Wisconsinites could be in store for a rough flu season thanks to a more active virus and the continued decline in vaccination rates this year. Fewer than 26 percent of […]
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A CBD shopkeeper discusses the myriad of cannabis-related bills and laws and their effects on Wisconsin, especially for border areas near Minnesota, Michigan and Illinois where recreational marijuana is legal.
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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.
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.
– Sheer Health co-founder Jeff Witten
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.
This story was originally produced by Stateline, which is part of States Newsroom, a nonprofit news network which includes Wisconsin Examiner, and is supported by grants and a coalition of donors as a 501c(3) public charity.
The Trump administration is no longer considering nursing as a professional degree. That means getting financial help to complete advanced degrees in nursing could become more difficult at a time when Wisconsin is facing a shortage.
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Abbott Laboratories is buying Madison-based biotechnology company Exact Sciences in a $23 billion deal, the companies announced Thursday.
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A farmhouse sits along a gravel road near Elgin, Iowa. For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a new report. (Photo by Scott Olson/Getty Images)
For at least the next dozen years, rural areas will continue to have only about two-thirds of the primary care physicians they need, according to a report released Monday.
The nonprofit Commonwealth Fund based its analysis on federal health workforce data. Its report comes just days after states applied for portions of a $50 billion rural health fund included in the broad tax and spending law President Donald Trump signed in July. Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one.
About 43 million people live in rural areas without enough primary care physicians, according to the report. Across the country, nearly all — 92% — of rural counties are considered primary care professional shortage areas, compared to 83% of nonrural counties. Forty-five percent of rural counties had five or fewer primary care doctors in 2023. Roughly 200 rural counties lacked one altogether.
Nationally, the report found there was an average of one physician per 2,881 rural residents. States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician.
Rural residents are less likely to use telehealth for primary care, largely because of limited broadband internet access. About 19% of rural respondents said they received health care from a primary care physician via telehealth over the past year, compared with the national average of 29%.
The report also took the pulse of states’ participation in national programs for rural areas, such as a federal loan repayment and scholarship program for physicians working in areas with a shortage of health care providers. In 2023, 40% of rural counties had at least one primary care clinician participating in the program — compared to 60% of nonrural counties.
While the demand for primary care physicians will surpass the supply, the study estimates that the supply of rural nurse practitioners will exceed demand over time, as nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the authors wrote.
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.
This story was originally produced by Stateline, which is part of States Newsroom, a nonprofit news network which includes Wisconsin Examiner, and is supported by grants and a coalition of donors as a 501c(3) public charity.
Updated versions of the COVID-19 vaccine became available this fall, and many Wisconsinites have questions about the timing of when they should get vaccinated.
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The Wisconsin Department of Health Services recently applied for $1 billion in federal funds to support three areas of rural health care: workforce, technology and care coordination services.
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Wisconsin lacks standards or health advisory limits for more than half of pesticide-related chemicals analyzed in the state, and there are currently no state surface water standards for pesticides.
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Karen Iverson Riggers scrawls on a giant notepad as the 12 people around her call out rules they think should govern the next two days they’ll spend together: “It’s OK to cry.” “Authenticity over correctness.” “Judgement-free zone.” “Say it messy.”
The group — a mix of mental health professionals, children and family workers and curious residents — is kicking off an “emotional CPR,” or “ECPR,” workshop, a community public health training teaching how to assist someone in crisis or emotional distress.
Training leaders Iverson Riggers and Lynn McLaughlin have dedicated the last several years to encouraging northeast Wisconsinites to deeply connect with one another — and giving them a free community space to do so — in hopes they can combat the social isolation many feel today.
“This is not an individual problem. It’s not like you are doing something wrong because you’re lonely or feeling isolated,” Iverson Riggers said. “This is a community design issue … Lots of folks are being forced to work themselves to death without having any free time to engage in any kind of community or connection.”
The pair founded Ebb & Flow Connections Cooperative, which runs a Community Living Room in downtown Appleton. They describe it as an “unconditionally welcoming” space, where community members can socialize, play games, hang out or confide in certified ECPR practitioners.
“There’s no requirement to belong,” McLaughlin explained. “You just do.”
Their approach to teaching social connection has proved successful enough that groups in several other Wisconsin counties are now trying to replicate the resources they offer. Plus, several state entities say their model is a method for building connection to prevent suicide.
With funding from the Medical College of Wisconsin, the pair spent two late-October days in Oshkosh training Winnebago County residents and workers.
Attendees practiced how to effectively listen to and assist people who are struggling, as a means to prevent self-harm and further distress. After the workshop, they’d be considered an ECPR “practitioner” and could go on to eventually work as a listener in a living room.
The pair’s idea for bringing more northeast Wisconsin residents together was born several years ago, when they were sitting in Iverson Riggers’ living room, discussing the unhelpful ways people typically respond to those struggling with mental health issues. They also lamented the general loss of “third spaces,” or places outside of home or work where people casually connect with their community without a cost barrier.
“So we said, ‘You know, what if there was a space where folks could go and could just be?’” Iverson Riggers said.
That question led them to devise the idea of the Community Living Room, where people could do just that.
In 2023, they received a grant from the Community Foundation for the Fox Valley Region, which they used to launch the concept as a pop-up event in different places — the local library, community gatherings, the children’s museum. There was always food and several ECPR-certified listeners in attendance.
Thanks to the relationships they built hosting pop-ups, a local developer gifted them space to open a permanent downtown Appleton location in October 2024. They pay just $1 in rent annually.
“It was created to break down all the barriers that people find to seeking support,” Iverson Riggers said. “There’s no appointments and no forms. There’s no requirement of a certain kind of identity or diagnosis. There’s no requirement about how you engage.”
Inside the space, which resembles a large apartment, several cozy couches invite visitors to get comfortable. There are tables to sit at or partake in board games or puzzles. A small kitchen area with a fridge is stocked with fresh snacks. A poster on the wall permits people to take what they need — clothing, food, safe sex tools, hygiene supplies and even Narcan.
“It just says something about creating a space … where we can go and connect and feel welcome without having to buy anything, without having to be a certain way, without having to conform to whatever the rules of the space are,” Iverson Riggers said.
How people use the space varies. Some simply pop in for a snack or a drink or to use the bathroom. Two visitors regularly come in and practice playing the guitar. Others want to connect one-on-one with the “listeners” trained in ECPR — at least two people who have taken the training are paid $50 per hour to be present.
While the staff are trained to help people who are experiencing emotional crises and are more than ready to assist if needed, the living room aims to be a “prevention space,” they said. They believe that if people feel less lonely and isolated, or know they have somewhere where they can get support, they may not reach the point of crisis.
“You know, it’s not just this joy-filled, ‘everything is peaceful’ (place),” McLaughlin said. “We’re learning how to navigate conflict in community. We’re learning how to support people in distress, in community.”
Since they started offering community ECPR workshops roughly seven years ago, they’ve helped train more than 2,500 people.
For years, they felt they were “pounding the pavement” to spread the word about their ideas for connecting neighbors. Now, they’ve turned a corner and have seen a steady increase in demand.
Community members across Wisconsin, including in Winnebago, Brown, Sauk and Sheboygan counties, have shown interest in replicating their approach. Prevent Suicide Wisconsin also shared Ebb & Flow’s approach in its 2025 Suicide Prevention Plan as a model for using peer support to reduce deaths by suicide.
Thanks to this, Iverson Riggers and McLaughlin expect they’ll soon be “overwhelmed” with interest. The increased attention has come with its own challenges — they had to cut back on meetings with people who want to replicate their approach in other counties. It’s also been hard to keep up with the demands of “chasing down funding” and keeping the downtown Appleton space in shape, Iverson Riggers said.
Lanise Pitts, a practitioner certified in ECPR, said she was drawn to the warmth of the cooperative and kept returning to events after she attended the training. The Community Living Room allows her to connect with people from different circles and different career paths that she would likely never meet otherwise, she said.
“When people just come in, it’s just like being welcomed to somebody’s house. Come in, find something to do, kick your feet up,” Pitts said while curled up on a couch in the living room. “When they leave, after we’ve done puzzles or colored or played card games or music games or had a 30-second dance party, it’s just like the weight gets lifted. Like you might come in with a lot of baggage, but when you leave out, you’re leaving some of that behind, and it just kind of dissipates.”
The Community Living Room currently has funding to be open two days a week. See a schedule here.
Miranda Dunlap reports on pathways to success in northeast Wisconsin, working in partnership with Open Campus. Email her at mdunlap@wisconsinwatch.org.
Wisconsin Watch is a nonprofit, nonpartisan newsroom. Subscribe to our newsletters for original stories and our Friday news roundup.
Feeling lonely? Appleton’s Community Living Room offers an antidote to isolation is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.
As the government shutdown approaches its end, Democratic U.S. Sen. Tammy Baldwin said hundreds of thousands of Wisconsinites could see their health care costs soar.
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Blister packs of hormone replacement therapy medication. (Getty photos)
WASHINGTON — The U.S. Food and Drug Administration announced Monday it plans to remove warnings from hormone replacement therapy drugs that can be used to address symptoms of menopause, saying the statements are no longer needed.
The black box warning, the strongest caution possible from the FDA, was added in the early 2000s after a study from the Women’s Health Initiative showed an uptick in rates of blood clots, breast cancer, heart attacks and strokes for women who used certain types of hormone replacement therapy.
FDA Commissioner Marty Makary said during a press conference the change for estrogen-related products “is based on a robust review of the latest scientific evidence.”
Makary rebuked the medical establishment for not putting enough effort into researching women’s health conditions, including menopause.
“A male-dominated medical profession, let’s be honest, has minimized the symptoms of menopause, and as a result, women’s health issues have not received the attention that they deserve. More than 80% of women have notable severe symptoms lasting up to eight years. How could the medical establishment get it so wrong for so long?” Makary said. “Women deserve the same rigorous sciences as is used for men.”
Department of Health and Human Services Advanced Research Projects Agency for Health Director Alicia Jackson said the black box warning on estrogen was based on “the flawed, overgeneralized and misinterpreted WHI study.”
Jackson said menopause leads to a series of complicated and often painful experiences for women, including “sleepless nights, derailed careers, painful sex, broken bones and a loss of wellbeing.”
Jackson explained that when the level of estrogen drops throughout and after menopause, “a cascade of disease and aging begins.”
“A preponderance of data now shows that estrogen, when started early, acts as a protective shield for the brain, lowering risks of memory loss, mental health decline and neurodegenerative disease, even Alzheimer’s,” Jackson said.
Makary said women should talk with their doctors and can request their estrogen levels be monitored as they approach the age where menopause typically begins and throughout that years-long process.
He said that sometimes doctors can prescribe microdosing for hormone replacement therapy, followed by a half-dose and eventually a full dose as a woman’s estrogen levels decrease over time.
Makary didn’t say how many of the companies that produce hormone replacement therapies plan to remove the black box warning but said he expects nearly all will do so.
“Companies are, generally speaking, very excited when the FDA tells them they can remove a scary warning on your product,” he said.
The FDA’s process for removing the black box warning requirement, Makary said, began with an expert panel earlier this year. The FDA’s subject-matter experts then conducted a “comprehensive review of the literature” and recommended the agency remove the requirement, which Makary accepted.
The scientists who were part of the expert panel, he said, have written an article that will be published in the Journal of the American Medical Association.
President of the American College of Obstetricians & Gynecologists Steven J. Fleischman wrote in a statement that he “commends the HHS leadership for improving the lives of perimenopausal women by making the estrogen products they need more accessible to them.”
“The modifications to certain warning labels for estrogen products are years in the making, reflecting the dedicated advocacy of physicians and patients across the country,” Fleischman wrote. “The updated labels will better allow patients and clinicians to engage in a shared decision-making process, without an unnecessary barrier, when it comes to treatment of menopausal symptoms. ACOG has long advised clinicians to counsel patients based on an individual’s unique risk factors and treatment goals; this announcement does not change ACOG’s guidance on estrogen therapy.”
Instances of movement disorders such as Parkinson's Disease and essential tremors are up. Fortunately, treatment is advancing as well. A neurosurgeon talked to Larry Meiller about the latest procedure available in Wisconsin.
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Wisconsin will be short by more than 10,000 nurses in 15 years, according to the state’s Department of Workforce Development. A professor at UW-Oshkosh told WPR’s “Wisconsin Today” one way to address the shortage is to bring more men into the profession.
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FRISCO, Texas – An Illinois transportation director shared the story of how propane school bus implementation turned things around for students with special needs.
Recently retired Diana Mikelski has 32 years of experience in student transportation and, until this summer, served as director of transportation for Township High School District 211 in Illinois, overseeing 163 buses and 45 vans transporting nearly 9,000 students more than 7,700 miles each school day.
She recalled in the Blue Bird-sponsored TSD Conference Lunch and Learn Saturday afternoon that the construction of a new parking lot necessitated a change to where the school buses were parked. When school bus drivers started the ignition on the diesel vehicles, the smoke penetrated a nearby school building. Things got so bad. the principal came running out to alert the drivesr of the issue.
Seeking a cleaner energy option, she said district administrators consulted with nearby districts and chose propane as the new fuel to transition to. She received a budget of $1 million approved by Township High School District and paired it with EPA grant money to initially purchase and implement 15 propane buses, in what she described as a “seamless” process working with Blue Bird, ROUSH CleanTech, fuel provider AmeriGas, and local vendors.
Mikelski reviewed the extra particulate matter filters and treatment that older diesel buses require, which means more work and more money spent. District bus mechanics adjusted to propane well, she said.
“My shop was fine. If you can handle diesel and gas, you can handle propane,” she stated.
Fuel currently costs her $1.25 per gallon for Township, which frees up funds for bus air conditioning and other perks.
Related: Webinar Discusses Impact of Propane School Buses on Costs, Health and Maintenance
Related: Propane School Buses Save Districts 50% on Total Cost of Ownership
Related: Roundup: Informative Green Bus Summit Held at STN EXPO West
Related: Propane ‘Easy Button’ to Replace Diesel School Buses, STN EXPO Panel Claims
Related: Students, Staff at Illinois District Approve of Propane School Buses
The propane buses were a boon for special needs students, Mikelski said. An amazed special education teacher called to inform her that students were coming into school calmer, de-escalated and ready to learn. Together they discovered that the propane buses the students were riding were quieter than the diesel ones, so both drivers and students could communicate without shouting. They could actually hear the music they used to soothe themselves, and some students did not need their normal noise cancelling headphones.
“Everyone was calmer, happier getting off the bus and going into the building,” she confirmed. “It is a marked improvement.”
STN Publisher and session moderator Tony Corpin recalled that Saturday morning’s keynote by Betsey Helfrich discussing legal aspects like Individualized Education Programs (IEPs) noted that parents seeing these benefits may request propane buses in their child’s IEP.
In addition to the sound-level reduction, Mikelski shared that students in wheelchairs did not have to create makeshift blanket shields against noxious diesel fumes while loading the school buses, as they sometimes had to do. She confirmed that propane buses do not have to idle longer than 15 minutes to warm up, even in Illinois winters.
“These buses are running cleaner than anything right now,” she said, referring to the ultra-low nitrogen oxide levels of 0.02 g/bhp-hr that ROUSH CleanTech propane fuel systems are certified to meet. She added that Ford, Blue Bird and ROUSH CleanTech were more than satisfactory partners, noting she is not anxious about winter operations.
She corrected common misconceptions that propane could literally blow up the whole bus operation. Corpin reviewed the domestically produced, clean and safe nature of propane, which is commonly used to cook food via burners and grills. Mikelski said she even performed a test using a white hanky test to illustrate that propane school bus tailpipes don’t emit black soot like older diesel models can.
“Know that you’re supported,” she said. “This is a very easy way to move into an alternative fuel without a lot of angst along the way.”
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People who rely on the federal Affordable Care Act marketplace to choose health insurance for 2026 must contend with a host of challenges as the open enrollment period begins. Those include hikes in premiums and other fees, the potential ending of tax credits that made payments more affordable, and fewer options in some areas.
That’s as a growing number of residents have used the marketplace. More than 300,000 Wisconsinites, or about 5% of the state’s population, signed up for plans last year at HealthCare.gov — more than double the enrollment from about a decade ago.
If you’re feeling anxious or overwhelmed while considering your options, here is some information that might help.
It began Nov. 1 and runs through Jan. 15. Choose a plan by Dec. 15 if you want coverage to kick in by Jan. 1.
Here’s some bad news: Premiums in Wisconsin will increase on average by 17.4% next year, a Wisconsin Watch analysis shows. If it’s any consolation, that’s less than the estimated 26% national hike as reported by KFF, a health policy nonprofit.
“Wisconsin is better than the national average,” said Adam VanSpankeren, navigator program manager of Covering Wisconsin, a University of Wisconsin-Madison Division of Extension program that helps people enroll in publicly funded health care. “Don’t be afraid to look at your plan and see what’s available because you’ll probably be able to find an affordable option.”
Premiums for most plans will increase by 9.4% to 19%. Premiums for a few outlying plans will surge by over 33.3%.
The increases depend on where you live. For example, the new benchmark plan in Milwaukee County will be 44% more expensive than the 2025 benchmark. That’s compared to an increase of just 8.13% in La Crosse and Trempealeau counties.
A benchmark plan refers to the second-cheapest Silver-tier plan, an Affordable Care Act concept used to calculate subsidies to help a marketplace enrollee pay their premiums.
Benchmark plans in Sawyer and Ashland counties will become the state’s most expensive next year, with 27-year-olds paying premiums of $637.57 per month. The two counties also stand out when comparing the average plan costs. The state’s cheapest benchmark plans will be found in Kewaunee, Brown, Door, Shawano, Oconto, Marinette and Manitowoc counties, where a 27-year-old will pay $444.58 monthly.
Statewide prices for Common Ground Health Cooperative will increase an average of 16.6% in 2026, including more noticeable hikes of at least 30% in Jefferson and Walworth counties. The company attributed the changes to rising health care costs and a changing federal landscape.
“By updating our rates, we can ensure the sustainability of our marketplace product and continue to deliver high-quality care to our members,” a spokesperson wrote in an email to Wisconsin Watch.
More than 86% of Wisconsin enrollees last year received advanced premium tax credits that lowered the cost of premiums by an average of $585, according to KFF.
But one major subsidy, the enhanced premium tax credit, introduced in 2021, is set to expire at the end of 2025. Democrats in Congress have called for the credits to be extended in a debate that’s central to the ongoing federal government shutdown.
The tax credit’s expiration would result in lower reimbursements for eligible households. Households with an income of more than four times the federal poverty level will no longer be eligible for any federal tax credit.
“How much Wisconsinites’ healthcare coverage costs will increase varies depending on age, income, plan selection, and available insurers in each county, but many Wisconsinites will see their premiums increase significantly, with seniors and middle-class families seeing some of the largest increases if Republicans in Congress do not extend enhanced tax credits under Affordable Care Act,” Evers wrote in an Oct. 27 press release.
A 60-year-old couple making around $85,000 in Barron County could see premiums skyrocket over 800%, with an annual increase of over $33,000 in costs, according to calculations by the Insurance Commissioner Nathan Houdek’s office. The same couple living in Dane County could see premiums triple, paying nearly $20,000 extra a year.
VanSpankeren says to examine your options as soon as you can, with help from insurance agents or navigators such as those at Covering Wisconsin.
“That (cost increase) does not mean be scared or anxious or stay away from the marketplace,” VanSpankeren said. “It means you’ve got to look again, and you’ve got to do your homework and work with a navigator if you need to.”
If you’re looking for a marketplace plan, it’s a good time to estimate your income for the year, VanSpankeren added, even if that seems difficult. If your income changes over the year, you can report that later.
“You’re just going to do your best, and that’s all anybody can do,” he said. “But really take that extra time to calculate it, however close you can, it’s going to help you a lot in terms of making sure your plan is affordable and making sure you’re not paying back in tax credits that you shouldn’t have gotten.”
He also suggested considering how often you expect to visit the doctor’s office over the year and whether you anticipate any major procedures. That will help determine what plan makes most sense to choose.
Residents in most counties will find fewer plan options as companies retreat from certain markets. Data from Houdek’s office show that 46 of Wisconsin’s 72 counties lost at least one insurance company. Up to four companies will stop serving Winnebago, Racine, Calumet, Milwaukee, Sheboygan, Outagamie, Manitowoc and Kenosha counties.
Two out of three providers currently serving Fond du Lac County have announced exits, leaving residents with just one option.
VanSpankeren worries dwindling options will push some residents out of the marketplace, leaving them unable to access any existing subsidies — potentially falling prey to providers that exploit people in need.
“This would be an opportunity for the good agents and brokers of Wisconsin to rise to meet that need and say, ‘Hey, there are these other things you’re looking for. This particular hospital, this plan actually covers it. Let’s talk about your options,’” VanSpankeren said.
Dean Health Plan by Medica, Fond du Lac’s remaining insurance provider, is “committed to being a stable presence in the community and supporting those who may need to choose a new plan,” spokesperson Ricky Thiesse wrote in an email.
The company encouraged residents to confirm whether their preferred doctors and hospitals are in-network, or if they need to select new providers to receive full benefits.
A majority (61%) of the health plans in Wisconsin will feature higher deductibles next year, increasing out-of-pocket costs before insurance starts paying. The most dramatic deductible increase will be $2,800.
Some providers are also adjusting co-pays and coinsurance rates to reduce company costs. That could require enrollees to pay more per doctor’s visit or spend more on certain drugs.
Catastrophic plans, a federal marketplace alternative, commonly feature low monthly premiums but very high deductibles before providers pay for care. They are seen as affordable ways to protect only against worst-case scenarios, like getting seriously sick or injured, according to HealthCare.gov. Catastrophic plans are open only to people under 30 or those who qualify for a hardship or affordability exemption.
But they are also getting more expensive next year, with premiums surging an average of 57.8%. Catastrophic plans make up the top six plans with the biggest premium increases in 2026.
VanSpankeren suggests comparing a catastrophic plan with Bronze- or Silver-tier plans that might offer more comprehensive coverage.
While individual comparisons will vary, a single 27-year-old enrolling in a catastrophic plan in 2026 would save an average of just $38 monthly compared to a Bronze-tiered plan.
“We don’t choose plans for people, and we don’t steer people towards plans. But I would say it is very rare for anybody that a navigator works with to choose a catastrophic plan,” VanSpankeren said.
Want to see how we crunched the data? Read our data analysis process here.
How to navigate the health care marketplace as premiums rise and options shrink is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.
Open enrollment through the Affordable Care Act Marketplace is now underway, and many Wisconsinites are seeing much higher premiums.
The post As ACA enrollment opens, Wisconsinites experience sticker shock appeared first on WPR.
The Trump Administration yanked more than $65 million in Title X funding from clinics nationwide in April, and some of that funding is still frozen, leaving clinics struggling to offer free or low-cost contraception and other family planning services. Some states are suing to get the funding back, but Idaho officials chose to forego it due to a conflict with state law. (Getty Images)
The Idaho Department of Health and Welfare quietly declined the entirety of its annual $1.5 million federal Title X funding, leaving patients statewide without free and low-cost contraception and reproductive health care services from a key family planning program.
Though thousands of Idahoans relied on the health care provided through Title X for over 50 years, the state made no public announcements as the decision took effect in April, leading to the closure of 28 out of 43 — about 65% — Title X-funded family planning clinics in public health districts throughout the state, according to the Idaho Department of Health and Welfare.
After turning down the Title X money entirely, Health and Welfare said there are no plans for the state to make up the difference by increasing the family planning budget.
In one district, Eastern Idaho Public Health, spokesperson Brenna Christofferson said contraception services are no longer available at all, which has only been communicated to existing Title X patients. Sexually transmitted infection testing and treatment, and breast and cervical cancer screenings are still provided using different funding sources.
Many of the clinics closed in eastern Idaho, including more populated cities such as Twin Falls and Idaho Falls, and more rural areas such as Salmon, Rexburg and Rigby. Title X services also ended at clinics like Terry Reilly Health Services in one of southwestern Idaho’s most populous areas of Nampa and Caldwell.
The decision to forego the funds came at the same time the Trump administration yanked more than $65 million in Title X funding from Planned Parenthood clinics and some independent reproductive health clinics across the country, much of which is still frozen, including for Idaho’s last remaining Planned Parenthood in Meridian. Spokesperson Nicole Erwin said Planned Parenthood continues to fundraise to help offset costs and keep family planning services affordable on a sliding scale.
Although Idaho’s move came at the same time national attention was focused on the frozen funds, it was a separate decision, according to Health and Welfare.
“The discontinuation of Title X funding … was not related to the federal administration’s Title X policy changes earlier this year,” said AJ McWhorter, spokesperson for the Health and Welfare Department. “The department made the decision to decline the funding to remain compliant with current Idaho laws concerning parental rights and counseling on pregnancy options.”
Nationally, seven out of 16 grantees have had their funding restored, while others have been waiting nearly seven months for resolution, said Clare Coleman, president and CEO of the National Family Planning and Reproductive Health Association.
“For Idaho to walk away from the money doesn’t just disadvantage and imperil young people, it imperils all the people in the state,” she said. “It hurts women, it hurts men, and it hurts young people.”
Coleman’s organization sued the U.S. Department of Health and Human Services over the frozen funds, and the case is still pending. A coalition of 20 Democratic-led states sued federal government agencies in July to halt its actions related to several social safety net programs, including Title X. That case is paused while the government is shut down.
In 2023, U.S. Health and Human Services reported Title X provided care to nearly 3 million people nationwide, a 7% increase from the prior year. Under the program guidelines, people with family income levels at or below 100% of the federal poverty level can receive services free of charge, while those making up to 250% of the federal poverty level pay a discounted rate on a sliding scale.
The program, established by Congress and signed by former Republican President Richard Nixon in 1970, is intended to prioritize low-income or uninsured people, including those who make too much to qualify for Medicaid, who may not otherwise have access to family planning and reproductive health services. Abortion services cannot be covered by Title X dollars.
The federal statute guiding the administration of Title X funds includes a section on adolescent services that says grantees cannot require the consent of parents or guardians before or after the minor has requested or received family planning services. Another section directs grantees to allow pregnant patients the opportunity to receive information and counseling regarding prenatal care and delivery, infant care, foster care, adoption and pregnancy termination. Idaho has a near-total abortion ban with few exceptions.
Idaho’s Legislature passed Senate Bill 1329 in 2024, requiring parental consent for “the furnishing of health care services” to a child, with the exception of lifesaving care. Idaho Capital Sun reported the law has also created difficulties for the state’s suicide hotline, because some minors need permission from a parent to receive certain services.
Coleman said the adolescent and pregnancy options requirements have long been part of Title X guidance, and it has not conflicted with state law because federal law should take precedence under the U.S. Constitution.
Idaho is one of at least two states that currently has no Title X funding, Coleman said, after Utah lost all of its Title X money when the Trump administration withheld funding from Planned Parenthood clinics, which were the only places offering those low-cost or free services. Planned Parenthood of Utah closed two of its centers — in Logan and St. George — in the wake of the decision to freeze funding. Logan is less than an hour away from eastern Idaho’s border.
Some states were temporarily left without Title X providers after the Trump administration’s actions in April, but the funding was restored at later dates for certain states, including Missouri and Mississippi. The federal health agency also restored funds in May for two states with abortion bans, Tennessee and Oklahoma, whose grants were revoked under Democratic President Joe Biden’s administration because of their refusal to include abortion among the options during pregnancy counseling.
In a letter from HHS to Tennessee state officials providing notice of the award, the acting chief grants management officer wrote, “Tennessee is one of only two states to have lost funding for failure to comply with the Title X 2021 regulations requiring counseling and referral for abortion. The department is declining to enforce this provision against the state, and you may rely on this letter to that effect.”
A total of 7,528 Title X clients were served across Idaho in 2024, McWhorter said. The 15 remaining family planning clinics are supported by other funds, and additional service sites may be added as funding becomes available. Those clinics are in two out of the state’s seven public health districts, which served about 1,400 people combined in 2024.
The closures add another challenge in an already difficult landscape for sexual and reproductive health care in Idaho. A recent study found that 94 of 268 practicing OB-GYNs left Idaho between August 2022 and December 2024, and care is becoming harder to obtain, according to residents, who say wait times are longer and certain treatment is unavailable locally.
Coleman said under Biden’s administration, when an entity lost Title X dollars for noncompliance or other reasons, there was an effort to reallocate the funding to another willing participant. Without that action, it would revert back to the U.S. Treasury, and the next opportunity for another Idaho entity to apply for Title X funding will be late 2026.
Amy Klingler, a clinician in rural eastern Idaho, told States Newsroom she was devastated by the closure of Eastern Idaho Public Health’s family planning clinic. She worked there in addition to another clinical job since 2006 and said there aren’t many other options for family planning care in that area of the state.
“Idahoans don’t trust doctors, but they trust their doctor,” Klingler said. “So when we see rural health care being eroded and doctors leaving Idaho or not coming to Idaho, I think that is really going to impact the health of people in our communities.”
The additional cuts to Planned Parenthood through Medicaid, along with overall Medicaid cuts that may force the closure of more rural hospitals and clinics, will force people to delay care until they are sicker and require more expensive medical care, Klingler said.
The minor consent for treatment bill had good intentions, she said, and in an ideal world, every child would feel comfortable talking to their family members about birth control. But she said she is confident there are young women who don’t get birth control because they don’t want to have that conversation with their parents.
And with Idaho’s abortion ban, unplanned pregnancies either have to be carried to term or the person must go to another state where abortion is legal. It’s also a felony in Idaho for someone to take a minor to another state for an abortion without parental permission.
“Providing free birth control is really powerful if you’re trying to prevent unplanned pregnancies,” Klingler said.
On her last day at the family planning clinic in June, Klingler said the staffers cried together.
“We often ended the day by saying, ‘We did some really good work today,’” she said. “And to not be able to do that good work kind of hurts the heart.”
This story was originally produced by News From The States, which is part of States Newsroom, a nonprofit news network which includes Wisconsin Examiner, and is supported by grants and a coalition of donors as a 501c(3) public charity.
Since the fall of Roe v. Wade, abortion policy and availability has been in flux in Wisconsin, and providers and advocates say it can leave patients confused.
The post Legal, but not easy: Wisconsin patients, providers confused by shifting abortion landscape appeared first on WPR.
A demonstrator stands outside the Wisconsin State Capitol in Madison, Wisc., in 2022 to commemorate missing and murdered Indigenous women and girls. Researchers have launched a new survey to determine the prevalence of brain injuries in Native survivors of sexual assault and domestic violence. (Photo by Stacy Revere/Getty Images)
Abigail Echo-Hawk, director of the Urban Indian Health Institute, recalled a Native mother in her 30s who started having memory loss and other dementia-like symptoms.
The woman had suffered multiple blows to her head and falls at the hands of her husband over the years. He had wanted to disable her, to make it more difficult for her to keep her children if she tried to leave him, Echo-Hawk said.
Many Native women have traumatic brain injury symptoms as a direct result of abuse, Echo-Hawk said. Tribal health advocates and groups serving survivors have long been aware of the problem, she said, but there has been little national research documenting the extent of it.
“It’s a very difficult thing to see,” said Echo-Hawk, of the Pawnee Nation of Oklahoma. “This is a pressing concern.”
The Urban Indian Health Institute, an Indigenous health research group, this month launched a first-of-its-kind national survey of American Indian, Alaska Native and Native Hawaiian women to determine the prevalence of brain injuries in Native survivors of sexual assault and domestic violence. The goal is to illuminate the extent of the problem, guide clinicians, raise public awareness and direct resources.
A 2015 study in Arizona found a higher incidence of traumatic brain injuries in Native women in that state, but the new survey is the first national, Indigenous-led study of its kind, according to the institute.
It comes as domestic violence groups across the nation are struggling with federal funding delays caused by the government shutdown. As the impasse continues, the Trump administration has furloughed grant workers at the Office on Violence Against Women, which is part of the U.S. Department of Justice.
Traumatic brain injuries can cause memory loss, confusion and long-term behavioral changes and raise the risk of dementia. Some abusers intentionally inflict traumatic brain injuries on their victims because it doesn’t leave visible bruises, according to the Brain Injury Association of America.
The link between domestic violence and traumatic brain injuries has been documented in women generally, and the effects of such injuries have been studied in former football players and veterans. But research on Native communities is lacking. Even when victims show up in ERs, their cases can go underreported.
In a previous survey of survivors, some Native women reported broken teeth, evidence of blows to the head, Echo-Hawk said. But pushing and strangulation also can cause traumatic brain injuries.
Violence is a public health crisis among American Indian, Alaska Native and Native Hawaiian women, who are overrepresented in intimate partner violence statistics. Fifty-five percent report experiencing intimate partner violence, and a disproportionate number of Native women and girls are murdered or go missing.
In a 2020 survey by the federal Centers for Disease Control and Prevention, nearly 44% of American Indian and Alaska Native women reported being raped in their lifetime.
“People are losing their children because of memory loss and dementia,” Echo-Hawk said. “When people are experiencing intimate partner violence, they end up in ERs. Their children suffer. The whole community suffers as a direct result. And the same with the crisis of missing and murdered Indigenous women and girls.”
Doctors and other hospital staff should receive more training on brain injuries and should know which communities are most likely to experience violence, said Nikki Cristobal, policy and research specialist for Pouhana ʻO Nā Wāhine, a nonprofit domestic violence resource center for Native Hawaiians.
Cristobal said one survivor told her clinicians hadn’t performed a brain scan or traumatic brain injury assessment on her, despite her ongoing psychological and cognitive symptoms. “It never occurred to anybody,” she said.
“We have to talk more about it,” said Cristobal, who worked with Echo-Hawk on developing the survey and is the principal investigator for the Missing and Murdered Native Hawaiian Women, Girls and Mahu state task force.
Native communities, including Native Hawaiians, have endured long-term, intergenerational traumas during colonization and forced assimilation that can’t be ignored when targeting the disproportionate rates of violence, Cristobal said.
“It’s the undercurrent,” Cristobal said. “It’s the precursor.”
Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.
This story was originally produced by Stateline, which is part of States Newsroom, a nonprofit news network which includes Wisconsin Examiner, and is supported by grants and a coalition of donors as a 501c(3) public charity.
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