to take effect in January. It will require prior authorizations only for certain services and prescriptions that the Centers for Medicare & Medicaid Services has identified as “particularly vulnerable to fraud, waste, and abuse, or inappropriate use.” Those services include, among other things, knee arthroscopy for knee osteoarthritis, skin and tissue substitutes, certain nerve stimulation services and incontinence control devices.

The companies get paid based on how much money they save Medicare by denying approvals for “unnecessary or non-covered services,” CMS said in a statement unveiling the program.

The new program has alarmed many physicians and advocates in the affected states.

“In concept, it makes a lot of sense; you don’t want to pay for care that patients don’t need,” said Jeb Shepard, policy director for the Washington State Medical Association.

“But in practice, [prior authorization] has been hugely problematic because it essentially acts as a barrier. There are a lot of denials and lengthy appeals processes that pull physicians away from providing care to patients. They have to fight with insurance carriers to get their patients the care they believe is appropriate.”

CMS responded to Stateline’s questions by providing additional information about the program, but offered few details on what the agency would do to prevent delays or denials of care. It has said that final decisions on coverage denials will be made by “licensed clinicians, not machines.” In a bid to hold the companies accountable, CMS also incentivizes them for making determinations in a reasonable amount of time, and for making the right determinations according to Medicare rules, without needing appeals.

In the statement announcing the program, Abe Sutton, director of the CMS Innovation Center, said the “low-value services” targeted by WISeR “offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress. They also increase patient costs while inflating health care spending.”

A vulnerable group

Dr. Bindu Nayak is an endocrinologist in Wenatchee, Washington, a city near the center of the state that bills itself as the “Apple Capital of the World.” She mainly treats patients with diabetes and estimates 30-40% of her patients have Medicare.

“Medicare recipients are a vulnerable group,” Nayak told Stateline. “The WISeR program puts more barriers up for them accessing care. And they may have to now deal with prior authorization when they never had to deal with it before.”

Nayak and other physicians worry the same problems with prior authorizations that they’ve seen with their Medicare Advantage patients will plague traditional Medicare patients. Nayak has employees on staff whose only role is to handle prior authorizations.

More than a quarter of physicians nationwide say prior authorization issues led to a serious problem for a patient in their care, including hospitalization or permanent damage, according to the most recent report from the American Medical Association.

And some patients are unfairly denied treatment. Private insurers have denied care for people with Medicare Advantage plans even though their prior authorization requests met Medicare’s requirements, according to an investigation from the U.S. Department of Health and Human Services published in 2022. Investigators found 13% of prior authorization denials were for requests that should have been granted.

But supporters of the new model say something must be done to reduce costs. Medicare is the largest single purchaser of health care in the nation, with spending expected to double in the next decade, according to the Medicare Payment Advisory Commission, an independent federal agency. Medicare spent as much as $5.8 billion in 2022 on services with little or no benefit to patients.

Congress pushes back

In November, congressional representatives from Ohio, Washington and other states introduced a bill to repeal the WISeR model. It’s currently in committee.

“The [Trump] administration has publicly admitted prior authorization is harmful, yet it is moving forward with this misguided effort that would make seniors navigate more red tape to get the care they’re entitled to,” U.S. Rep. Suzan DelBene, a Washington Democrat and a co-sponsor of the bill, said in a November statement.

Physician and hospital groups in many of the affected states have backed the bill, which would halt the program at least temporarily. Shepard, whose medical association supports the bill, said that would give CMS time to get more stakeholder input and give physicians more time to prepare for extra administrative requirements.

“Conventional wisdom would dictate a program of this magnitude that has elicited so much concern from so many corners would at least be delayed while we work through some things,” Shepard said, “but there’s no indication that they’re going to back off this.”

Adding more prior authorization requirements for a new subset of Medicare patients will tack on extra administrative burdens for physicians, especially those in orthopedics, urology and neurology, fields that have a higher share of services that fall under the new rules.

That increased administrative burden “will probably lead to a lot longer wait times for patients,” Nayak said. “It will be important for patients to realize that they may see more barriers in the form of denials, but they should continue to advocate for themselves.”

Dr. Jayesh Shah, president of the Texas Medical Association and a San Antonio-based wound care physician, said WISeR is a well-intentioned program, but that prior authorization hurts patients and physicians.

“Prior authorization delays care and sometimes also denies care to patients who need it, and it increases the hassle factor for all physicians,” he told Stateline.

Shah added that, on the flip side, he’s heard from a few physicians who welcome prior authorization. They’d rather get preapproval for a procedure than perform it and later have Medicare deny reimbursement if the procedure didn’t meet requirements, he said.

Prior authorization has been a bipartisan concern in Congress and statehouses around the country.

Last year, 10 states — Colorado, Illinois, Maine, Maryland, Minnesota, Mississippi, Oklahoma, Vermont, Virginia and Wyoming — passed laws regulating prior authorization, according to the American Medical Association. Legislatures in at least 18 states have addressed prior authorization so far this year, an analysis from health policy publication Health Affairs Forefront found. Bipartisan groups of lawmakers in more than a dozen states have passed laws regulating the use of AI in health care.

But the new effort in the U.S. House to repeal the WISeR program is sponsored by Democrats. Supporters worry it’s unlikely to gain much traction in the Republican-controlled Congress.

Shepard said his organization has talked with state and congressional representatives, met with the regional CMS office twice, and sent a letter to CMS Director Dr. Mehmet Oz.

“We’ve looked at all the levers and we’ve pulled most of them,” Shepard said. “We’re running out of levers to pull.”

Venture capital jumps in

CMS announced in November it has selected six private tech companies to pilot the AI programs.

Some of them are backed by venture capital funds that count larger insurance companies among their key investors.

For example, Oklahoma’s pilot will be run by Humata Health Inc., which is backed by investors that include Blue Venture Fund, the venture capital arm of Blue Cross Blue Shield companies, and Optum Ventures, a venture capital firm connected to UnitedHealth Group, the parent company of UnitedHealthcare. Innovaccer Inc., chosen to run Ohio’s program, counts health care giant Kaiser Permanente as an investor.

Nayak said she knows little about Virtix Health, the Arizona-based private company contracted by the feds to run Washington state’s pilot program.

“Virtix Health would have a financial incentive to deny claims,” Nayak said. “It begs the question, would there be any safeguards to prevent profit-driven denials of care?”

That financial incentive is a concern in Texas too.

“If, financially, the vendor is going to benefit by the denial, it could be a problem for our patients,” Shah said. He said that Oz, in a speech at a recent meeting of the American Medical Association, assured physicians that their satisfaction and turnaround times would be metrics that Medicare would factor into the tech companies’ payments.

Editor’s note: This story has been updated to correct a reference to Medicare Advantage and to CMS Director Dr. Mehmet Oz’s speech to the American Medical Association.

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

A Biden-era protection for reproductive and gender affirming health care information was upended by a federal judge in Texas in June. Despite several lawsuits, key privacy rules for medical records remain, but some experts say they aren’t sufficient. (Photo by Dave Whitney / Getty Images)

The four lawsuits at the center of a Republican-led effort to ensure law enforcement can access reproductive health records are now mostly resolved, after attorneys for Texas Attorney General Ken Paxton agreed last week to dismiss the last remaining suit challenging the legality of a foundational health privacy rule.

Paxton filed the lawsuit in September 2024 arguing that Democratic President Joe Biden’s administration illegally created a rule under the Health Insurance Portability and Accountability Act barring certain reproductive health care information from being disclosed if a procedure such as abortion was obtained in a state where it is legal.

The federal HIPAA law is meant to protect patient information generally, especially when that information travels between providers. It contains exceptions for information that can be disclosed to investigators, who can subpoena records from other states. 

Ashley Kurzweil, senior policy analyst for reproductive health and rights at the National Partnership for Women & Families, said the dual threat that Paxton’s lawsuit presented was alarming on a much wider scale than just reproductive health care, so it is a relief that the case is dismissed. Overturning key privacy protections from 2000 that formed the basis of the Biden-era rule could have thrown the entire health care system into chaos, she said.

“We are thrilled that the 2000 privacy rule is still in effect. It is hugely important that it is still in place,” Kurzweil said. “However, (it) provides insufficient safeguards for reproductive health care information when it comes to the broader landscape of increased criminalization risk that people are facing.”

The 2024 rule specifically relating to reproductive and gender-affirming health care information was nullified in June by U.S. District Judge Matthew Kacsmaryk. His ruling came in a Texas-based case filed by a clinician in a small town who said the rule created a conflict with her responsibility to report child abuse, because she considers abortion and gender-affirming health care to be child abuse.

Without those 2024 protections, doctors can choose whether to report patients to law enforcement, Kurzeil said, and some might also be discouraged from offering reproductive health care altogether to minimize legal risks.  

States Newsroom reported more than 400 people were charged with pregnancy-related crimes in the two years after the U.S. Supreme Court’s Dobbs decision, according to data from the nonprofit Pregnancy Justice. 

One of those people was Brittany Watts, an Ohio woman who went to the hospital with miscarriage complications and waited for hours without receiving help. After miscarrying at home and returning to the hospital, staff called the police, accusing her of abuse of a corpse. A grand jury declined to indict her, and Watts is now suing the hospital. 

In nine of the 400 cases, pregnant people were accused of researching or attempting to obtain an abortion.

Advocacy group dropped effort to appeal Texas ruling

The case before Kacsmaryk is the only one of the four that resulted in a ruling. Although it was filed in the last few months of the Biden administration, the bulk of the case was litigated under Republican President Donald Trump’s Department of Justice.

Repealing the rule was a directive in Project 2025, the conservative blueprint published by the Heritage Foundation. Several prominent anti-abortion organizations were part of the panel that drafted Project 2025, and many of the people involved in writing the 900-page document now work for the Trump administration.

Democracy Forward, a nonprofit legal organization, represented Doctors for America and the cities of Columbus, Ohio, and Madison, Wisconsin, in an attempt to intervene in the case because they did not expect the government to defend the rule. If they were allowed to intervene, they could appeal Kacsmaryk’s opinion striking down the rule regardless of the Trump administration’s decision.

Their attempts were denied by Kacsmaryk, and while the organization did initially appeal that decision, the attorneys dropped the effort in September, saying in a court filing that “the resources of the parties and the courts would be best conserved by dismissing this appeal.”

In a statement to States Newsroom, a spokesperson for Democracy Forward said they will continue to pursue every tool available to defend reproductive rights from political interference and anti-abortion extremists.

The other two cases are in Missouri and Tennessee, where Republican attorneys general also challenged the 2024 reproductive health care-specific rule. The Missouri case was dismissed in September, because Kacsmaryk’s decision had a nationwide effect, and the Tennessee attorney general asked the court to dismiss their case for the same reason. The judge in that case has not yet granted the motion.

Shield laws help, but federal backstop would address more situations

Texas and Louisiana have recently launched investigations into out-of-state doctors who, through telehealth, prescribed and mailed abortion medication to patients in their states where abortion is outlawed.

Texas officials have repeatedly investigated and attempted to prosecute people for either leaving the state to seek abortion care or for prescribing abortion medication from a different state. At the end of October, a New York judge dismissed a civil case brought by Paxton seeking $100,000 in damages from a provider the AG said prescribed abortion pills to a woman in the Dallas area, according to The Texas Tribune. Officials in Louisiana attempted to extradite the same New York doctor on criminal charges related to an abortion medication prescription for a pregnant minor. That case was also rejected.

Those attempts were some of the first that tested shield laws implemented by 18 states, including New York. Four others have executive orders from Democratic governors saying they won’t comply with extradition requests for investigations into reproductive health care.

Texas has also passed a law allowing people to seek at least $100,000 in damages if someone they impregnated or someone they’re related to received abortion pills by mail from another state. That law took effect Thursday, Dec. 4.

Kurzweil said those shield laws are a vital help to patients seeking care, but the addition of a federal protective rule would be ideal.

“The two in tandem would be much more fulsome and would address gaps that come up,” she said.

U.S. Senate Minority Leader Chuck Schumer, D-N.Y., and House Minority Leader Hakeem Jeffries, D-N.Y., speak with reporters during a press conference in the U.S. Capitol building in Washington, D.C., on Wednesday, Dec. 3, 2025. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — U.S. Senate Democratic Leader Chuck Schumer announced Thursday the chamber will vote next week to extend enhanced tax credits for three years for people who purchase their health insurance from the Affordable Care Act marketplace, though the plan seems unlikely to get the bipartisan support needed to advance. 

While it would typically be difficult for the minority leader to schedule a floor vote, Senate Majority Leader John Thune, R-S.D., agreed that Democrats could bring up a health care bill of their choosing in exchange for voting to end the government shutdown.

Schumer told reporters in recent days to “stay tuned” for details about the legislation while maintaining all Senate Democrats were united around the proposal. The three-year plan he previewed during his floor speech appears identical to one House Democratic leaders have been pressing for in that chamber. 

“Any Republican who claims to care about premium increases on January 1 has only one realistic path, and that’s to support our bill for a simple, clean, three-year extension,” Schumer said. “If Republicans block our bill, there’s no going back. We won’t get another chance to halt these premium spikes before they kick in at the start of the new year.” 

The vote will take place next Thursday, Schumer said. 

Clock ticking on solution

Health care costs have surged to the forefront of the national conversation in recent months, with both Democrats and Republicans in Congress pledging to find solutions. Both agree much more time is needed to make larger, structural changes. 

The Senate committee in charge of health care policy held a hearing Wednesday where senators began to coalesce around extending the enhanced tax credits beyond the end-of-December sunset date. But a bipartisan bill has not yet been introduced in that chamber on that subject. 

Health, Education, Labor and Pensions Chairman Bill Cassidy, R-La., said just after the hearing wrapped up there will likely be a GOP bill, or even a bipartisan one, to counter Schumer’s bill. 

“Yeah, absolutely,” Cassidy said. “I’d like to have a plan that both sides can vote for. But there will be a Republican plan if I have anything to do with it.”

Congress has an especially brief time frame to find a short-term resolution on the expiring tax credits, which would lead the cost of ACA marketplace plans to rise by hundreds or thousands of dollars. 

Open enrollment for ACA marketplace plans ends at different times throughout the country, with some states finishing on Dec. 15. Residents of other states are able to sign up through varying dates in January, but with their coverage starting later in the year. Lawmakers are set to leave Capitol Hill on Dec. 19 for their winter holiday break. 

A poll released Thursday by the nonpartisan health organization KFF showed nearly 60% of ACA marketplace enrollees could not cover the costs of a $300 annual increase in their premiums, while an additional 20% said they couldn’t afford a $1,000 jump in prices per year. 

Gottheimer, Kiggans unveil House bipartisan bill

At the same time Schumer was speaking on the Senate floor, a bipartisan group of House lawmakers, led by New Jersey Democratic Rep. Josh Gottheimer and Virginia Republican Rep. Jen Kiggans, introduced a bill they said could address some of the short-term issues facing ACA enrollees. 

“Although we may have different opinions over the long-term solutions for reforming marketplace health care or if there are even better and cheaper options for publicly available health insurance, we agree on the many aspects of the short-term solutions,” Kiggans said. 

The legislation — which needs to pass a floor vote, make it through the Senate and garner President Donald Trump’s signature — would extend the enhanced ACA marketplace tax credits with new income caps, “guardrails for waste, fraud and abuse” and an overhaul of the pharmacy benefit manager, or PBM, system, Kiggans said. 

The bipartisan group of representatives would then move on to the second part of their plan, not included in the bill, where they would try to make more structural changes to the entire country’s health care system. 

Those bills, Kiggans said, would address hospital billing transparency, implement Health Savings Accounts and advance the Give Kids a Chance Act “to accelerate pediatric cancer treatments and expand access to life-saving therapies for children battling rare diseases.”

Gottheimer said the group wants House leaders to put their bill up for a vote before members leave town for the two-week, end-of-year break. 

“In the last month, families have seen their health insurance premiums surge as they’ve shopped for insurance during open enrollment because enhanced premium tax credits are set to expire, as we all know, at the end of the year,” Gottheimer said. “In fact, because of this, for millions of families on the ACA, their health premiums will rise an average of 26% next year. 

“In Jersey, where we live, it could be even rougher with a 175% increase. That’s $20,000 for a family of four. And that’s why we’re all here together to try to solve this problem, do something about it, and avoid a massive new tax on hard-working families,” he said.

Senators don’t see future in bipartisan House bill

Schumer and other Senate Democrats didn’t appear to take the bipartisan House plan seriously when pressed about it during an early afternoon press conference, asking reporters in the room whether Speaker Mike Johnson, R-La., would actually put it on the floor for a vote. 

“As for whatever House proposals there are, we’ll always look at something, but I don’t even see 15 Republicans supporting it right now,” Schumer said. “Sure an individual or two or three people can say this or that. It’s not going to solve the problem.”

Schumer maintained Senate Democrats’ three-year extension, which does not come with income caps or other changes to the tax credits proposed by centrist Republicans, is the best path forward.

He appeared frustrated when reporters asked him why he didn’t include changes that could have swayed at least some GOP senators to vote for the bill. 

Schumer said it wasn’t worth it for Democrats to put together a bill that a few Republicans might support when he doesn’t expect Speaker Johnson to put the bill on the floor in that chamber given strong opposition to the enhanced tax credits by “half his caucus.”

“Come on,” he said. “The fault is there, not with us.”

The website of Connect for Health Colorado, the state's health insurance marketplace, is pictured on Aug. 27, 2025. (Photo by Chase Woodruff/Colorado Newsline)

WASHINGTON — Americans who purchase their health insurance through the Affordable Care Act marketplace are bracing for a steep rise in costs next year that many say they will not be able to afford, according to a poll released Thursday by the nonpartisan health organization KFF.

Nearly 60% of enrollees surveyed could not cover the costs of a $300 annual increase in their premiums, while an additional 20% said they couldn’t afford a $1,000 jump in prices per year. 

About 90% of those polled said it would be somewhat or very difficult to afford health insurance within their budget if they could no longer purchase a plan through the ACA marketplace.

The spike in prices is predominantly due to the end-of-year expiration date for enhanced tax credits for ACA marketplace plans. Republicans in Congress have so far declined to extend the subsidies, while Democrats shut down the government in an unsuccessful attempt to continue the credits.

While increases would vary considerably based on location, income and plan type, a Sept. 30 KFF analysis projected individuals’ annual premiums would rise between around $350 and more than $1,800.

Open enrollment for ACA marketplace plans ends at different times throughout the country, with some states finishing on Dec. 15. Residents of other states are able to sign up through varying dates in January, but with their coverage starting later in the year. That doesn’t give Congress much time to broker a deal before the ability to purchase a plan for next year closes.

No progress on negotiations

The Senate is expected to vote next week on a Democratic bill to extend the subsidies, though that legislation appears unlikely to get the 60 votes needed to advance in the Republican-controlled chamber. 

The Health, Education, Labor and Pensions Committee held a hearing this week to explore short- and long-term options to bring down health care costs, but senators on that panel didn’t reach a clear consensus. 

KFF President and CEO Drew Altman said in a statement the “poll shows the range of problems Marketplace enrollees will face if the enhanced tax credits are not extended in some form, and those problems will be the poster child of the struggles Americans are having with health care costs in the midterms if Republicans and Democrats cannot resolve their differences.”

The KFF poll showed only 9% of marketplace enrollees have a lot of confidence that Republicans in Congress will address rising health insurance costs, with 24% saying they had some confidence, 25% saying they didn’t have much confidence and 42% responding they had no confidence in GOP lawmakers on that particular issue.

Blame falls to Trump

ACA marketplace enrollees would predominantly fault President Donald Trump if their overall health care costs, including premiums, co-pays and deductibles, were to increase by $1,000 next year, though Republicans and Democrats in Congress would share nearly as much blame, the survey found.

Thirty-seven percent would place the responsibility with Trump, while 33% would cite GOP lawmakers and 29% would fault Democrats with the rising costs.

Those numbers fluctuate significantly depending on a person’s political affiliation, with 65% of Republicans saying they would blame Democrats, while 20% would credit Republicans in Congress and 14% would fault Trump.

Forty-four percent of people who identified as independents said they would blame Trump, while 32% said they would cite Republicans in Congress and 23% said they would fault Democrats.

Among Democrats, 49% would blame Trump, 46% would credit congressional Republicans, with the remainder would fault members of their own party.

KFF conducted the survey of 1,350 people between Nov. 7-15. It has a margin of error of plus or minus 3 percentage points for the full sample, with a plus or minus 6 percentage points margin of error for political party affiliation questions.

Louisiana Republican U.S. Sen. Bill Cassidy talks with reporters in the Dirksen Senate office building on Wednesday, Dec. 3, 2025. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — The U.S. Senate committee that oversees health care started coalescing around an approach to lower costs for Americans during a Wednesday hearing, though several hurdles lay ahead.

Republicans and Democrats on the panel appeared to accept that enhanced tax credits for people who purchase their health insurance from the Affordable Care Act marketplace should not expire at the end of the year. Just days are left for open enrollment and premiums are expected to greatly increase. 

The bipartisan momentum among a select group of senators will need to build significantly in the days ahead if an extension of the subsidies is going to speedily garner the 60 votes needed to advance in the Senate and then move through the GOP-controlled House. 

It will also need President Donald Trump’s signature to become law, and he has so far not signaled support for an extension.

“I’m hoping that we can find a bill that can get 60 votes, that can fix the problem with the exchanges for January 1, 2026,” Health, Education, Labor and Pensions Committee Chairman Bill Cassidy, R-La., said. “It shouldn’t be a Republican solution. It shouldn’t be a Democratic solution. It should be an American solution.”

Cassidy cautioned lawmakers on the panel from pressing for “grandiose ideas,” saying Congress must “have a solution for three weeks from now.”  

A ‘political problem’ seen for the GOP

But extending the ACA marketplace subsidies, possibly with tweaks, is just a short-term solution that senators on the committee agreed will need to be followed up with an overhaul of the American health care system. 

Any efforts on larger-scale legislation will bump up against the deeply entrenched politics of the Affordable Care Act, well-funded lobbyists and next year’s midterm elections, none of which will make the process easy. 

Vermont independent Sen. Bernie Sanders, the ranking member on the panel, said he appreciated Cassidy’s “sentiment about wanting to do something quickly,” but said Republicans should have focused on the expiring ACA tax credits earlier in the year, instead of leaving it until now.  

“The reason for this hearing, to be frank, is that my Republican friends understand they’ve got a political problem,” Sanders said. “Their political problem is that all over America today, people on the Affordable Care Act are opening up packages coming from the insurance companies, and guess what? Their premiums on average are doubling and in some cases in my state are tripling or quadrupling.”

Sanders said Congress should extend the enhanced ACA marketplace tax credits for another year, or two, or three, while lawmakers sort through larger, structural issues around health care costs. 

“Yes, the current system is broken. Yes, we need to create a new system,” Sanders said. “But unfortunately, we aren’t going to do it in two weeks.”

Sanders suggested the committee hold a series of hearings in the months ahead featuring leaders from other developed countries that provide health care to all of their residents.

Extensions of tax credits debated

Maine Republican Sen. Susan Collins said “there’s a limit to what we can do in this first year” and that lawmakers are “going to need a two-year plan.”

Collins indicated that she wants to see “reasonable” income caps to limit eligibility for ACA marketplace tax credits in any short-term extension that Congress may pass. 

Washington state Democratic Sen. Patty Murray said Republicans who are serious about addressing the spike in costs for ACA marketplace enrollees should work with Democrats to pass a “clean, one-year extension” of the enhanced subsidies. 

“And if their call for reforming tax credits is serious, we should look at that. We can talk about those reforms ahead of the 2027 year,” Murray said. “But I have to say, I’m not optimistic that most Republicans are serious about this because they refused to talk about this problem before right now, and I’ve been down this road before.”

Murray also rebuked Cassidy for not focusing the committee’s attention on the expiring tax credits earlier in the year by taking a swipe at his vote to confirm Health and Human Services Secretary Robert F. Kennedy Jr.

“This is about as serious as expressing concern about RFK Jr.’s anti-vax crusade after voting to make him the most powerful public health official in the country,” Murray said.

‘Reasonable caps’ backed

Alaska Republican Sen. Lisa Murkowski said members of the committee need to focus on what the next few months and years look like for Americans’ health care costs. 

“I think we’re going to need to have a short-term extension. But I think we can put reasonable caps on. I think that we can put some of the parameters that we have been talking about. There’s no great secret sauce here to how we’re going to deal with this particular dilemma that we’re in,” Murkowski said. “But we’ve got to be looking longer term to — how do we ultimately reduce these costs of care?”

Murkowski said she was also concerned about a decrease in funding for public health and prevention initiatives, before asking the witnesses appearing before the committee what their top recommendations would be for “prevention-type programs that have the strongest evidence for reducing long-term costs.”

Joel White, president of the Council for Affordable Health Coverage in Washington, D.C., said Congress should allow “premium discounts in the individual market for wellness programs,” which he said is currently illegal.

Marcie Strouse, owner and partner at Capitol Benefits Group in Des Moines, Iowa, suggested lawmakers open up health savings accounts “to allow for more holistic and preventive services.” She also said Congress could highlight “direct primary care and making sure people are actually getting the care that they need.”

Dr. Claudia M. Fegan, national coordinator at Physicians for a National Health Program in Chicago, suggested enhanced primary care and screening people for diseases like cancer that can be easier to treat when caught early. 

Wisconsin Democratic Sen. Tammy Baldwin said the hearing clearly demonstrated that there is “underlying agreement that this system needs a lot of reform.”

But, she said, Congress needs to take a look at the entire health care system, not just the Affordable Care Act. 

“I want to make a point that just under 50% of Americans get their health insurance through employers or group insurance, 20% are on Medicaid, 15% on Medicare, 1% on TRICARE or VA, and just over 6% are in this market,” Baldwin said. “There are problems with this market. But I have to say that abandoning the ACA … is not going to solve the system as a whole.”

Ohio Republican Sen. Jon Husted appeared supportive of a short-term extension of the enhanced ACA tax credits to provide Congress more time to address larger issues with health care affordability.

“We can freeze the subsidies where they’re at right now for a temporary period of time. I don’t know if that’s one year or two years to help give some relief,” he said. “And by the way, just because we continue those tax credits does not drive down the cost. It transfers the burden to the taxpayer and future generations. But it is a little help right now that we both can agree on. And then we’ve got to fix it.” 

Husted said there are easily a dozen bills that Congress could take up individually to start bringing down health care costs. 

Hawley offers plan for health costs tax exemption

Missouri Republican Sen. Josh Hawley also appeared to side with extending the enhanced ACA marketplace tax credits in the short term.

“We are looking at a massive crisis unless Congress acts and acts soon,” Hawley said. “And my message is to the leadership of this body — to the leaders of the House, the leaders of the Senate —maybe it’s time we all locked ourselves in a room and got to a solution here.”

Halwey pitched a bill he just introduced to exempt health care from taxes. 

“If you pay premiums, you ought to be able to deduct that from your taxes. If you have out-of-pocket medical expenses, you ought to be able to deduct every dollar off of your taxes. You want to lower the cost of health care immediately. Do that. No taxes on health care for any American,” Hawley said. “And you set an upper limit so you don’t have rich people gaming the system. I get it. That’s fine. But let’s think about working people in this country who cannot afford health care.”

Hawley said it should be allowed whether an American itemizes on their taxes or not. 

All three panelists seemed initially supportive of the idea. 

Redoing tax credits in 2026

Cassidy said after the two-hour hearing he’s working to get support from lawmakers in both political parties for an integrated approach for next year.

“You could use the income that would be used to extend the subsidies, apply them to the bronze plan, because the bronze plan is so much less expensive. You could then put that balance into the health savings account,” Cassidy said, referring to coverage levels in plans on the ACA marketplace. “So it does continue the support using the existing mechanisms we have, but integrates the HSA, which gives first dollar coverage and could potentially lower the net deductible.”

Cassidy said Congress could extend the open enrollment period for the ACA marketplace and then fund the Health Savings Accounts, which are tax-advantaged savings accounts, before the end of March. 

“People would save their receipts and submit them for payment,” he said. “People do that all the time.”

Senate Majority Leader John Thune, R-S.D., speaks to reporters while walking to his office on Nov. 10, 2025 on Capitol Hill in Washington, D.C. (Photo by Tom Brenner/Getty Images)

WASHINGTON — Republicans and Democrats in the Senate agree that health care costs are rising too quickly and expect to vote next week on legislation that could help Americans. 

The only catch is that party leaders hadn’t decided as of Tuesday what to include in the bills. 

Senators also seemed to accept that neither proposal will garner the bipartisan support needed to advance, leaving the tens of millions of Americans who purchase their health insurance from the Affordable Care Act marketplace with complicated decisions to make before open enrollment in some states ends as soon as Dec. 15. 

ACA marketplace plans are expected to increase by 26% on average next year, though a failure by Congress to extend enhanced tax credits would lead monthly payments for subsidized enrollees to increase by 114% on average, according to analysis from the nonpartisan health organization KFF. 

“I don’t think at this point we have a clear path forward,” Senate Majority Leader John Thune said. “I don’t think the Democrats have a clear path forward.”

Vote on Democratic bill expected

Thune guaranteed a small group of Democratic senators a floor vote on a health care proposal of their choosing in exchange for their votes on the spending package that ended the government shutdown. 

Democrats are widely expected to put forward a bill to extend enhanced tax credits for people who buy their health insurance from the Affordable Care Act Marketplace. Those subsidies are set to expire at the end of the year without congressional action. 

But it isn’t clear if the Democratic bill would extend the credits for one year or a longer period. 

GOP leaders are trying to rally support around a health care proposal of their own, while acknowledging it won’t get the 60 votes needed to advance under the Senate’s legislative filibuster rules. 

Thune said Republican senators had a “robust discussion” about health care issues during their closed-door lunch, where Finance Committee Chairman Mike Crapo of Idaho and Health, Education, Labor and Pensions Committee Chairman Bill Cassidy of Louisiana presented some ideas. But no final agreements were reached. 

Thune, R-S.D., said conversations will continue ahead of the vote next week and likely afterward.

Senate Minority Leader Chuck Schumer of New York said Democrats “have a plan” but declined to say exactly what it entails.

“Stay tuned,” Schumer said. “We had a great discussion and I will tell you this: We will be focused like a laser on lowering people’s costs.”

Looking for a solution

West Virginia Sen. Shelley Moore Capito said Republican talks on health care have been “vigorous” but that they hadn’t yet “decided on the clear path.” 

Capito said her “expectation” is that GOP senators will put a bill on the floor next week to bring down the costs of health insurance premiums and health care as quickly as possible, though that hadn’t been finalized.  

“I like the idea of people having control of the money as opposed to insurance companies, where they take a 20% profit,” Capito said, echoing comments by President Donald Trump. “I think that has merit.”

Capito said senators didn’t discuss during their lunch whether to extend open enrollment or possibly reopen it next year, should Congress pass a health care bill that addresses the ACA marketplace tax credits in some way.

New Hampshire Democratic Sen. Jeanne Shaheen said there is no indication there will be bipartisan agreement to extend the enhanced ACA subsidies or any other health care proposal by next week’s vote, though bipartisan conversations continue.  

As for Democrats’ plan, Shaheen said it wasn’t “clear” what legislation party leaders will put on the floor for a vote or when they’d make that announcement. 

‘Mindful of the timeline’

North Dakota Republican Sen. John Hoeven said there is “strong support” among GOP lawmakers for making changes to how the enhanced ACA tax credits work before extending them for any length of time. 

But he said those negotiations will take more time. 

“In my opinion, if we have (the vote) next week, we probably won’t be at a point where we can get a big bipartisan agreement,” Hoeven said. “It’s more likely they’ll put something up that fails. We put something up that fails. And we keep working towards, hopefully, something that can work and that is bipartisan.”

There is a “good chance,” he said, that will happen in December or January, a timeline that would likely put a solution after open enrollment closes. 

Hoeven declined to say if a deal would extend open enrollment or include a second window for Americans to select insurance, but said Republicans are aware of the deadlines. 

“We’re very mindful of the timeline,” Hoeven said. “So all the things we’re talking about recognize that it needs to be able to take effect next year or this year.”

The Bottles and Breastfeeding Equipment Screening Enhancement Act became law on Nov. 25, 2025. The bipartisan legislation aims to strengthen protocols for Transportation Security Administration employees handling breast milk, formula and related items. (Getty Images) 

After years of advocacy efforts, a bipartisan measure became law last week to make travel easier for parents who encounter problems going through airport security with breast milk and formula.

Congress passed a law in 2016 that deemed breast milk, formula and toddler drinks “medically necessary liquids” that can go on planes and in carry-ons in quantities larger than 3.4 ounces, along with ice and gel packs and other related accessories. But airport security officers are not always trained on the policy, and parents continue to face issues nearly a decade later, States Newsroom reported, sometimes experiencing flight delays or being forced to dump milk handled unhygienically. 

Three years ago, after a bad experience in an airport, engineer and science TV host Emily Calandrelli called on Congress to make the Transportation Security Administration enforce its own breast milk policy. She’s championed the legislation alongside lobbying groups like Chamber of Mothers, founded by working moms in 2021. 

The group’s cofounder and CEO Erin Erenberg said in a statement that the measure’s passage was “a victory for every parent who has been mistreated or dismissed while simply caring for their baby.”

The Bottles and Breastfeeding Equipment Screening Enhancement Act was approved unanimously in both chambers of Congress this year. It ensures that TSA streamlines standards and requires officers to follow protocol when screening passengers who are breastfeeding and carrying milk, formula or juice on planes for their babies. Within 90 days of the bill being signed by President Donald Trump on Nov. 25 — and then every five years after that — the agency must issue or update guidance to minimize the risk of contamination.

“I’m thrilled to say that the BABES Act is officially the law of the land,” said Democratic Rep. Eric Swalwell of California in a statement Monday. “As a husband and father, I know how challenging it can be to fly with a newborn. … This is about dignity, peace of mind, and protecting families at one of the most vulnerable moments of parenthood.”

“This bill guarantees clear rules, proper training, and full transparency so parents can travel knowing their baby food will be protected, not mishandled or thrown away,” said Republican Florida Rep. Maria Salazar in a statement. 

Under the measure, TSA agents must maintain hygiene standards when handling breast milk, formula and related items — ice packs or other cooling devices, for example — to lessen the chance of contamination. The law also directs the Department of Homeland Security Office of Inspector General to audit TSA compliance with the law and submit a report to Congress within one year of enactment.

Salazar cosponsored the bill in the House alongside GOP Florida Rep. Anna Paulina Luna and Democratic Reps. Swalwell and Brittany Pettersen of Colorado. 

“Like so many moms, I’ve experienced the frustration of having to throw out milk or pumping supplies, despite them being TSA-approved. Outdated regulations or lack of training shouldn’t add to an already stressful situation,” Pettersen said in a statement. 

The Senate passed the bill with unanimous approval in May. GOP Sens. Ted Cruz of Texas and Steve Daines of Montana carried the bill in the upper chamber along with Democratic Sens. Mazie Hirono of Hawaii and Tammy Duckworth of Illinois. 

“Our bipartisan legislation will ensure the TSA keeps its employees up to speed on their own policies and updates those policies as necessary. It’s the least we can do to help parents travel through airports with the dignity and respect they deserve,” Duckworth said in a statement. 

This year is the first time the bill advanced in both chambers despite being introduced several times in previous sessions. 

During his testimony before the bill’s passage in the House on Nov. 17, Swalwell thanked Calandrelli for speaking out about her experience of being forced to check her ice packs and being questioned for needing breastfeeding supplies while traveling without an infant. 

“It is a success story for anybody who believes that they can write to their legislator and see a change in the laws that govern us,” Swalwell said.

Calendrelli said the same thing to her followers on Facebook.

“But now, 3.5 years later — we turned a terrible experience into a Bill that will become a law. That humiliation to legislation pipeline, amirite?”

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.