One group working on this is Dollar For, a nonprofit focused on helping people access the financial assistance that hospitals are legally required to offer patients who make less than a certain amount.

An Arm and a Leg host Dan Weissmann checks back in with Dollar For founder Jared Walker about how his small organization managed to help erase more than $55 million in medical bills last year while navigating difficult new funding challenges and ever-shifting political terrain.

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

Dan: Hey there. 

So, 2026! On New Year’s Day, pretty much every morning news show had a not-so-good news story ready to go.

News anchor: This morning, more than 20 million Americans…

News anchor: …will see healthcare premiums double, triple, or go even higher…

News anchor: …after Congress failed to extend certain subsidies under the Affordable Care Act.

Dan: A lot of people will end up without insurance. Or with much crappier insurance, because they can’t afford anything better. Or paying a lot more for insurance than they can afford. Or some combo platter.

And because employer plans got more expensive too — and a bunch of employers weren’t ready to pay more — lots of folks ended up with insurance from work that leaves them on the hook for more.

All of it leaves a lot more people a lot more vulnerable this year to overwhelming bills: for insurance premiums, for medical care, for medicine.

So: I thought it would be a good time to check in with one of the people who has given me the most inspiration, and has taught me the most about how we can push back against some of this.

That would be Jared Walker, the founder of the nonprofit Dollar For.

I first talked with Jared five years ago, right after he went super-viral on TikTok sharing a secret that was hiding in plain sight: 

Jared Walker: Most hospitals in America are nonprofits, which means they have to have financial assistance or charity care policies. This is gonna sound weird, but what that means is that if you make under a certain amount of money, the hospital legally has to forgive your medical bills.

Dan: Millions of people kept watching as Jared quickly demonstrated how to apply — and then wrapped up with an offer:

Jared Walker: I run a nonprofit that does this, so, uh, DM me and I will actually do it for you. Let’s see if we can crush those medical bills.

Dan: Here’s what Jared said to me a couple weeks later about that offer. 

Jared Walker: Yeah, that was, that really backfired. No, uh… 

Dan: Thousands of people had gotten in touch to take him up on his offer. And Dollar For — a SUPER-tiny nonprofit that Jared had started to help people in his hometown of Portland, Oregon — suddenly had a bigger, national mission that Jared was scrambling to meet.

Jared Walker: ?I’m excited. We’re gonna help a lot of people and, uh, hopefully we can get some funding to scale what we’re doing because shit’s wild. 

Dan: And it has been wild ever since.

Talking with Jared over the last five years — and watching the Dollar For team scale up their ambitions and impact — it’s been one of the most inspiring and eye-opening stories I’ve ever seen. 

?So I was excited to talk with Jared a little after New Years, to hear how things were looking to him in 2026.

I’d already seen the numbers: They helped people wipe out 55 million dollars worth of hospital bills in 2025 — a huge increase from the year before. 

Jared Walker: As far as impact goes, what we were able to do with the money that we raised, like we’re rolling, like Dollar For is killing it

Dan: So I was surprised when Jared said: 2025 had been tough.

Jared Walker: We started the year with two of our biggest donors, basically just backing out. 

Dan: Some of the Trump administration’s early disruptive moves– like trashing foreign aid– had led those donors to re-think their priorities. Dollar For lost half a million dollars — almost a third of their budget. Suddenly Jared found himself scrambling to replace it.

Jared Walker: Just trying to, to make up that, $500,000, gap was, uh, fun.

Dan: He managed to make up about two hundred thousand dollars. He says Dollar For didn’t lay anybody off, but some people went to half time.

As the year went on, more political news forced Jared and Dollar For to re-think *their* strategy for 2025. It was another scramble.

Meanwhile, Dollar For kept setting new records — wiping out two-thirds more medical debt than the year before.

It’s left Jared and his colleagues thinking hard about how they chart their path in a world that’s still changing fast.

The story of where they’ve been in the last year — and what they’ve done across the last five years — continues to help me think about the big picture like nothing else. So it’s a great place for this show to kick off 2026.

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

To go back to the beginning for a minute. When I first talked with Jared five years ago, he was already looking at the big picture. How big a difference it would make if more people actually got the charity care they qualified for. Here he is in January 2021.

Jared Walker: We’ve had millions of people now that have declared bankruptcy over medical bills that they legally didn’t even have to pay if they knew about this. And that’s like – that should upset people. 

Dan: This is one reason I find Dollar For’s work so compelling — along with their scrappy approach, and their accomplishments: from the start, they’ve always made the scope and the stakes of our health care system’s dysfunction so clear, so stark. 

But — talk about scrappy — when I had that first talk with Jared, he was scrambling to respond to the messages pouring in — thousands of them. He was grabbing whoever he could for help.

Jared Walker: My niece is like 16. I was like, yo. Here’s my credentials. Get on here and start replying to people.

Dan: Then, by the time I talked with him just a few months later, in the summer of 2021, he had taken incredible steps to start scaling up Dollar For, with help from dozens of volunteers.

Including — especially — folks who heard about him on this show.

Jared Walker: I was just shocked at how many people were reaching out saying, I, I heard you on this podcast, I heard you – and I’m like, well, I’ve only been on one podcast, so I know it’s this one. 

Dan: Honestly, this is another part of what makes Dollar For my favorite story. Because it shows how many people are ready to jump in and help.

And how much people are ready to contribute: In just a few months, Jared and a volunteer army — including generals, a couple of wildly qualified folks who put in close to full-time hours for a while — had done something incredible.

They’d built Dollar For a website where anyone, anywhere in the country, could check to see if they qualified for financial assistance, and ask for help applying.

Because every hospital sets its own criteria for who qualifies, setting up that system meant grabbing the charity-care policies from more than two thousand different hospitals, and coding all of the criteria into a database. 

The website with that database went live in the summer of 2021 — less than six months after Jared first went viral on TikTok.

He and his colleagues have been building and refining their operation ever since. And working towards making a big-picture difference.

Last time I checked in with Jared, it was late 2024. Dollar For had put out a couple of research reports estimating the size of that big picture: 

They found that less than a third of the people who qualified for charity care actually got their bills forgiven. 

If all of those people actually got the charity care they qualified for, Dollar For found that would mean 14 billion dollars in hospital bills, in medical debt, would vanish. 

14 billion dollars that hospitals could be forgiving under their own policies, every year. 

Jared definitely noticed that that number, 14 billion dollars, dwarfed the amounts Dollar For had been able to address by working case by case. Like, they were closing in on clearing 32 million dollars in hospital bills that year. Which is a LOT for a tiny organization. Jared was like…

Jared Walker: It sounds great, and then you see the 14 billion number and you’re like, oh, shoot. What are we doing? What are we doing?

Dan: Jared and his colleagues had started a strategic planning process that would lead them to say: Let’s focus on making a dent in that 14 billion dollars by advocating for new policies. Laws to make hospitals at least check to see if people are eligible for charity care before chasing them for bills they can’t pay.

And while they were planning, the ground beneath them started to shift.

The Trump administration took office and among other things, immediately started slashing foreign aid.

?Newscaster 1: President Trump says he wants U-S-A-I-D, the relief agency, helping millions of people around the world to be shut down.

Newscaster 2: Just yesterday, U-S-A-I-D employees in Washington were told to stay home.

Jared says some of his donors reset their priorities — to fill in gaps internationally. One of them finalized their decision just as Dollar For was wrapping up their first board meeting of 2025. 

Jared Walker: I get this email from our biggest donor saying, hey, we’re gonna cut the 300K. 

Dan: Oh wow. 

Jared Walker: Um, and my board chair goes, Jared, what happened to your face? Is everything okay? And I was like, am I gonna tell my whole board right here right now that we just lost our biggest funder?

Dan: I asked Jared later by email: Hey, so did you spill the beans then? His response:

“lol. I did not tell them in that moment. My thought process was ‘ I don’t want to end our first board meeting of the year with this bomb. We are all hyped on the new year… let’s keep that energy. The board can’t change this email”

Jared filled them in later, and started hustling to fill the budget gap. They kept working on their strategic plan through the first few months of 2025.

By the spring, they were putting finishing touches on it — and then the news cycle intervened again. 

Jared Walker: We went into 2025 with this idea of we are going to do more policy work, we’re going to push more policy, we’re going to advocate for better charity care laws, and then… Medicaid cuts, right?

Dan: The Trump administration’s big legislative proposal — the “One Big Beautiful Bill” — aimed to offset big tax cuts in part with big cuts to Medicaid spending. 

Newscaster: Republicans are looking to slash two trillion dollars – with a T– in long term spending. And Medicaid could be a target.

Dan: And a ton of those Medicaid dollars go to hospitals.

Jared Walker: And when you are getting every single headline is ‘Woe is me, we’re a hospital, we’re not gonna make it. You’re gonna bankrupt hospitals…’

Dan: That was gonna make pushing new rules for hospitals — forcing them to be more generous — a tougher sell.

And here’s where these two stories — Dollar For gets hit by big, fast-moving changes in 2025, and two: Dollar For wipes out a lot more medical debt than ever before in 2025 — we’re gonna see where they intersect.

That’s coming right up.

This episode of An Arm and a Leg is a co production of Public Road Productions and KFF Health News.  That’s a nonprofit newsroom covering health issues in America. 

With all of these big-picture changes — like cuts to Medicaid –Dollar For decided to pivot. 

Jared Walker: we kind of slowed down and said, okay, if people are gonna lose Medicaid, if people are gonna, if their insurance premiums are gonna go up, if all these things, what we need to do is we need to double down on direct service and help more as many patients as we can because the appetite for policy change might not be there.

Dan: They had a communications and marketing team who had planned to spend the year pushing Dollar For’s policy message.

Instead, they focused on spreading the word about charity care and Dollar For. Pitching Jared to reporters. It worked. He says he was featured in more than 90 news stories before the year was out. 

Jared Walker: I was on more podcasts than I’ve ever been on, ever, doing local news stuff. So the marketing team was cooking pretty good as far as getting the word out.

Dan: That meant more folks coming to Dollar For looking for help with charity care. Which is one thing that drove up the number of people Dollar For was able to help.

The other was the payoff on a long-term investment. 

In the spring of last year they finished a project they’d been working on for a long time: Making it easy for patients to fill out a charity care application directly on Dollar For’s website. 

Jared Walker: A patient goes to dollarfor.org. They fill out household size income, what hospital it tells ’em if they’re eligible. If they are, it bounces them right into a digital application. They can do that on their phone, tablet, computer. They’re filling it out and it is automatically mapping their data into the correct hospital form.

Dan: This is the big upgrade:  I don’t have to follow a link to the hospital’s website and find their form. I don’t have to print anything out. 

I’m staying on Dollar For’s user-friendly site, answering questions from my hospital’s application form — because every hospital’s form is different, and some ask for more information than others, the back-end work by Dollar For to give me the right questions? That’s a big deal.

And: The Dollar For team is putting those questions to me in plain, user-friendly English. Which not every hospital form necessarily does. If I get stuck, I message the Dollar For team to get help, directly.

When I’m done, it shows me the results and says:

Jared Walker: Here’s your completed application. Does everything look good? thumbs-up it, we submit it to the hospital, and then we do follow up from there

Dan: Jared says they also created a portal where patients can check on the status of their application, and jump right into a chat with a patient advocate.

I was like: You know, that’s pretty impressive. Your year did not totally suck. 

Jared Walker: Yeah. It is honestly like, you’re like reminding me of, I’m like, oh yeah, we did some, we did some really cool stuff last year.?

Dan: And he sees room for new tech to help them get even more efficient — yes, with help from AI. 

Jared Walker: ?And like, we’re very much in the camp of this is a great tool, it’s not gonna solve all of our problems

Dan: But he does see a few areas where it could help. 

Including — helping his team do something they actually haven’t had the capacity, like the time, to do yet: quality control on the documents patients submit with their applications– like proof of income. 

Jared Walker: Sometimes people accidentally upload a, you know, a picture of their cat instead of their, you know, W2 or, or whatever. So if we could have an AI tool, scan the document and make sure that it matches with what they said…

Dan: And flag situations where  a human at Dollar For should take a look before sending it in…

Jared Walker: that would also save us a bunch of back and forth with the hospital and the patient

Dan: In other words, save time for everyone. And maybe help Dollar For’s rep with hospitals.

Jared Walker: It kind of makes us look bad if we send documents to a hospital and it’s a photo of somebody’s cat, you know?

Dan: That would cost money – Jared estimates a quarter of a million dollars, including the cost of adding Dollar For’s first full-time CTO.

Meanwhile, they haven’t stopped pushing for policy change. In 2025, Dollar For published a study that kind of turned the telescope around on the question it had addressed the year before. If hospitals gave financial assistance to everyone who qualified, they’d found it would save patients 14 billion dollars a year.

This time, they asked: how much of a hit would that 14 billion dollars be to the bottom line for America’s hospitals? How much of their income would they be losing?

Dollar For’s answer: zero point seven percent. 

Jared Walker: Like, this is like a fraction of, a fraction of what these hospitals bring in. 

Dan: Not all hospitals, as Jared is quick to note.

Jared Walker: Like, there’s, you know, 8,000 hospitals in America and they’re not all equal. There are big hospitals, there are small hospitals. Obviously, it’s very hard to, you know, generalize these things.

Dan: Like we’ve talked about here before: Some hospitals really ARE on the verge of going under. And some have profit margins of more than thirty percent. And there’s everything in between. 

But here’s the number that really jumped out at me from that Dollar For report. It’s not just the amount of charity care that hospitals withhold is basically tiny compared to their overall revenue. 

The total amount of income hospitals get directly from patients’ pockets — all the bills I hear about on this show, and that we all know are out there, the bills that drive people into debt, into bankruptcy…

All of that money, all of that suffering represents just 2.5% of what hospitals get paid for care, according to KFF data that Dollar For cites Two point five percent. 

I don’t have a really deep insight here, but this number jolts me back to awareness of how big this health-care industrial complex is. And how much its dysfunction costs our whole society. 

Like, zoom out. We spent five TRILLION dollars a year on this stuff — and so many people still don’t get the health care they need.

It reminds me that — along with understanding ways we can help ourselves and each other — individual, day-to-day ways — it’s important to understand why health care costs so freaking much. Where all that money goes, what we can maybe do about it.

Meanwhile, back to Jared and how he sees things going in 2026. 

Jared Walker: Health care is going to get worse. Health care is going to be more unaffordable than it was. Health care is going to put more people into bankruptcy, more people into a bad financial situation. 

Dan: Which makes the need for Dollar For’s work more obvious. Dollar For isn’t in danger of going away.

But all of the rapid change in the last year — the accomplishments and the setbacks — has Jared thinking hard about how to keep moving forward over the long haul.

Jared Walker: Dollar For has just been so scrappy. We’ve just been so scrappy, you know. I don’t want to be the, you know, the unpaid intern organization that’s just like, you know, burning everybody out. I want to be able to pay people well. I wanna be able to provide incredible healthcare benefits. I wanna be able to have a 401k match. Like, I want people to thrive at Dollar For.

Dan: That’s how you make sure people can stick around and keep growing, and figuring out how to make the biggest impact in a wild environment. 

As we wound up our conversation, I wanted to tell Jared about how An Arm and a Leg’s 2025 had gone. Partly because I thought it might cheer him up a little bit.

So I told him about how a medical student named Thomas Sanford had put together a resource guide for patients based on our reporting, and started handing it out. How other listeners had been helping refine it.

How we’d put a version on our website — prompted by Thomas’s idea that health care workers could decorate the “badge reels” on their lanyards with a QR code patients could scan. 

Jared Walker: Yeah. Putting it on the lanyard. I love it. And it is just something that we need more of is like, how do we empower the patient and the healthcare worker and the people that are, you know, up to fight it.

Dan: That’s it right there. The place we’re in right now — just with health care, the big picture can look really scary. Trying to take on the whole thing — heck, just trying to take in the whole thing, the big picture– it’s a lot. 

And it doesn’t mean we stop trying. But we’re not individually responsible for fixing the whole thing right away. And we can find things to do — ways to help ourselves and each other IN THE MEANTIME.

Like by using the kinds of things we learn here to take a little more control over our own lives — and helping other people take control over theirs.

We spent a lot of the last couple of months asking you to help us keep doing our work– and you really came through. A lot of you included notes with your donations, incredible, heartening notes.

I’m gonna share one here — we actually shared it in the First Aid Kit newsletter last week — but I’m repeating it because it illustrates something:

“This amount, $85.23, is the amount I avoided paying because you taught me how to take notes when speaking to my insurance company, always getting the name of the representative and the call reference number.”

And here’s what I take from that: Every time any of us gets back a little capacity — saves a little money, saves some worry — from a system that threatens to overwhelm us…

That’s capacity we can put to use. To nourish ourselves and each other. To bank some new strength. And things that seem small — saving 85 dollars. Telling someone about Dollar For and helping them connect to charity care.  There’s no way to know if they’ll add up to ENOUGH to move ourselves toward the structural change we need. But every bit truly does count.

So: Thank you again. For listening. For sharing what you know — I learned about Dollar For because listeners to this show saw Jared’s TikTok and made sure to tell me about it.  And for doing what you can for yourself, and your family, and the people around you. 

We’ll have a new episode for you in a few weeks.  

Till then, take care of yourself.

This episode of An Arm and a Leg was produced me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

[Names redacted for web transcript.]

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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.

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In Maine, lawmakers unanimously voted to remove medical debts from credit reports. While a nationwide court ruling has cast doubt on the new law’s future, a consumer rights attorney tells Weissmann why she remains optimistic.

And a law in Oregon aims to prevent corporations and private equity firms from gobbling up medical clinics, raising prices, and, sometimes, delivering worse care.

Plus, the team behind An Arm and a Leg has some good news of its own to share.

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

Dan: Hey there–

It has been a long year, and yes, 2026 is shaping up to be a doozy.

As I record this, it’s looking like any hope that Congress will extend certain     Obamacare subsidies for next year are looking like a long shot. Experts say millions of people could lose insurance coverage.

And– not to rub it in– but the federal government actually backtracked this year on another issue we’ve talked about here: Keeping medical debts off of people’s credit reports.

The Biden administration spent years crafting a rule to establish that protection.

The Trump administration has actually said recently: those protections are ILLEGAL.

But states have been enacting laws of their own this year … which means lots of people are still protected. 

And this is where we pick up a series we started a few weeks ago — looking at things that DID NOT SUCK in 2025.

Cuz not only did some states fill in holes left by the feds .Other states were staking out new ground. 

For example, a new law in Oregon goes hard at a core reason why health care keeps costing more all the time: 

Big corporations and investors keep gobbling up more and more medical practices— jacking up prices and  (at least sometimes) delivering significantly crummier care.

Oregon’s new law aims to slam the brakes on that.

In fact, lots of states have done lots of things that did not suck this year.

A few weeks ago, we looked at state laws that push back against some ways insurance companies delay and deny care. 

And new state laws that protect people from getting their homes and their paychecks taken away because of medical debt.

Laws like these passed in lots of states — red states, blue states, purple states. With bipartisan support.

So did laws restricting middleman companies like pharmacy benefit managers from jacking up what people pay for drugs. And laws restricting price-gouging by hospitals.

We’re digging into these few examples to look at how laws like this get made– and defended. 

They take a combination of political work and some hard-core nerding out. And when they pass, laws like Oregon’s become models other states can pick up on.

So, let’s go.

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

Of the half-dozen states that passed laws to keep medical debts from dinging people’s credit, most of them look “blue” on a political map: New Jersey, Rhode Island, California.

But Maine is a little more purple. And Maine’s law passed unanimously.

Here’s State senator Donna Bailey, who sponsored it.

Donna Bailey: I don’t remember a lot of heavy pushback, which was pleasantly surprising to me, quite honestly.

Dan: Surprising because it’s not like just saying “let’s help people with medical debts” guarantees success in Maine. 

Donna Bailey: We did have a bill last session that did not go through and did not have bipartisan support.

Dan: Donna Bailey had sponsored that one too. This time, she was determined to win. When she campaigned for re-election, she promised to go for it. She says her previous bill had been more complicated. This one had a single focus. 

And when it came up in committee, her colleagues heard some compelling testimonies.

Patty Kidder: We pay our mortgage on time every month. But because of unpaid medical bills, we were unable to just go buy a new or used car when the engine blew in our only working vehicle…

Andrea Steward: I began accumulating my own medical debt at 17 when I discovered, which I only discovered on my credit report, when I was trying to purchase my first home in 2022…

Dan: But legislators also heard hard numbers. Fresh numbers, released that very day

From a survey showing that almost half of Mainers were carrying medical debt.

A lot of them wound up with dings on their credit because of it. Which meant — as they said in the survey — medical debt on credit reports was causing them real problems.

Ann Woloson: It’s affecting their ability to get jobs. It’s affecting their ability to buy a car. It’s affecting their ability to rent an apartment. Something needs to be done about it.

Dan: That’s the person who commissioned the survey.

Ann Woloson: I’m Anne Woloson and I’m executive director for Consumers for Affordable Healthcare, a nonprofit, nonpartisan advocacy organization based in Maine.

Dan: How long has the organization been around?

Ann Woloson: We’re gonna be celebrating our 40th anniversary next year.

Dan: Wow. And you haven’t solved the problem of affordable healthcare in 40 years.

Ann Woloson: Nope. Unfortunately. I guess I’m not doing a very good job. Right.

Dan: Well, there might be some countervailing forces.

Dan: Hearing the story behind this bill, I don’t think Ann Woloson is bad at her job.

For years, she’s convened a strategy meeting on Thursday mornings at 9am. Consumer advocates, health care advocates. 

Ann Woloson: We used to meet at the State House pre pandemic, but now we meet over, we meet over Zoom slash telephone. However. Whatever’s easy. Sometimes people are in their car.

Dan: She says in fall 2024, the group started looking ahead to the next legislative session. 

Ann Woloson: We were starting to talk about like what more can we do with medical debt? And somebody probably said, well, I’ve been talking to Senator Bailey and she’s interested in submitting a bill to address the reporting of medical debt to creditors. And we’re all like, oh, that sounds like a great idea. That’s something we can get behind. 

Dan: Ann Woloson found some money in her budget to run a survey — like twelve thousand dollars.

Ann Woloson: Which maybe doesn’t sound like a lot, but for a small nonprofit, that’s a, that’s a lot of money.

Dan: I don’t have it in my pocket. Right? It’s money.

Dan: Ann Woloson says: this was a strategic investment.

Ann Woloson: We will frequently hear from industry representatives that such and such. This is not really a problem. I don’t know where this is coming from.

Dan: And they dismiss individual testimony as a few isolated hard-luck stories.

Ann Woloson: Well, here we have this survey that shows, yeah, medical debt is a problem. So it’s not just something that we’re pulling out and saying is a problem.

Dan: Nobody voted against the bill. Not in committee. Not on the Senate floor, not in the House. It was a better return on investment than Ann Woloson had hoped for. 

Ann Woloson: So there was, I would say, almost a unanimous feeling out there that something needed to be done about this. I wasn’t really expecting that.

Dan: State Senator Donna Bailey says she thinks — along with the survey — the Biden administration’s push on the issue helped. Partly because it raised the issue’s profile.

And partly because the actual rule– finalized just before Biden left office — may have left opponents thinking the stakes were lower. 

Donna Bailey: Some politicians who may have been opposed, were just like, well, it doesn’t matter if we pass something on the state level. It’s already, you know, forbidden at the federal level, so going to put their energies elsewhere.

Dan: On the other hand, advocates like Ann Woloson were looking at something else: The 2024 election results. Joe Biden may have pushed through this rule before leaving office, but he was still… leaving office. 

Ann Woloson: It was in the back of my mind and probably several other people’s minds, that were working on this um, that we needed to codify something in Maine in case something changed at the, at the federal level. 

Dan: Which of course, something did. Within weeks of taking office, the Trump administration effectively shuttered the agency behind the rule: the Consumer Financial Protection Bureau.

By that time, the collections industry had already sued to invalidate Biden’s medical-debt rule.

The Trump administration ?didn’t do much to fight that lawsuit, and over the summer a federal judge found the rule illegal. Donna Bailey and her allies were definitely watching. 

Donna Bailey: We’re like, wow. You know, thank goodness we put something in law at the state level.

Dan: But there was a new potential threat. The judge who zapped the federal rule went farther.

In his ruling, he wrote that not only did the Biden rule violate a law called the Fair Credit Reporting Act– but that same federal law would pre-empt state laws like Maine’s, and nullify them.

Then, a few months later, in October, Trump’s CFPB issued its own legal opinion — basically elaborating on the judge’s reasoning, arguing that, yep: State laws like Maine’s should be tossed.

Which definitely sounds like it sucks.

But here’s where things get good and nerdy.

I don’t think anybody’s been pushing on this issue of medical debts and credit reports longer — or nerding out harder — than Chi Chi Wu. She’s an attorney with the National Consumer Law Center. You’ve heard from her before on this show.

She’s not thrilled about the judge’s ruling, but she says it did not suck as much as news reports at the time suggested. 

Chi Chi Wu: The judge did not quote, unquote, rule that state laws were preempted. 

Dan: She uses a nerdy legal word to describe the judge’s statement about pre-emption: Dicta. Meaning, if I’ve got this right, just talking. Not actually making law on this issue of pre-empting state measures.

Chi Chi Wu: It wasn’t central to the ruling. It wasn’t briefed. He didn’t do any analysis. I mean, preemption under the Fair Credit Reporting Act is really complicated. A little bit head spinning. There’s some case law out there and he didn’t consider any of it because frankly the issue wasn’t really before him. So, that’s the part that didn’t suck as bad as you might think.

Dan: Basically, Chi Chi Wu says, to get rid of those state laws, plaintiffs would have to challenge them in court, one at a time. For the record, she thinks the arguments against those laws are weak.

Chi Chi Wu: But they push it. I mean, they push it and they see if a court will buy their arguments. They often push theories that aren’t supported even by the text of the statute. And sometimes they get away with it, unfortunately. I mean, they have very expensive lawyers that, you know, this is how they earn their big bucks by pushing the law as much as they can in favor of their clients.

Dan: I actually talked with one of those high-priced lawyers recently. Who was not ready to claim victory– or accept defeat in advance. She was like, “These things have to be litigated.”

Which of course has started. Actually, in Maine. 

But Donna Bailey says — based on early proceedings in that case– she’s not worried: 

Donna Bailey: The interesting part was that the court did not put any stay on the legislation, so it was still allowed to go into effect.

Dan: That is, the court hasn’t granted a preliminary injunction, which would have prevented Maine from enforcing the law while the case plays out. Which will take … a while.

And if courts do eventually rule against states like Maine, Chi Chi Wu has legislative tweaks to suggest that could make state laws more lawsuit-proof. 

If you want to nerd out, we’ll have links in our First Aid Kit newsletter.

But now, we’ll look at a state that came out swinging this year in a big new fight:

Oregon passed a law to prevent big corporations and investors from taking over medical clinics and basically strip-mining them for profits.

That’s next. 

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. These folks are amazing journalists. Their reporting wins all kinds of awards every year. We are honored to work with them.

Dan: In the spring of 2024, a news story broke in Oregon that eventually drew national attention. 

News anchor: You called and we listened. We have been getting all kinds of calls and emails from patients who were dropped without any warning. It is our top story tonight. KEZI 9…

Dan: These were patients at Oregon Medical Group, a chain of clinics in the Eugene area. And these patients had just gotten letters in the mail

News reporter: telling them their primary care provider is leaving the medical group and the need to find care somewhere else.

Dan: Other patients only got the news when they called to make an appointment. 

Over the course of a couple years, more than thirty doctors had quit Oregon Medical Group — and left thousands of patients stranded.

A doctor at one area hospital told a local news outlet more and more Oregon Medical Group patients were starting to show up at the ER. 

Some of them just needed refills on prescriptions, since that their regular doctors were gone. Not fired, it turned out. Quit. 

Ben Bowman: Those doctors left because they didn’t agree with the way the practice was being run. This wasn’t what they signed up for when they went into medicine.

Dan: That’s Ben Bowman. He’s a democratic state rep from the Portland suburbs. 

He says he’s talked with some of those doctors personally. Others talked with reporters. 

They said they’d quit because the practice changed after a takeover by Optum. That’s a name that may sound familiar. Optum is a giant subsidiary of the even-more-giant UnitedHealth Group. 

We’ve talked about Optum more than once on this show because it’s got tentacles in just about every part of healthcare. 

Including running medical practices. These days more than 10 percent of ALL doctors in the US work for Optum. More than for anyone else by huge margins. 

Optum took over Oregon Medical Group in 2020, and — as doctors later told reporters– it ended up making big changes. Doctors said dictates from Optum had them spending less time with each patient, with more patients to see, and, after Optum cut staff, with a ton more paperwork to grind through themselves. 

To top it off, at least some of them said they got socked with pay cuts.

But quitting their jobs meant truly leaving their patients behind. Their contracts had non-compete clauses, so they couldn’t just see their patients somewhere else nearby.

Ben Bowman: Some of them went to work in other areas. Some of them left the state of Oregon. Some of them were so burned out. They said they’re done with medicine.

Dan: News reports say as many as 10,000 patients got left behind. And here’s why Ben Bowman was talking with those doctors — and why he’s the guy you’re hearing from:

By the time those stories hit the news, Ben Bowman and some allies had already been fighting for more than a year to fix what he and others say is the root cause of what happened in Eugene. 

Which is probably going to sound familiar.

Ben Bowman: Over the last 10 to 15 years, there’s been a rapid acceleration of corporate and private equity ownership over medical clinics. 

Dan: These are businesses that owe it to their investors to put profits first. But health care providers are supposed to put patients first. 

Ben Bowman: Those two things are inherently in conflict sometimes and we get to decide as a state: how are we going to resolve that tension? And in Oregon, we want the answer to be that the doctors are making the decision that’s in the best interest of their patient.

Dan: Ben Bowman’s saying “we get to decide as a state” and here’s what “we in Oregon want the answer to be” because this year he and his allies won a big legislative fight.

He talked about how they did it with this show’s senior producer, Emily Pisacreta. 

Ben Bowman: This is probably a much longer story than you’re asking for, but,

Emily: No, I love it. I love it. It’s great.

Dan: Emily? Really long?

Emily: I promise not too long. It starts with an intellectual puzzle. 

Bowman could see that big corporations and private-equity — PE for short — were taking over more and more medical practices. All over, including Oregon. 

Ben Bowman: Now, here’s where it gets weird. Oregon, like many states, most states, has long had a corporate practice of medicine law on the books.

Emily: …that basically says, to own a medical practice, you have to have a medical license. A corporation or group of investors can’t get one of those. 

Ben Bowman: But at the same time, we’re seeing this rapid increase in corporations and PE firms buying clinics. How is that possible if we have a law that says you can’t do that?

Emily: In 2023, Bowman read an article in the New England Journal of Medicine that seemed to offer some answers — and maybe a blueprint for building stronger guardrails. 

One of its authors is Erin Fuse Brown. 

Erin Fuse Brown: …and I am a Professor of Health Services, Policy, and Practice at the Brown University School of Public Health.

Emily: I met Erin back in 2022, when we looked at how private equity firms were buying up gastroenterology practices and raising the prices on colonoscopies. One investor was calling it ‘The Golden Age of Older Rectums.”

Dan: I still love that you found that quote. And Erin helped us with your next story about private equity. Where ER doctors in California were suing to kick a private-equity backed company out of emergency rooms there. 

Emily: The big issue in that case: California’s corporate practice of medicine law. Erin’s a lawyer by training. She was already chewing on this question 

Erin Fuse Brown: We have all these laws in the books. Well, why doesn’t the corporate practice of medicine prevent this?

Emily: And what I love is: That case in California helped her start to crack that question. 

Because she knew that the answers– what Erin calls the nitty gritty stuff — that’s all buried in contracts. Contracts she didn’t have access to. 

Erin Fuse Brown: They tend to be confidential. Um, they’re private contracts. It’s very difficult to see them.

Emily: But now those California contracts were evidence in a lawsuit. So she could study them.

Erin Fuse Brown: That litigation allowed us to get a, a sense of how these contracts are structured. 

Emily: And here’s the basic structure.

Erin Fuse Brown: An entity like a hospital or one Medical or Optum, stands up something called a management service organization.

Emily: A management service organization — MSO for short .

The MSO is ostensibly just there to take care of “back office” stuff — like billing or HR or compliance — to make the business run better. Here’s how they end up actually running the show. 

Erin and others call this the “friendly physician model.”

The MSO brings in a figure-head doctor — the friendly physician–  who works for them as an executive. 

Then the MSO fronts this friendly physician money to buy a majority stake in the practice, which puts the friendly physician in charge of the medical side. 

So on the one hand, they’re an OWNER. They own the practice — thanks to money from the corporate MSO.

And on the other hand, they’re an EMPLOYEE — working for the same corporate MSO. 

Which Erin says is a conflict of interest.?

Erin Fuse Brown: The conflict of interest is that they’re taking all of their marching orders from their ultimate boss, who is the MSO, right? They hit their numbers, then their compensation goes up from the MSO. So they’re really sort of like a business manager who happens to have an MD behind name. 

Emily: I think of it as kinda like… the CIA covertly installing its favored leader in a foreign country Except the leader openly, publicly taking a salary from the CIA. Oh, and maybe has maybe never even been to the country.

Erin Fuse Brown: Like the owner– who has an MD, who has a license and is therefore eligible to own the practice – they may live in a different state. They may never have stepped foot in the practice

Emily: And they start changing the way the practice is run in a way that makes the corporate entity the most money. Even if it’s not great for clinicians and patients. 

Erin Fuse Brown: You’re gonna see patients not in, you know, 15 minute appointments. You’re gonna see them in nine minute appointments.

Emily: And she says they ratchet up the pressure to do things like “upcode” — assign diagnoses with higher-priced billing codes. 

Erin Fuse Brown: The MSO can send sort of notices to, it’s like high performing clinicians saying like, congrats, you get a bonus. Or reminders, like, you’re on the bottom of the list, you’re not hitting your targets. We need you to upcode more. Basically make us more money. And if you don’t, then we’re gonna punish you either by giving you worse scheduling times, we’re gonna dock your pay or, you know, or do other things.

Emily: And then… maybe there’s a non-compete, making it harder to leave, like at Oregon Medical Group.

So Erin and a pair of other researchers published that paper that said — and I’m oversimplifying a bit — that if you want a real ban on the corporate practice of medicine — you need take on these MSOs, and this friendly physician set-up.

After Ben Bowman read that paper, he got in touch with Erin and her colleagues, and eventually they sat down to work together. 

Going into the 2024 legislative session, Bowman had the blueprint. And he had allies — like former Oregon governor John Kitzhaber. Who used to be an ER doc himself.

He got co-sponsors from both parties. And they had a powerful coalition of outside supporters. 

Ben Bowman: We had patient advocacy groups, we had labor unions. We had the Oregon Medical Association. We had the Oregon Nurses Association.

Emily: Of course there were opponents.

Ben Bowman: You can imagine the interests who didn’t wanna see this happen, like basically any large corporation, which includes four of the six largest corporations in America…

Emily: Like UnitedHealth Group. Obviously. But also CVS. Amazon. Not to mention dozens of private equity firms you’ve never heard of. 

He says the bill looked like it would pass — but Republicans blocked it with a last-second parliamentary trick. So it didn’t get a vote. That was March, 2024.

Then, a few weeks later, Oregon Medical Group hit the headlines. 

Ben Bowman: You can imagine the feeling in Eugene. Ten thousand people who get this piece of mail saying you don’t have a doctor anymore, including elderly people who were relying on that primary care doctor to fill their prescriptions and to keep them healthy.

Emily: A few months later, a neighborhood group in Eugene hosted a town hall. 

Ben Bowman: It included legislators. It included leadership of the Oregon Medical Group. It included Optum Oregon leadership,

Emily: Yep, Optum Oregon showed up. And handed Ben Bowman and his allies a talking point. 

Ben Bowman: The head of Optum, Oregon said in that, in that town hall, this quote: 

Dr. Phil Capp, Optum Oregon: …the experiment of having physician directed healthcare in this country over the last 50 or 70 years didn’t work. It didn’t work. So we have to try a new way. 

Emily: Bowman says that line helped make the stakes really clear when he brought his bill back in 2025.

Ben Bowman: What is at stake in the corporate practice of medicine debate is do you want your healthcare decisions when you’re in an exam room being made by a doctor? Or do you agree with what Optum’s stated position was? Which is we think somebody else should be making that decision. Not physicians.

Emily: And when the 2025 session started, he had another new advantage: his party tapped him to be majority leader.

Ben Bowman: I think that was really helpful, that this was no longer just like a freshman legislator’s bill. This was the house majority leader saying, this is really important to me and my constituents.

Emily: This time the bill passed by more than two-thirds. The final language has limits. It doesn’t apply to hospitals – which also gobble up tons of medical practices. It doesn’t apply to telehealth providers.  And doesn’t totally ban MSOs. But it makes really clear what MSOs are allowed to do– what kind of decisions they can make. For instance, they can’t limit how long a doctor spends with a patient.

Ben Bowman: a corporate owner, a non-physician, cannot dictate to a doctor “you can only see this patient for 15 minutes.”

Emily: And they can’t make clinicians sign non-compete clauses. Those doctors can fly free if they want. 

And crucially — the new law addresses the conflict of interest in that “friendly physician” figurehead setup. It limits how much control they can have in the medical practice if they’re really working for the MSO.

Erin Fuse Brown says this provision got the most pushback from the industry–– and it’s the one lobbyists are working to prevent in other states.

Erin Fuse Brown: And that’s telling, right? If the industry is most concerned about the dual compensation, dual ownership then that is where the rubber hits the road.

Emily: And based on what she learned from Oregon, she’s put together model legislation for other states. 

Which, Ben Bowman says, is something his opponents were afraid of all along. He says out of state companies sent lobbyists to Oregon to fight his bill.

Dan: Whoa. Emily, thank you so much for that story. I love the idea that companies outside of Oregon are already scared that other states will adopt a version of this law. 

We’ll be watching both of these stories in 2026, and others — including stuff we just didn’t get to. 

I mentioned earlier that states moved to restrict pharmacy b  enefit managers, and to restrict price gouging by hospitals. But I don’t think I mentioned that the most aggressive laws on those topics were from two states that show up bright red on political maps: Arkansas and Indiana. 

We’ve gotta get around to that. 

Meanwhile, it was SO heartening to report these stories. Because that meant meeting advocates and legislators from around the country — folks I’d never heard of before, people I’m so glad to have met, because they’re doing so much smart, dedicated work to make things suck less.

Emily: 100% and I will add that I also got to talk with people in states like Colorado and California who have been doing incredible work to lower drug prices on things like insulin and the rheumatoid-arthritis drug Enbrel. 

Following up on what they’ve accomplished and getting those stories on the show is one of the things I’m especially looking forward to in 2026.

Dan: I am so looking forward to having you do that — and speaking of what you’ll be doing in 2026, Emily, I think we’ve actually saved the best news for last.

Anybody who’s been listening to our show recently knows: Like a lot of people, we’ve been SWEATING health insurance for 2026. 

Emily: I mean, I’ve been sweating bullets. I moved to an Obamacare plan this year, and without the enhanced subsidies that are set to expire, I didn’t know how I was supposed to afford those premiums.

Dan: I’ve been sweating too. Because if that happened: Could you afford to actually keep working here part-time? 

We’ve been exploring an alternative: Could you get insurance through An Arm and a Leg? It would be less expensive, and better insurance. 

But we’d need to increase your hours — from 20 hours a week to 30 or more.

Could An Arm and a Leg afford to do that? I didn’t know.

But I ran some numbers last week — looking especially at the donations people have been making since our fundraising season started in November.

And the answer is: YES. People have been so generous so far, I’m ready to make that commitment. 

Emily: We have the all-time greatest community of listeners.

Dan: Seriously. Don’t get me wrong: The numbers so far do not mean we are ALL SET for 2026. 

So, if you’re listening to this, and you’ve been considering making a gift — PLEASE DO IT. We are counting on you. 

Not only so Emily gets better, more-affordable health insurance. But so WE GET FIFTY PERCENT MORE EMILY.

Now, you’ve just heard Emily’s reporting right here. You’ve been hearing it. You know how amazing her work is.

But you may not know: Emily’s also the reason for a lot of OTHER stuff you’ve noticed. 

Like, we brought back our First Aid Kit newsletter this year, and made it weekly? 

You don’t see Emily’s byline on it– because she’s the EDITOR. You don’t wanna hear all the backstage work — on that project and others — but it’s been huge.

Having fifty percent more of Emily’s time is gonna power SO much new work in 2026. You’re going to absolutely love it.

And we definitely need your help to make it happen. 

To make that gift, just go to arm and a leg show dot com, slash support.

Arm and a leg show dot com, slash support.

You may be asking: Hey, Dan, will my gift be MATCHED? I’ve heard you talk about the NewsMatch campaign from the Institute for Nonprofit News. Is that still in effect?

And the answer is: Maybe, if you act fast. You all gave a lot more in November than we expected — which was AMAZING… and it means we have fewer matching dollars left at this point.There are still SOME — but they’re going fast. If you want your gift doubled, head NOW to arm and a leg show dot com, slash, support.

But no matter what, to make this plan work — fifty percent more Emily — every dollar you give us this month counts more than ever. 

Thank you SO much to everybody who’s already given, who’s allowed us to get here, to make this commitment. 

If you haven’t yet, now’s your time: The place to go is arm and a leg show dot com, slash support.

Thank you SO much! We’ll be back with one more episode before the end of the year.

Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann along with Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

The team behind “An Arm and a Leg” examines their own limited options, walking through how they approached reading the fine print to weed out the worst choices — and potentially save thousands of dollars.

Plus, KFF Health News senior correspondent Julie Appleby explains what could happen if Congress changes course and extends the enhanced premium tax credits for Obamacare enrollees that are due to expire at the end of the year. And a listener wonders: Is paying for health insurance even worth it at this point?

Credits

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

Dan hosting: Hey there. As we started writing up this episode, the U.S. government was starting to re-open, after the longest shutdown ever. ?Eight Democratic Senators had made a deal.

News anchor: But this deal has Democrats divided. It does not include an extension for Obamacare subsidies, which is what the party was holding out for.

Dan hosting: And people were pissed. Here’s a couple examples from our social-media feeds… 

TikTok user hunteralexanderpowell: eight Democrats caved and betrayed the American people tonight

TikTok user shaneechchi: The Democrats caved. The Democrats caved! What? I have tried to calm down so many times to record this video, but Senate Democrats…

Dan hosting: Those Democrats did extract one sliver of a concession: A promise from Republican Senate Majority Leader John Thune to schedule a vote on extending the subsidies for early December. Which lots of people found… unsatisfying. One more from our feed here. There’s some strong language in this one: 

TikTok user 2rawtooreel: After 40 days of fighting for our subsidies, we got a pinky promise. What a gut punch. The eight Dems caved and then they fucked our families. And that’s the way they all became the bitch-ass bunch. The bitch-ass bunch.

Dan hosting: Yeah. News reports pretty much all say: That vote will fail.

But even if they’re wrong, even if some unexpected deal gets made, expect nightmares. Logistical nightmares. Tech nightmares. Julie Appleby is a reporter with our pals at KFF Health News.

She talked to folks who run the Obamacare exchanges in a bunch of states and asked them: Hey, if Congress makes a deal, what happens next?

They were like: Well, we’d have to take our websites down to plug in the new numbers. 

Julie Appleby: And that could take maybe up to a week.

Dan: Yeah, a week. Julie says that took her by surprise.

Julie Appleby: I guess I mistakenly assumed, naively assumed that, oh, it’d be pretty easy. Let’s just, you know, program these numbers in. It might take a couple hours or whatever, but no, it’s not just a simple let’s throw a switch and change all this stuff…

Dan hosting: And there’s a ticking clock: If you want an Obamacare plan that starts covering you on January first, you have to sign up by… December 15. And again, IF there’s a vote to do any of this, it’s not supposed to happen until December. Tick-tock… 

So look: Nobody can predict the future, but if you’re looking at Obamacare for 2026: Don’t count on those extra subsidies being there.

Meanwhile, premiums are going up — both for Obamacare plans and for employer-based insurance.

We’re gonna spend the rest of this episode looking at: OK, now what? It’s the worst ever year to choose insurance. What do you do? We’ll hear from a listener who wrote to us asking for advice, and we’ll look at what next year looks like for ourselves — for me and my colleague Emily Pisacreta. 

There are folks who have it worse than we do. Millions of people just won’t be able to afford insurance at all for next year. But our stories give a sketch, a little sample — and some lessons and tools that I hope will come in handy for anyone asking the same questions we are.

Like a lot of our stories — like our whole beat– there’s no happy ending here. This absolutely sucks.

We’re talking about choosing the LEAST crappy option here. Which, even when all the options are crap, is STILL WORTH DOING. Because some options are so much crappier than others. But sorting out which ones means learning to read some fine print. So let’s get to it.

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

Let’s pick up where we left off a couple of months ago: With this show’s senior producer, Emily Pisacreta. 

Dan hosting: Hey Emily.

Emily hosting: Hey Dan.

Dan hosting: So, let’s recap… 

Emily hosting: Yeah, so before… I had insurance from another part-time job. But that job ended over the summer.

Dan hosting: And An Arm and a Leg has always been so tiny, I never thought about budgeting for anybody else’s health insurance.

Emily hosting: So I had to look for Obamacare. And I ended up getting help from the absolute best person: Elisabeth Benjamin. She’s Vice President of Health Initiatives at the Community Service Society of New York. 

Dan hosting: She has been one of our go-to sources for years–  because her fights to protect New Yorkers from medical debt are epic.

Emily hosting : And as it happens, she’s also a navigator for Obamacare — she helps people choose and sign up. She invited me over to look at my options.

Elisabeth Benjamin: Ok, so ready?…

Emily hosting: The good news: I qualified for a subsidy.

The bad news: That was gonna come to a screeching halt come January. She suggested we meet again in November to look at my 2026 options.

So, last week, we did– just a couple days after those Senate Democrats had folded on the enhanced subsidies. 

Elisabeth Benjamin: It’s quite clear that the enhanced premium tax credits are gonna sunset. Right?

Emily: Yeah.

Elisabeth Benjamin: Yeah. Which is really horrible for patients.

Emily: Are you surprised or did you sort of see the writing on the wall?

Elisabeth Benjamin: I find understanding Congress and the federal government and what they’re gonna do really challenging. I would’ve thought people would’ve wanted to do something, but it’s, it’s hard when people aren’t getting SNAP benefits and planes aren’t flying. And for me I would’ve thought that they would’ve been able to come up with a compromise, but they didn’t. So…

Emily: Yeah. 

Elisabeth Benjamin: So, you know, I don’t know. All right. Lemme show you your thing. 

Emily: You wanna share your screen? 

Elisabeth Benjamin: Okay. Um, so here’s your account. Here’s your eligibility. You know, this is what you have right now. Your tax credit is $385 a month. Your income, if it’s unchanged, means you will be eligible for no tax credit next year.

Emily hosting: So we kinda knew this was coming. I make a little more than 400 percent of the federal poverty level, which means I don’t qualify for that enhanced premium tax credit anymore. 

Elisabeth Benjamin: You are being impacted by the expiration, like you are going from. Spending whatever it was, 400, $400 a month to $800 a month.

Emily hosting: Actually it’s going from $496 to $867. And all this for what’s called a Silver Plan. You know, not platinum, not gold. 

Elisabeth Benjamin: You’re not talking about Cadillac coverage here. You have a big deductible.

Emily hosting: Yeah… that’s $2500 before I can afford to see a doctor in person. A doctor who’s in-network. In an itty bitty network. I kinda wondered what I would get if I leveled up. 

Elisabeth Benjamin: So you wanna do the cheapest gold or like a mid price

Emily: Yeah. Let’s just see what the cheapest golds look like.

Elisabeth Benjamin: So the cheapest is 1100. $1,100. So that’s a lot. 

Emily hosting: Yeah so that was out of the question. And we looked at a slightly cheaper silver plan, too. But the deductible was a lot higher and the ER coverage was pitiful.

Elisabeth Benjamin: Just walking into an emergency room in New York City is like $10,000. So you’d be basically paying your whole emergency room visit. Whereas right now you have real protection, you only have $500…

Emily hosting: And anyway for all its holes, my current plan — like of these New York state marketplace plans — does actually have a big advantage over every other health insurance plan I’ve ever had. Zero dollar copays for my absolute do or die stuff — my insulin and my continuous glucose monitor.

Dan hosting: Yeah. That’s just one way where you live really matters.

Emily hosting: Yeah and I’m never leaving, I’m like the worst kind of New York chauvinist. But the cost of living here means this premium increase is gonna really hurt. I’m gonna need another job.

Dan hosting: Yeah, but I wanna keep you in this one. And we are working on a plan there. We’ll come back to it later. 

Emily hosting: Mmhm.

Dan hosting: Meanwhile, you’ve given us a snapshot of Obamacare.

Obamacare plans aren’t the only place where costs are going up. According to a survey of 1,700 businesses, the rate hikes on employer plans are the biggest in 15 years.

And you know who’s on an employer plan? My family. My wife and I both have small little businesses, and we’ve been able to buy small-group coverage for ourselves that way — which means we do get to choose from plans that aren’t on the Obamacare exchange. 

So, here’s a little heartwarming scene from my house — me showing my wife Devorah what our health insurance is going to cost for next year.

Devo: All right.

Dan: Make sure we’re recording. Let’s see. Yep. Here we go. Alright, so let me just show you what I have been looking at. 

Devo: Alright.

Dan:  And be aware that it super sucks. 

Devo: Alright.

Dan hosting: And here’s what I showed her: Our insurance plan is going up by 500 dollars a month in January. Six thousand dollars a year. 

Devo: I’m not allowed to say bad words, right? 

Dan: You’re totally allowed to say, are you kidding me? Bad words are very appropriate. 

Devo: Bad words are forming in the thought bubble over my head. 

Dan: You can say them all you want 

Devo: Okay. Fuck. 

Dan hosting: Absolutely fair. The new total for our plan is terrifying.. And — for reasons I’ll get to — that plan still looks like our best option.

Meanwhile, we’d heard from a listener — Jess lives in Indiana. She asked us to just use her first name, to protect her family’s privacy.

And she wrote to ask: Have you ever done a show about whether having health insurance is even worth it? A perfectly understandable question. We talked in early November.

Jess: Does it ever make sense to just, if you feel relatively healthy, like if I take what I’m paying for a premium and put into the bank account is, does that make more sense than just giving over this huge percentage of money? It feels like there’s not an answer.

Dan hosting: In her case, it looked like insurance for her and her husband would go up a couple hundred bucks a month, for the same crummy, bare-bones plan they already have. That could still leave them on the hook for like 17 thousand dollars in medical bills.

Jess: Obviously I feel really lucky that like we don’t work through the federal government or any number of folks who are dealing with much more this year than we are. But then at the end of the day, it’s really hard to press the button, and sign up for something that you’re like, well, I know I’m not gonna get great care because the one plan I chose like really limits the amount of doctors I can go to.

Dan hosting: And she says that limited list of doctors, it’s got a lot of turnover.

Jess: So like, we’ve been through how many doctors in the past five years? Then I know that if anything bad does actually happen, I still gotta come up with like $17,000 to like pay those bills, on top of everything else. So sometimes I’m just wondering like where, like with a system that doesn’t make any sense, where’s the line where for… I just feel like a lot of people are gonna be thinking about this, this year. Like, what? I’m gonna keep the money, I’m gonna put it in the bank and with people losing their jobs and stuff too, like maybe it’s time to just bulk up your savings. I don’t know.

Dan hosting: Jess and her husband run a small business. It hasn’t been a great year, and next year could be kind of dicey. On the other hand, her dad survived a major bout with cancer earlier this year. That experience had already been noodging her toward pressing the button: paying the extra for insurance. And then a little after she wrote to me.  

Jess: I was like visiting dad, this fall, So it had been long enough that he actually got the like ex– like I think it’s probably the explanation of benefits or whatever…

Dan hosting: Yep, explanation of benefits: That’s the insurance paperwork that shows the total chargesfor all that cancer treatment, and what the insurance company paid.

Jess: And he’s like, do you wanna know how much that cost? it was a million dollars. And I was like, okay, I guess I’m getting health insurance again this year. 

Dan: Oh my God. Wow.

Dan hosting: She and her husband *can* find the extra couple hundred dollars a month. And they will. But it still feels unresolved. 

Jess: I really love, like really trying to understand a problem I’m trying to solve and making sure I’ve like, I feel like that’s the, that’s the hard thing with this is that like every year I’m like, have I thought of everything?

Have I considered all the parameters? Have I I done the right research?

And just kind of feeling like on your own with it, even though, you know, everyone’s going through the same thing.

Dan: For sure. For sure.

Jess: It sucks.

Dan hosting: Here’s what’s coming next: 

We’re gonna come back to Emily’s story– and mine. There’s a POSSIBLE less-sucky option for Emily — it’s gonna take some doing — and in every case: 

We’re looking closely at the options we DO have. Going through all that paperwork is not fun, but the details we found buried there are gonna make a HUGE difference  

We knew where to find them because we’ve been doing this — looking at the puzzle of shopping for health insurance — for a lot of years now. 

We’ll walk you through some of what we did, and recap some of what we’ve learned over all this time.

That’s coming right up.

This episode of An Arm and a Leg is produced in partnership with KFF Health News — that’s a nonprofit newsroom covering health issues in America. These folks are incredible journalists — their work wins all kinds of awards, every year. We are honored to work with them.

Let’s go back to my house for starters. As you may recall, our plan for next year is gonna cost about 500 dollars more every month. That’s 6 thousand dollars for the year.

And Devorah and I were processing.

Devo: I mean… 

Dan: It’s a lot.

Devo: That’s a lot of money. 

Dan: It’s a lot of money. 

Devo: And that’s just like additional money. Like we’re already hemorrhaging money on health insurance, like before it goes up $6,000. 

Dan: Right? Right. We’re already paying a lot. We’re already paying a lot, and so we’re looking at adding $6,000 to that and… 

Devo: Can I have a different timeline?

Dan: Yeah, we’d all like that. Right now there are alternatives. Um, they’re not great. 

Devo: Okay. 

Dan hosting: Our broker had sent us a couple other plans to look at. And they were a little less: Instead of 2600 dollars a month,

Dan: …They take it down to about 2300.

Devo: Okay. 

Dan: But by paying $300 less, we pay more for things like office visits, which we use a fair amount of, um, to see therapists and stuff like that.

Dan hosting: I mean, look: ?You think I could make a show like this without some serious support for my mental health?

One reason we’re looking at these super-expensive plans is: our therapists accept them. The co-pays to see them for the “less-expensive” plans were much higher — it ate up all the savings. I had a whole little spreadsheet.

And I was hoping Devorah would be like, “Wow, you’re so good at math!” But she was looking at those totals for the full year and doing her own math.

We’ve got a kid who’ll be applying to college next year, and Devorah’s been using a tool called the “net price calculator” — looks at a bunch of factors, and gives an estimate of what we’d probably pay after any financial aid. 

Devorah was mentally comparing what she’d seen there to what my spreadsheet said we’d be paying for health care next year.

Devo: Do you know that this looks exactly like what the net price calculator says we might pay for college in a year? No, I’m serious. 

Dan: I know you’re serious. 

Devo: I’m like writing the net price calculator with our income and it’s coming out with like almost the exact number you’re saying we could pay on healthcare.

Dan: Yes, that’s right. And this is… 

Devo: that’s insane. 

Dan: And this, right. Well, and this is, the big number to look at next is deductible. And that’s where things get very different. 

Dan hosting: Especially because all of these plans — the “cheaper” ones and our current one–had a feature I’d never noticed before: *family* deductibles. A kind of safety valve where if one person’s expenses passes a certain point, insurance kicks in for the whole family. 

On the quote-unquote “cheaper” plans, those family deductibles were five thousand, even ten thousand dollars more.

I mean, I hope we don’t end up in that kind of territory. The deductibles on our current plan are already in the thousands of dollars. But if we ever got there, I’d sure want to stop the bleeding five thousand dollars sooner.

Devo: I kind of am leaning towards 

Dan: Yeah. Keeping what we have. 

Devo: Keeping what we have.

Dan: Right? Yeah. It’s weird because I’m like, wow, but that’s 

Devo: $6,000 more a year. Okay. Okay. I’m gonna go take some deep breaths now. 

Dan: Yeah, 

Devo: I don’t like it. 

Dan: No, me either. Sorry. Thank you for joining me with this. I’m sorry. Super sucks.

Dan hosting: It does — and six thousand dollars is a LOT of money for us. But it turns out, those “alternative” plans don’t save us any money, and they leave us potentially on the hook for thousands and thousands of dollars more.

So I am taking this as a win. And it’s the lesson: If there’s ANY way to look beyond the monthly premium, you gotta do it. 

Read the fine print! If you’ve got ongoing health care stuff — or stuff you’re GONNA do next year, like, I dunno, have a kid? — price it out for any plan you’re considering.

Learn the stupid vocabulary: Deductible. Out of pocket max. This time around, I actually learned a new one: FAMILY deductible.

And then we get back to Emily’s case. Which actually has a happier side to it. Especially after we read some fine print.

Emily, we left you with Elisabeth Benjamin. She had a couple of options for you.

Emily hosting:  Yeah. I could either re-enroll in what I have now for 867 dollars a month. Or get a plan with a slightly cheaper premium with even crummier coverage. No matter what, I’m looking at paying a way bigger percentage of my income on health insurance.

Dan hosting: Yeah, because you’d lose the subsidy you have now. But my guy Kurt, my insurance broker, 

Emily hosting: Kurt! 

Dan hosting: He says there’s another way: If I can bring you on at 30 hours a week — versus now you’re at 20 hours — then Blue Cross of Illinois would consider you a full-time employee, eligible for ben efits with An Arm and a Leg. And.. you, know, I’m working on it…

Emily hosting: I know. I know you are.

Dan hosting:  Yeah so, toward that end, Kurt has sent me a couple of plans that you could enroll in. And like even if you had to pay the whole premium, they’re less than these New York plans. One’s like six hundred, the other is about six-ninety.

But the question is: Does that really save you money? It depends on what they  cover. I dug up the spreadsheet Kurt had sent me.? And we looked at it together on Zoom last week. 

… I’ll put it in the chat.

Emily: Okay

Dan: so the first number is, let’s just look

Emily: Wait I’m putting I gotta put Zoom on, uh, 200% here.

Dan: Yeah, yeah. You for sure. 

Emily: …cuz they’re little. Okay, okay. 

Dan: So. This number really pops out at me, what is the overall deductible? It seems to say $850 deductible. 

Emily: Mm-hmm Mm-hmm .

Dan: Sounds pretty good. Sounds a little like, is that a typo?

Emily hosting: OK- lower premium, lower deductible. What about my copays? Remember – my New York marketplace options have zero dollar copays for insulin and diabetes supplies. 

Dan: This would be one where we would like, have to do a little more digging to figure out what your out OFP pocket would be.Let me see what I can find out. Lemme see what I can… 

Emily: Yeah I mean like the advice that we were giving people like— contact your HR department. It’s like, Dan are you the HR department? 

Dan: I am, I am. So I’m like, yeah, let’s do this. Let me, this is gonna take a 

Emily: Yeah yeah.

Dan hosting: Honestly, it took forever. We spent another twenty minutes on that call, trying to get information from my Blue Cross website, and then from Google. Which ended up sending us to Facebook group discussions and Reddit threads. 

Emily, you took some time on her own– OK a lot of time– you called your insurance, and your pharmacy, and I forget who else– and ultimately, with your incredible Google skills, you found the document we needed: The 2026 formulary for Illinois Blue Cross plans.

Emily hosting: Yes, the formulary. That’s an insurance company’s list of ALL THE DRUGS they cover–  and what you’d pay for each one. If you’re a First Aid Kit newsletter subscriber, you know we just wrote about them last week. Ok, so we started off looking for my continuous glucose monitor supplies.

At first, it looked like: They were gonna be kind of expensive. $60 a month. But there were little letters off to the side– one was CW, which seemed to stand for “cost waived.” We hit Control-F…

Dan: Okay. So that’s here. It says, uh, cost waived – CW –Medicines marked with a CW in the coverage requirements and limits column are mandated in the state of Illinois to have $0 member cost.

Emily: Hey.

Dan: Yeah, right. Yeah.

Emily hosting: Next… we looked up my insulins.And I do have a copay there – $85 a month, which is unfortunately pretty normal. And so this plan was still looking like a winner. Because of that lower deductible. And then — after we did one more round of due diligence — we figured out — it was even better than we initially thought.

Dan hosting: Yeah, we downloaded another set of paperwork. Every plan has a document called the Summary of Benefits and Coverage, so we grabbed those. With the New York plans, those documents confirmed: you would have to pay out that whole deductible before seeing a doctor. Then we looked at that same document for this Illinois plan. And found THIS:

Dan: If you visit a healthcare provider’s office, primary care to treat an injury or illness, deductible does not apply.

Emily: Hell yeah.

Dan: Yeah. Whew. All right. That seems like a good deal.

Emily: Yeah. Yep. Exactly.

Dan: All right, cool. This is excellent. Okay. So I think what we’ve found through our sleuthing, your sleuthing is, yeah, this is a better deal and it’s all in the fine, it’s all in the fine print.

Emily: It is, yeah.

Dan: Yeah. Alright. All right. Well this is good. I feel like we are like, now all you gotta do is raise money to bring you on for the extra hours and you know, but like we’ve done the hard part.

Emily: Yeah, yeah, exactly. Exactly. We’ve deciphered, um, insurance lingo…

Dan: Oh my God.

Emily: …and now we just have to pass a hat around, so.

Dan: Let’s do it. 

Dan hosting: So, OK, we have modeled some stuff for you here:

If there’s medical stuff you know you’re gonna need: Look beyond the monthly premium.

Look at that Summary of Benefits and Coverage. Look for the drug formulary. Read the fine print. Use Control-F. Make calls. 

And we have a ton of resources to help you keep the whole thing straight: We’ve covered this stuff before, in depth, in our First Aid Kit newsletter, and on the podcast — and we’ve collected the most-important, most-useful stuff, and organized it into a Starter Pack on our website.You’ll find a link wherever you’re listening to this.

And look: there are people for whom NONE of this gets you to something workable. The spikes in health insurance premiums, and the lower subsidies, they mean a lot of people are just stuck.

The folks at NPR talked with a woman last week who’s in the middle of cancer treatment. Her health insurance is scheduled to jump from three hundred some dollars a month to like 12 hundred dollars. Which she absolutely cannot afford.

There will be people looking to take advantage of this whole crunch: Pitching junk insurance plans and other “bargains” that don’t actually cover enough.

And there will be a lot of people facing bills they just cannot pay. Medical debt — and aggressive debt collections — all of that is gonna hit even more people.

Which, honestly, is why it’s so important for us to keep doing this work. Together. So many people are going to be in so much need in the coming year — years.

Everything we can learn about fighting unfair bills, applying for financial assistance, avoiding ripoffs, and HELPING EACH OTHER. We’ve gotta keep spreading it around.

And to do all of that: We need your support. For example: yes I want Emily to have more hours so she can have insurance, but I need more of her time because we’ve got so much work to do. 

So yeah, we need your help.

And this is the ABSOLUTE best time to help us. Through the end of the year, the NewsMatch campaign from the Institute for Nonprofit News is matching donations of up to a thousand dollars.

And if you’re catching this in November, well: Through the end of the month, because of a special matching fund from the Jonathan Logan Family Foundation, those donations are DOUBLE-matched. 

You give us a hundred dollars, and in November, it gets turned into three hundred dollars. 

And lots of you have been taking advantage of this opportunity in the last few weeks. It’s amazing.

And some of you have been adding notes. Kimberly from Texas wrote: “Thank you for all your hard work! I feel surrounded by support knowing you, your (tiny) team, and all your listeners are out there, caring so much.”

Kimberly, thank YOU so much.

OK: The place to go is arm and a leg show dot com, slash support.

Arm and a leg show dot com, slash, support.

We’ll have a link wherever you’re listening. Everything you give gets matched. Let’s do this now.

Thank you SO much. Arm and a Leg show dot com, slash, support.

We’ll be back with another episode soon. Till then, take care of yourself.

This episode of An Arm and a Leg was produced by Emily Pisacreta and me, Dan Weissmann, with help from Claire Davenport — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

And in fact:  Here are the names of a few people who have pitched in for this year’s NewsMatch campaign. 

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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This story can be republished for free (details).

But meanwhile, in the states, there were some wins for health care access. “An Arm and a Leg” host Dan Weissmann examines how lawmakers from across the political spectrum accomplished meaningful reforms. This episode takes listeners to Nebraska, which instituted aggressive new restrictions on prior authorization, and Virginia, where lawmakers banned wage garnishment and capped interest rates for certain medical debts.

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

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Dan: Hey there, you don’t need me to tell you. 2025 has been a lot. 

I mean, just with health care: As I record this, the US government has been shut down for more than a month over whether to extend health insurance subsidies that more than 20 million people rely on. 

I mean, if Congress resolves this tomorrow– and I’m not holding my breath–it’s still gonna be a huge mess.

And I could definitely go on. But I’m not gonna do that.

Instead, I’ve been spending my time these last few weeks looking at what’s happened this year that didn’t suck and what we can learn from that. 

And it turns out, at the state level, there’s a lot to look at. 

All over the country, state governments took action this year to make things suck a little less — on things like medical debt and health insurance and the price of drugs.

And it happened dozens of times this year in a lot of states.

Nebraska Newscaster: New tonight, new Nebraska legislation will make it easier for patients to access healthcare.

Maine Newscaster: We’re on your side tonight as a new law aimed at protecting Maine consumers from the impacts of medical debt goes into effect.

Virginia newscaster: Virginians are only one medical crisis away from bankruptcy according to advocates. That’s why the General Assembly passed a bill to create some protections for people facing medical debt.

Dan: And I’ve been talking with people who helped get new non-sucky laws passed this year.  In red states, blue states, purple states. 

And I cannot wait to start introducing you to some of these folks and to share what I’ve learned about what they got done — and maybe most important: how they did it…’cause we need more non-sucky laws passed in as many places as possible.

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

Here. Let me introduce you to somebody.

Eliot Bostar: My name is Eliot Bostar and I am a legislator in Nebraska. I represent Legislative District 29, which covers essentially South Lincoln, our capital city.

Dan: I thought Nebraska was interesting. One ’cause it’s a state we don’t hear from as often. It’s not a blue coastal state. 

Eliot Bostar: Whatever the opposite of that is, that’s what we are. Yes.

Dan: And Eliot Bostar sponsored and passed legislation this year imposing new rules on prior authorization. 

That’s where your doctor or your provider tells you you need something, a drug, a test, a procedure, and the insurance company comes back and says, yeah, not so fast. Your provider has to show us why that’s necessary.

And look, just to zoom out: 

There’s an argument here that not everything that gets prescribed or ordered is actually necessary or even appropriate. But in practice, prior authorization can result in treatment getting delayed or denied in ways that seem arbitrary and unreasonable and that have big consequences. 

In a recent survey from the American Medical Association, almost 30% of doctors said problems with prior authorization had led to a patient getting hospitalized or becoming permanently disabled, or sustaining other permanent damage, or almost dying, or actually dying. 

Amy Killelea is a professor with Georgetown University’s Center on Health Insurance Reforms.

They’re part of a research team tracking prior authorization, and whenever they give a talk to college students, to policy nerds, to groups of patients with conditions like diabetes, they’ll say this.

Amy Killelea: Raise your hand if you’ve ever had a problem or um, an emotional reaction to prior authorization, and every hand in the room goes up. It’s so ubiquitous. It’s something that everybody can relate to on like a fundamental, visceral level. 

Dan: Amy Killelea says this kind of anger is starting to show results. The Georgetown Center tracks state laws on prior authorization.

In 2024 they know of 10 that passed.

In 2025, so far, they have logged 20.

And looking over their list, a couple of things stand out. One is these are 20 politically diverse states. Alaska, Rhode Island, Arkansas, California, Montana.

You get the idea. The other thing that stands out is these things they’re regulating generally make you go, wait. There was no law against that before? 

I mean, Nebraska’s new law regulating prior authorizations is about as aggressive as anything I’m seeing on this list. And the results are just, like, common sense.

Like for one big example: if an insurance company denies your prior authorization request, or an appeal, that denial now has to come from a licensed clinician with relevant experience.

And when I talked with Eliot Bostar, I was like, wait, like this wasn’t required before?

Eliot Bostar: You’d be surprised. So, I’ll give you an example. A neurosurgeon was attempting to get approval for fusing of a cervical disc in the spine, right? There was a person that was at risk of honestly paralysis and got an initial denial, appealed, and got another denial. And that denial came from a pediatrician. 

Dan: Like a general… 

Eliot Bostar: General practice pediatrician.

Dan: How old was the patient?

Eliot Bostar: An adult.

Dan: Okay. Not, not, not, not a candidate for pediatric care. All right.

Eliot Bostar: Or, a request is put in for a medication by a prescribing physician and a denial comes back from a dentist.

Dan: Yeah. None of that was illegal under Nebraska law, until now. 

And not just Nebraska. Four other states passed similar rules just this year 

And there are more what I’ll call, “wait, what?” kind of provisions in Nebraska’s new law.

Like it sets a deadline for how long your insurance can make you wait for a yes or no on prior authorization, or like, they can’t make you wait for prior authorization to approve an ambulance ride to the ER. 

And Nebraska’s law also features a technical provision that I don’t think anybody would’ve imagined a few years ago.

It outlaws the use of AI as the sole basis for denying coverage. 

And Eliot Bostar says insurance companies don’t say they’re doing that, but he’s seen examples that look a lot like it. 

Eliot Bostar: Physicians putting in a request through a digital platform, um, putting in all the information, hitting submit, and then instantly getting a denial. There’s not a lot of ways that can happen, right? It’s not that there was a human who sat there and read it all and was thoughtful, analyzed the case, and made a determination of denial within half a second. So something else happened in that time, and so that should not happen anymore.

Dan: Two other states, Maryland and Texas restricted the use of AI this year, according to that cheat sheet I got from Georgetown. 

So, Elliot Bostar and his colleagues got a big win. He says the state medical society, Nebraska’s chapter of the American Medical Association and the state hospital association were big allies. 

But health insurance companies are powerful opponents. Eliot says, in earlier years, he and his allies had tried taking smaller swings at prior authorization– and gotten swatted away. This time, they went big.

Eliot Bostar: The decision was made that we were gonna, we were gonna really go after all of it. We’re gonna go after all of it.

Dan: He says a lot of that decision came down to sheer frustration and a little bit of political calculation. A big swing can rally people to you and give the other side good reason to take you seriously.

Eliot Bostar: I think it’s important to make clear that we’re not going to put up with a system that’s this broken, any longer. You can be really direct. So you can tell the insurance companies, we’re gonna do something. And you can either kind of work with us on how to do that or, or not.

Dan: And then he set out to divide and conquer.

Eliot Bostar: If insurance companies themselves don’t necessarily agree with each other, or they’re not fully aligned on a bill or on a policy, that can effectively neutralize the industry.

Dan: I asked him:, how’d you figure out who you might be able to pick off? 

Eliot Bostar: So Blue Cross Blue Shield in Nebraska is just a Nebraska company, right? They’re part of the larger Blue Cross, you know, network, but they are just a Nebraska company versus United is not.

Dan: He said by the time the bill came up for a hearing, he’d been negotiating with insurance companies for months and he didn’t get everything he wanted. But you know, it passed.

Eliot Bostar: I don’t think anyone voted against it. 

Dan: Eliot Bostar says his strategy got a boost from some specifics of Nebraska’s legislative structure.

Like there’s just one house, a Senate. 49 members smallest in the country, and elections are nonpartisan. So things work differently than they do in most places.

Eliot Bostar: There’s no majority leader. There’s no whip, there’s no any of that.

Dan: He says that setup allowed him to hand sell this proposal to one colleague at a time. 

So some lessons here: 

One, go big. Why the heck not? 

Two: Figure out who you can pick off in the opposition. 

Three: However the political structure works in your state, work it.

Because, you know, lawmakers in 20 states made new rules on prior authorization this year. They don’t all work like Nebraska. 

One caveat here, states don’t have all the power. With health insurance, that’s especially true. 

You know, we’ve talked about this before. If you get your health insurance from work– especially if you work for a good sized company– your health plan is probably set up in a way where state insurance regulations don’t apply.

But Eliot Bostar says he gives local employers a two-part pitch to offer their workers similar protections. 

One, they can save money because delaying care now can mean more-expensive care later. 

Two, because new state protections raise everybody’s expectations. 

Eliot Bostar: And how much of a unfortunate shame would be if their employees didn’t receive the same benefits that perhaps their neighbors are.

Dan: In other words, you want to piss off your workers? He says sometimes it works. 

Just ahead: In Virginia, a new law bans wage garnishment for medical debts — and caps interest at just three percent. Democrats passed it. The Republican governor signed it. How’d they pull it off? 

That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering healthcare in America. These folks are amazing journalists. Their reporting wins all kinds of awards every year. We are honored to work with them.

Ok, let’s meet a couple folks from Virginia.

Amanda Gago Silcox: I am Amanda Gago Silcox. I am the education and resource manager here at Virginia Poverty Law Center.

Jay Speer: I’m Jay Speer. I’m the Executive director and consumer rights attorney at the Virginia Poverty Law Center.

Dan: Their organization, VLPC, for short, does a bunch of stuff. 

Among other things, they operate toll free helplines for folks struggling to pay utility bills. They coordinate with local legal aid offices across the state and. They lobby in the state capital. 

Medical debt is a big issue for them, and this year they helped pass a law that will limit how far Virginians can get chased for medical debt specifically, it caps interest on medical debt at 3%.

Amanda Gago Silcox: And then the bill also bans garnishing the wages of anyone qualifying for financial assistance.

Dan: …which seems like common sense.  like if you qualify for financial assistance from a hospital, you should be getting your bill reduced or canceled, not getting money grabbed from your paycheck. Or having your home foreclosed on to pay a hospital bill, which has also happened, and which the new law will also ban. Along with … getting arrested over a hospital bill. Yeah.

And there’s another provision that VPLC really pushed for in this bill. It’s gonna sound technical, but this is big.

Amanda Gago Silcox: It prohibits, the sale of medical debt to a debt buyer unless they follow basically the same requirements as are required of medical creditors.

Dan: Here’s why that’s big. There are two kinds of collection agencies. There’s the kind that work for a hospital or whoever and get paid basically on commission and then — as Jay explains– there debt buyers. Those are different. 

Jay Speer: They’re the ones that pay anywhere from one to 5% of what’s owed and then sue you for the whole amount. Debt buyers deal in volume. They get, they buy thousands and thousands of debts and they sue everybody.

Dan:Yeah, Jay says VPLC has analyzed data from across the whole state court system-  and saw just how many lawsuits debt buyers were actually filing.

Jay Speer: In Virginia last year, they filed 45% of the lawsuits in Virginia. Um, so it’s a huge amount.

Dan: 45% all lawsuits, like..?

Jay Speer: …of all lawsuits were filed by debt buyers.

Dan: The new law aims to put the brakes on that, at least from medical debts. 

Jay Speer: It says if you sell the debt to a debt buyer, you have to have an agreement with that debt buyer that they will follow these rules.

Dan: That is, they won’t charge more than 3% interest. No garnishing wages, no foreclosing on homes, no arrests. Jay thinks requiring these kinds of agreements could basically mean providers just won’t be able to sell to debt buyers. ‘Cause he’s been studying how that whole side of medical debt actually works.

Jay Speer: I’ll tell you right now, there is no such thing as these agreements between providers and debt buyers.

Dan: Hmm.

Jay Speer: All debt buyers buy is a spreadsheet with names and numbers on it. They’re not gonna enter into these agreements. Maybe I’m wrong. I mean, they could change their whole practice, but I would be surprised.

Dan: That’s the kind of insight VPLC brought to the push for this law. But Amanda admits that push wasn’t part of some master plan. 

Amanda Gago Silcox: And you know, I wish that we had planned many, many days and months, to work on this bill, but it kind of fell in our laps.

Dan: She says late last year, she heard from an advocate with a national group called Blood Cancer United–  they advocate for cancer patients, not cancer–with a pitch for the idea.

Amanda Gago Silcox: I’ll be quite honest, I was like, wow, this is really aggressive. I don’t know about this.

Dan: Jay was skeptical too. Getting a bill like this passed would be one thing, even with Democrats holding majorities in both legislative houses, but then Republican Governor Glenn Youngkin would need to sign it.

Jay Speer: And the governor also has a history of vetoing tons and tons and tons of bills, five times more than any other governor’s ever vetoed. And so that’s hanging over the whole thing.

Dan: But Amanda says The folks at Blood Cancer United were very gung-ho. They promised to bring patients with powerful stories to tell

… and they thought VPLC’s technical expertise, including their research on debt buyers, would add a lot.

And they’d already lined up a sponsor: Delegate Carrie Delaney, who had just succeeded in passing a bill to keep medical debts off of credit reports.

Jay Speer: So we knew she was serious about it. I mean, that’s always a consideration when you’re thinking about legislation is, who’s your patron? Are they really serious about it?

Dan: VPLC decided to join up. Amanda took point on their lobbying, she says. It wasn’t easy.

Amanda Gago Silcox: I remember there being a day where it just felt like we were giving up little pieces here and there, and I was like, I just don’t know if what we’re gonna get out of this is worth it. We’ve given up everything. This doesn’t even do anything anymore. 

Dan: Specifically, she says the cap on interest looked like it was gone. 

Amanda Gago Silcox: Yeah. I thought we were gonna have to give that up.

Dan: Somehow the interest cap came back in. Amanda got her faith back. 

And she says there were also moments that gave her confidence, like just making the rounds of legislators offices to drop off information and sign up for a time to meet with the lawmakers.

Amanda Gago Silcox: When we were talking to their administrative assistants and we mentioned that we were there to talk about medical debt and many, many of the administrative assistants mentioned, oh yeah, like my husband had cancer and we had X, Y, Z, Or I had a friend who had breast cancer and she had this happen to her. So it really resonated with, with legislators’ staff, with the folks that they’re surrounded with. So I think that really helped us continue pushing.

Dan: And they won. Both houses. Now It was the governor’s move. 

Jay Speer: So Virginia has a weird process. Where they send the bills to the governor. The governor either signs the bills, vetoes the bills, or makes a quote recommendation. In this case, he made a recommendation.

Dan: He wanted to weaken the bill, so that sends it back to the legislature.

Jay Speer: And they either accept his recommendation, which puts the bill in, into law, or they reject it. Then it goes back to the governor. And the governor then has two choices. He could veto it or sign it. So it’s a risky business to reject his recommendation because you’re almost taunting him to veto it.

Dan: So when legislators DID reject the governor’s recommendation, Jay and Amanda say they were shocked.

Amanda Gago Silcox: We were shocked when it went back to the governor and he did in fact sign it. I mean, I thought we were, it was gonna be vetoed. 

Jay Speer: I was sure he was gonna veto it. I mean, like I said, he is vetoed like God five times more bills than any other governor. 

Jay Speer: I think the only explanation is he’s nervous about this and it makes him look bad to not help people out with medical debt.

Dan: They didn’t get everything they wanted. 

The law doesn’t take effect till July, 2026,, and it exempts credit cards, including medical credit products like CareCredit, which issues a plastic card–  and charges 33% interest after a promotional period.

Amanda Gago Silcox: So this is definitely an area where there’s some work to be done.

Dan: Yeah, like me, these folks are never gonna run outta material. Meanwhile, they won a victory this year. They really didn’t think they’d get. And talk about having a lot of material. I reported a whole story about how Maine passed a law to keep medical debts off of credit reports. State Senator Donna Bailey sponsored that bill, which passed unanimously, and a similar bill had failed before, but this time she says: 

Donna Bailey: I don’t remember a lot of heavy pushback, which was pleasantly surprising to me, quite honestly.

Dan: We’ll get to that one.

By the way, five other states did the same thing this year, total of 15 since 2023, and a bunch of states passed new regulations on pharmacy benefit managers. The most aggressive was probably Arkansas. So yeah, there is more news that didn’t suck coming.

And speaking of things that don’t suck as we bring you this episode, it’s November, which means I get to test something I’ve been saying to my colleagues for a long time. Reaching more people with An Arm and a Leg is both our mission imperative, ’cause we wanna be of the most use to the most people. And it’s our business model ’cause the way we’ve gotten this far is by asking you listeners, will you help us keep doing this? And a certain fraction of people have always said yes. And I’ve said, if we can reach more people, well that’s more people to say yes. And that will allow us to do more and keep growing. And this year I get to test that because Seattle’s Public Radio Station, KUOW, became our distributor this year, and they’re helping us reach a lot more people than we did a year ago, like twice as many.

And so I get to test this theory and under really favorable conditions because. November is the beginning of a project called News Match from the Institute for Nonprofit News. Now news match matches individual gifts of up to a thousand dollars. And this month through a special gift from the Jonathan Logan Family Foundation, especially for an arm and a leg news match is double matching your gifts.

So if you’ve been listening, if you have found this show entertaining and empowering and useful, if you think it’s cool to hear what states are doing to make things suck less and how they’re doing it, if you found it useful when we ran down ways to save money on prescription drugs. If you think it is awesome that Arm and a Leg listeners have been coming together to build tools to help other folks stay out of medical debt, then this is your chance to make a lot more of that happen. ’cause every dollar you give us this month is matched two for one. You give us 50 bucks, it turns into $150. You give us a hundred, bam it’s 300. 

And you know, we have so much work to do. All you have to do is go to armandaleg show.com/support.

That’s armandaleg show.com/support and News Match will make your gift count for triple Your support becomes super support. 

I mean, let’s do this, Armand leg show.com/support. 

Thank you so much. We’ll be back before Thanksgiving with our next episode. Till then. Take care of yourself.

(Psst: Arm and a leg show dot com, slash, support. Thanks!)

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. 

Claire Davenport is our engagement producer.

Sarah Ballema is our Operations Manager. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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.

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This story can be republished for free (details).

She has developed a strategy for addressing high insurance premiums — one that’s based on giving patients reliable information about how much they, and their insurer, would have to pay for care. The system is already working in Massachusetts. Could it be a model for the rest of the country?

Ho explains to Dan Weissmann, host of “An Arm and a Leg,” why she thinks this approach could help curb high prices and how listeners can help prove it by sharing their medical bills.

Credits

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

Dan: Hey there–

Vivian Ho is a health economist at Rice University and the Baylor College of Medicine in Houston. And since early 2024, she’s been giving talks at… HR conferences. Which is not a typical gig for an economist.

Vivian Ho: Um, yes. Economists don’t usually do that. We love to go talk at our own conferences.

Dan: But she’s been eager to spread a pretty big message.

Vivian Ho: There’s a potential to save workers, um, you know, and employees a lot of money.

Dan: And a few weeks ago, she sent me an email asking for help with what she’s trying to do: 

She’s wants folks to send her hospital bills for a study she thinks could be part of saving people a lot of moneys. She wondered if I’d encourage people to pitch in.

And honestly, I wanted to say yes before I even really knew anything specific about the study.

I should say: Vivian Ho has been a donor to this show. That’s actually how I met her and learned about her work. And became kind of a fan. 

Over the last few years, she’s been digging up and publishing evidence we need, to push back against the way health care keeps getting more and more expensive.

This is stuff a lot of us suspected, to say the least — stuff reporters have documented examples of — but she’s demonstrated they’re actual trends, not one-offs. 

For instance: When nonprofit hospitals make big profits — and they often do – they call them surpluses– they don’t generally use that money to help patients, by giving more charity care to reduce people’s bills. 

In one study, she compared hospital finances in the early 2010s and near the end of the decade. As the decade was ending, she found nonprofit hospitals were a LOT more profitable than they’d been before. 

And they’d gotten a lot richer, with like seventy percent more cash in the bank than they’d had earlier.  

But they were actually giving out less charity care.  

 She told me she ran that down after she got help understanding a big set of data that helped her see what hospitals actually do with their money– and started to poke around in it.

Vivian Ho: I say, well, I’m just gonna go have a look at, you know, one of the local hospitals and see what it says and then I pull it up and I go, oh wow.

Dan: She took a peek at one hospital’s “fund balance” — that’s non-profit speak for an institution’s savings, like for a rainy day. 

Vivian Ho: The fund balance for one of the hospitals across the street from Rice University is five and a half billion dollars. And so, you know, then it’s like, well, I need to take a closer look at this.

Dan: Here’s a couple things she found: That fund balance — the “rainy day fund” — was enough to run the hospital for more than two years. And it runs a healthy profit margin. 

And her study showed when she zoomed out: This is not a one-off. Among hospitals that do well, it’s the norm.

And this kind of data — this kind of EVIDENCE of how things work, of who benefits, and how much, from the totally unfair and unaffordable prices we’re all up against — it’s ammunition. 

Vivian Ho is looking for people to share their hospital bills with her, in order to build up her arsenal of information . 

She’s got a strategy in mind for how to deploy that information to save a lot of people a ton of money. It’s interesting.

And: I have no idea if this specific strategy will pay off.

But here’s what I do think: ?If we’re going to fight against the greed and exploitation that make our health care system so unhealthy — so deadly — we’re gonna need all the fighting power we can get.

So, I’ve sent Vivian Ho a hospital bill. And at the end of this episode I’ll encourage you to do the same. 

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

Dan: Vivian Ho has been a health economist for like 40 years. And you could say she has mixed feelings.

Vivian Ho: Health economists, they work on so many different things and they are all important and interesting. But I do think the issue of the cost of healthcare and the cost of health insurance premiums is the biggest problem putting a burden on the average American citizen. And I don’t think as a profession that we spend enough time on that basic issue. I feel kind of – well, it does make me quite sad because here I am, I’ve worked in this career for this entire time, and things aren’t getting better. They’re actually getting much worse.

Dan: And that, she says, is why she does things like go to HR conferences these days. She’s got the motivation and she’s got the freedom to do it. 

Vivian Ho: So I’m super lucky. I’ve got tenure at Rice and you know, I’m a member of National Academy of Medicine. I’ve sort of achieved everything that I wanted to achieve, and now it’s, it’s all about, well, what can we do?

Dan: She’s decided to go after what she now sees as the biggest problem. Not the ONLY problem, but the biggest driver in prices that only seem to go up more every year.

Hospital systems are consolidating — gobbling each other up. So they get more bargaining power with insurers. They get higher prices without necessarily delivering more value.

Which isn’t what economists always expect. Bigger can mean better, more efficient. That’s what Vivian Ho used to expect.

Vivian Ho: I started this whole research agenda sort of 10-15 years ago, and I thought bigger was going to be better. I thought because of economies of scale and that if you allowed hospitals to acquire physician practices, there would be less duplication of services, you’d save money. But then the problem is there’s no mechanism that forces a provider to pass any savings onto the consumer. So there may be economies of scale, it’s just you and I as consumers aren’t able to enjoy any of those benefits.

Dan: That’s something we’ve talked about on this show. Like a lot. But what Vivian Ho has been able to demonstrate is: At this point, the average profit margins for hospitals — including “non-profit” hospitals — are actually higher than average profit margins for insurance companies.

Vivian Ho: There’s plenty of rural hospitals and smaller hospitals that lose money, but net, when you average on just how much profits the consolidated systems are making and you add them up all over the country, it’s much higher than what you get for the total profits of insurers.

Dan: Which isn’t to say that insurance companies don’t have a BIG role to play in our suffering. 

Vivian Ho: Insurers are, in many ways, not doing what they should be for customers. Certainly the show demonstrates that in many ways and that they are earning high profits. I’ve just looked at the data and concluded that the hospitals are earning much higher profits than the insurers are, and that’s where we’ve gotta focus our attention. 

Dan: I mean, there’s so much to unpack there, right? One is, wow, the hospitals are earning higher profits than insurance companies, and the insurance companies, by and large, are publicly traded entities that answer to shareholders. And the majority of hospitals in the United States are, as far as the IRS is concerned not-for-profit entities.

Vivian Ho: Exactly. We’ve been doing research lately that unfortunately shows that our not-for-profit hospitals behave a lot like for-profit companies.

Dan: So, okay, how do we get at that? 

Vivian Ho: Oh, uh, how do we change the behavior of what’s going on? 

Dan: Yeah.

Vivian Ho: Yeah. So…

Dan: Here’s Vivian Ho’s game plan. It’s complicated, and I’m not in a position to say, “this’ll totally work” — but there’s a lot that’s worth knowing here.

Especially this:

When Vivian Ho talks to business executives or HR managers, she brings out another set of data. And this is data that’s only become available in the last few years. 

Insurers now have to show what they pay hospitals. Not the sticker price, the negotiated price.

So, Vivian Ho’s talk includes a slide showing some details from three Houston hospitals. Blue Cross pays one of them about 22 thousand dollars for spinal fusion surgery. Another one gets 66 thousand — three times as much.. 

And the slide shows: That math is similar for other procedures. 

Vivian Ho: Employers didn’t realize how different the prices could be at their local hospitals. They thought, you know, anyone would think, oh, the prices couldn’t be that different. And now that some of the data is starting to make it out there, it’s becoming clear you really could save a lot of money.

Dan: I mean, you MAYBE could — if you could give your workers a good reason to go to the hospital that charges less.

Vivian Ho has a model for how that could work. It’s — based in part on a story I call Once Upon a Time in Massachusetts. 

That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. They’re a nonprofit newsroom covering health issues in America. Their reporters do amazing work. They win all kinds of awards every year. We’re honored to work with them. 

So, here’s our story — Once Upon a Time in Massachusetts — straight from the story’s author.

Elena Prager: I am Elena Prager. I’m an assistant professor of economics at the Simon Business School at the University of Rochester.

Dan: And while doing her dissertation, she came across a very unusual set of data. 

Elena Prager: I was like, wow, goldmine.

Dan: Here’s the story: Massachusetts has an agency that basically runs employee health benefits for all state employees, and a lot of local-government workers too.

And once upon a time — starting in 2010– they tried something unusual. 

Elena Prager: Possibly because they were lucky, possibly because they were smart, they designed their health insurance plans – at least when it came to hospital care – based everything on copays. And what that means is that you are given a dollar number. Let’s say $250 or $500 and like that’s it. That’s the number. If you go to hospital A, you pay 250, you go to hospital B, you pay 500. The end.

Dan: Which is totally different from how we’re used to looking at hospitals, right? I mean, regular insurance plans typically say, “You’ll pay like 10 percent, or 20 percent or 30 percent of whatever the total bill turns out to be.” 

Elena Prager: And the patient is left scratching their head being like, well, how do I know what the total bill is gonna be? Even if the hospital tells me something. Like, what if something goes wrong with the anesthesia? They have to call in an extra specialist. There’s a complication. More stuff gets done. Like it’s very, very hard to, for a patient and even really a provider, to predict in advance what’s gonna be done to them and therefore what the price is going to be.

Dan: So there’s no way for me to take price into account if I need to go to the hospital.

But Once Upon a Time in Massachusetts, there was. It was a co-pay. Whatever insurance plan you were on, it worked the same way:

Go to hospital A — where prices are generally higher — your copay might be five hundred dollars.

Go to hospital B — that charges the insurance plan less for stuff — you’d pay two-fifty.

And Elena Prager found the data that showed what happened next.

Long story short, she found that over three years, patients started using lower-priced hospitals more often. Patients saved money, and so did the health plan. 

And actually, Massachusetts still runs its health plans this way, but– 

 Vivian Ho doesn’t think other employers can just get their insurance companies to adopt this same model. 

VIVIAN HO: It’s actually a fair amount of work.

DAN:  Work for the insurance company. Doing the math to figure out which tier is which, and what the copays would be.

Vivian Ho: and of course it gets the hospitals really upset.

Dan:  The folks in Massachusetts had a ton of leverage that most employers don’t have:  

Elena Prager says they represented a huge chunk of the insurance market like a twelfth of it. Enough business that it was worth insurance companies’ while to put in the work.

But now, Vivian Ho has her eye on a couple of new services that are promising to do something similar.

One is actually a subsidiary of everybody’s favorite insurance company: United Healthcare. They make an app called Surest.

Surest Ad: It’s easy to shop for a vacation rental or your next flight, but when it comes to something like healthcare, not so easy. That’s why Surest is a health plan, designed to be simple with clear upfront costs.

Dan: Here’s how Vivian Ho describes the mechanics of this kind of app.

Vivian Ho: Doctor tells you you need to go get an MRI, you punch an MRI, the app knows where you live, and it says, here’s a list of providers where you can go get an MRI. And then if you go to this particular place, there’s no copay and there’s actually no deductible, and then if you go to this MRI place, well, you know, there’s gonna be a $25 copay or a $50 copay. Yeah. Isn’t that kind of mind blowing?

Dan: I tell her: That sounds like I would want that if I trusted that the place that costs my employer less is, you know, gonna take good care of me.

Vivian Ho: Right. Well that’s why I’m trying to get funding to do an analysis to look at the spending and quality implications of using one of these apps.

Dan: That is: Do people using these apps end up choosing lower-cost providers? AND: Do they get good care when they do?

Vivian Ho wants to study that. But first she needs to study something else. 

Vivian Ho: All of these apps and price shopping applications, they all depend on having the correct data. Now, the insurers are required to disclose this information by federal rules. It is slowly coming out. It’s not all there yet, but no one’s actually looked to see whether it’s accurate.

Dan: Oh.

Vivian Ho: So there’s been a lot of focus on, is the price there or is it not there, but not is it the price that the patient is actually getting billed.

Dan: And this is why Vivian Ho wants our hospital bills. 

Because: Whether or not one particular strategy is gonna pan out, the data itself contains ammunition. One hospital gets paid twice as much as the ones across the street? 

I mean, that’s information I want out in the open, and getting put to use. 

But that information can  only be useful if we know the data is accurate. And right now, there’s no way to know. 

Insurers are publishing big data sets, but how  do we *know* somebody at the insurance company didn’t just go to Chat GPT and say, “Make me a giant spreadsheet with these fields on it?”

Vivian Ho says if she has enough ACTUAL bills — a thousand would be good, three thousand would be great — she can check. 

Actually, even better: She wants your itemized bill and, if she can get it, the paperwork you get from your insurance company about what they paid. The thing that says “This is not a bill.” It’s an “explanation of benefits” — or EOB for short.

And, she recognizes, this isn’t a TINY ask.

Vivian Ho: I realize it’s time consuming. It does, you know, because you gotta sit down. It’s like, what’s my password and log in, and then you’ve gotta, you know, find one of these EOBs.

Dan: Oh, and you’ve gotta cover up all your personally identifying information.

Vivian Ho: We don’t wanna see your your name and address and so, you know, it takes time to you, you can sort of print these out and use a Sharpie and cross them out.

Dan: It does sound like a huge drag, but I’m here to tell you: I did it. And it took me maybe five minutes.

I don’t know how Vivian Ho’s specific strategy will play out, and honestly, neither does she.

Vivian Ho: You know, I am going at this at sort of like many different angles.

Dan: Yeah.

Vivian Ho: So just trying to raise people’s awareness of there are huge price differences. This is, this is what it takes to address the issue. 

Dan: If you’ve gotten a hospital bill in the last year or so, and you’ve got five minutes — maybe set a note on your calendar for when you DO have five minutes? — I’d love it if you gave this a shot. 

Grab a sharpie, fire up your printer, dig up your login. Print out a bill and an EOB, scratch out your identifying information, take a picture on your phone — wow, this is sounding long, but honestly, it took me five minutes — so do those things, and send the images to pricecheck@rice.edu. 

Vivian Ho’s got researchers standing by.

Coming up on this show: We’re gonna take some time as the year ends, to look at some things that DIDN’T suck in 2025. 

Which basically means: Places where state governments stepped in to protect us from ripoff prices. Which, it turns out, happened! 

News archive 1: Oregonians burdened by medical bills may soon get a break on their credit scores.

News archive 2: New law aimed at protecting Maine consumers from the impacts of medical debt goes into effect.

News archive 3: Tonight Indiana governor Mike Braun signs 10 health care-related bills into law.

Dan: Happened enough that it’ll take more than just one episode to give you a good sample.

That’s next time on An Arm and a Leg.

Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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.

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This story can be republished for free (details).

In this mini-episode, host Dan Weissmann talks with Sanford about how handing out charity care information on tiny cards snowballed into an ever-growing list of resources to erase medical debt. They discuss the inspiration behind his project, the role “An Arm and a Leg” listeners played in building it, and how others can contribute. 

Credits

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

Dan: Hey there. So here’s a story — a project — that’s given me more encouragement than anything I can think of lately. It’s driven by you– by listeners to this show.

One of my big dreams for An Arm and a Leg, from almost the beginning, has been to connect people, to help folks learn to help each other. 

And I think I’m seeing the beginnings of a win. 

It started with one listener, trying to do what he could for people right around him. He asked us for advice, we asked folks who get our First Aid Kit newsletter to pitch in. 

And now, with that help, our original listener has started creating a tool I think can ultimately help a LOT of people help each other. 

It seems like the start of a virtuous cycle. And you can help keep it going, and growing.

OK, here’s the story — so far:   

Thomas Sanford goes to medical school in Brooklyn. He says he’s listened to this show for years, but some of the things we talk about here got more vivid for him last fall, as he started his third year.

Thomas Sanford: …where I go out of the classroom and I start spending my days in the hospital interacting with patients and and appreciating that for especially folks in my area — which is one of the poorest parts of Brooklyn– that can be a financial death sentence. It will ruin you in debt that you cannot get out of. And I listened to your episode about Dollar For, the nonprofit that helps people apply for charity care. 

Dan: We’ve talked about Dollar For a lot over the last few years. Their founder, Jared Walker, has helped a lot of people, including me, understand how powerful hospital charity care can be. 

A few months ago, Jared’s small organization hit a big milestone: 

Eliminating more than 100 million dollars in hospital bills, over just a few years.

Jared Walker: And we have been able to do that without charging a single dollar to patients.

Dan: That’s Jared, in a video he posted over the summer to mark the occasion.

Jared Walker: We’re a nonprofit. We help people eliminate hospital bills, mostly by enforcing hospital financial assistance policies,. These programs reduce or eliminate hospital bills for people within certain income requirements. The problem is, is they don’t tell you. So we do.

Dan: Now, working in a hospital himself, Thomas Sanford decided to help spread the word.

He wrote to the folks at Dollar For, and they sent him a PDF for a “touch card” — it’s like the size of a business card. 

It says, “Struggling with hospital bills? Most hospitals offer bill forgiveness programs. On average, a family of four, earning less than 100 thousand dollars a year will qualify. Dollar For can help – for free.”

And then, there’s a web address in big type, and a QR code to scan — and on the back of the card, the whole thing in Spanish.

Thomas Sanford: And I just went and printed out a thousand of them, started handing ’em out to residents and giving them to patients.

Dan: Handing them out to other residents, so they could pass cards to their own patients. 

Thomas says he also left boxes of cards in the break room, so residents could grab as many as they wanted. And then he went to other local hospitals to distribute the cards in bulk.

Thomas Sanford: A lot of little hospitals or community clinics that have like little like business card holders, on the counter in the waiting room, and I just bring a stack and just dump them in.

Dan: And all of this is already extremely cool. And then, Thomas did something else: He wrote to us — to tell us about what he was doing, and to ask for help.

Because over the course of months,as he’d been passing out these cards, Thomas had found: Charity care didn’t necessarily cover everybody’s needs — like paying for prescription drugs. 

Thomas Sanford: And just very frankly, I was busy doing the whole medicine thing, trying to take care of people, and I wish I had the time to sit with them and, you know, search for what would help them specifically, and I just didn’t. So I was looking for, really hoping for, very selfishly, a resource where I could just say, here’s your one-stop shop. It’ll almost certainly cover what you need. I hope this helps.

Dan: He wrote to us, to ask if we knew of anything good. And honestly we didn’t.

So we asked you for help. In our First Aid Kit newsletter, we told Thomas’s story, we added a link to that PDF from Dollar For — because that seemed worth passing around — and we did two more things:

First, we made our own first draft — basically, an annotated list of the resources we would put on a one-page handout.

And second, we asked: Help! What are we missing here? Including: Has anybody actually already made a version of this?

And: You wrote back! 

As it turned out, a couple of you had worked on some great online projects. One was from the nonprofit PIRG — another group I’ve learned a ton from over the years. And the other was actually created by the federal government. 

And, they were great! We wrote about them in First Aid Kit, with links. Other folks had tipped us off to resources that hadn’t been on our original lists — we added those..

And THOMAS took all of that and ran with it. Meaning: He started printing up a rough draft to hand out.

Thomas Sanford: I keep a little stack of them in my backpack, as it’s become somewhat complete and vaguely presentable, and at times I’ve just be like, hold on, leave, come back and be like, here you go.

Dan: And he says: It worked. He told me about this especially dramatic example.

Thomas Sanford: I was in the emergency department and someone come in having a heart attack — very serious. This could kill you. And their only concern when they got there is, what is this going to cost me? And it’s a difficult time to be having that conversation, but being able to say, look, here’s a crummy first draft of something I’ve been working on. I hope this gives you a little relief, but please, right now, let me focus on what’s a little more important, which is keeping you alive 

Dan: Recently Thomas wrote to us AGAIN, to say: Here’s the vaguely-presentable version I’ve been handing out. Can I get more help making it better?

We went back to you — published Thomas’s draft in First Aid Kit, asked if anybody could pitch in, created a sign-up form.

And you’ve been pitching in! Thomas says he’s added more resources, and he’s gotten help making things more presentable.

Thomas Sanford: Just little type things about, you know, me not having to use a period correctly. Big things like maybe you name this document a little more correctly.

Call it help with your medical expenses.

Dan: He’s just shared the most recent version with us, and he says he could still use more help. 

Thomas Sanford: If you know how to copy edit, and you can take my terrible descriptions and make them great. If you know graphic design and can make my, very basic, PDF into something that’s a little more presentable, that would be amazing. Also, if you want to make a version of this, you customize for your own hospitals. instead of a link for dollar four, put in a link to your hospital’s charity care policy. 

Dan: This is actually one of the coolest things. Thomas is using what’s called a “Creative Commons” license. That basically means anybody can take it, make copies of it, make variations on it. 

Thomas Sanford: You can make your own version of it. You don’t need my permission. You can do whatever you want with it. The only thing you have to do is share it under the same license and share it freely

Dan: And give credit to the original creator, so people know where it started. But Thomas wants people to make it their own.

Thomas Sanford: I think that that’s really the ideal: when people start taking it, just make their own version, put it out there and it sort of just evolves on its own, becomes the best thing it can be.

Dan: So, I hope you can see why I’m so excited about this project. I think it’s got incredible potential.  I’m inviting you to pitch in, however you want, and however you can. 

?And at Thomas’s suggestion: We’re posting a PDF of the current version. Print it out, make copies, tell us how you’re using them. 

We’re also posting a google doc that ANYONE can comment on. 

And we’re posting that sign-up form again, so you can volunteer to pitch in. Designers, editors, experts — translators.

And especially: if anyone has a talent for organizing groups of volunteers on a project like this, PLEASE GET IN TOUCH. That would be truly amazing. 

You’ll find these links wherever you’re listening 

And the place where we’re really gonna keep digging in on this project is where it started — in our First Aid Kit newsletter. I’d love for you to sign up. The place for that is www dot arm and a leg show dot com, slash, first aid kit.

That’s arm and a leg show dot com, slash, first aid kit.

This has been a little mini-episode of An Arm and a Leg– a show about why health care costs so freaking much and what we can maybe do about it:  Together– right?

We’ll be back with a full-length episode soon. Till then, take care of yourself.

This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta — and edited by Ellen Weiss. Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

 Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially.

You can join in any time at arm and a leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

Her search is off to a rocky start. Pisacreta gives listeners a sobering look at how the high price of health insurance plans could change her life and those of millions of others looking for Affordable Care Act plans, as premiums, on average, are projected to increase by more than they have in recent years.

Joined by “An Arm and a Leg” host Dan Weissmann and KFF Health News senior correspondent Julie Appleby, Pisacreta examines how recent budget cuts by the Trump administration for navigators — the people charged with helping individuals, families, and businesses sign up for ACA plans — could make it harder to find the right plan and to pinpoint what people can expect in November when open enrollment kicks off. 

Credits

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

Dan: Hey there–

Over the summer, our pals at KFF Health News published a story with the headline: “Insurers and customers brace for double whammy to Obamacare premiums.”

Basically– whammy number one — insurers are planning to raise premiums for 2026 —

And whammy number two: federal subsidies for Obamacare policies are scheduled to get a lot less generous. 

Together, these whammies mean millions of people will be looking at paying a LOT more every month — like hundreds of dollars more. 

Folks are going to need as much advance warning as possible, to figure out how to prepare for a hit like that.

Meaning: This is our kind of story. 

And this one hits a little close to home. Because one of those folks is An Arm and a Leg’s senior producer, Emily Pisacreta.

Emily: Yeah, it’s a wild time. I’ve never had to do this before. Cuz I’ve always had health insurance through work. I’ve totally shaped my life around that because I have diabetes, and without health insurance, I can’t afford what I need.

Dan: But that health insurance has never come from An Arm and a Leg. When Emily started working here as an intern, she was the first person besides me to work more than a few hours a week. We didn’t have an employee health plan because we didn’t have employees.

And we’re still so tiny, so tiny. Apart from summer interns, there’s still only ever been one other person working more than a few hours a week besides the two of us. I’m still the only full-time person, and we still don’t have an employee health plan.

Emily: And until recently, that worked for me– I had another part-time job, and it had health benefits.

Except my contract with that job just ended. 

So for the first time, like more than 20 million other people, I’m looking at open enrollment. And I gotta say, it’s one hell of a year to do that. 

Dan: You’re a double-whammy case study. 

And to get a broader perspective, the two of us talked with Julie Appleby, the reporter who wrote that “double-whammy” story, and since then you’ve continued to do more homework. 

Emily: It’s been pretty intense!  

Dan: For real. And I’m a little bit of a case study too:

Suddenly I’m finding out what our country’s “system” — where health insurance gets tied to jobs — looks like … from the employer side. It’s a whole new adventure. 

We don’t know exactly what we’re going to do. Honestly, I don’t think anybody does.

But we’ve learned a ton. About what we’re up against — along with millions of other people — and our options.

And by tackling this right now — six weeks before open enrollment starts — I hope we can help a lot of other people start planning early with solid information. Let’s go.

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

So, we started by checking in with the person whose reporting first got us looking at this story.

Julie Appleby: It’s recording. It looks like it says 10, 11,

Dan in interview: perfect.

Julie Appleby: I have notes and I’ll try not to rattle the papers. 

Emily in interview: I mean, if we have a reporter on tape rattling papers, I feel like that’s probably okay.

Julie Appleby: Okay. That’s a plan, man.

Emily in interview: Yeah. Why don’t we start out, could you just like, tell us your name and what you do and where you work?

Julie Appleby: So this is Julie Appleby. I’m senior correspondent at KFF Health News.

Emily in interview: What sort of stuff do you cover?

Julie Appleby:  I cover healthcare policy, but that’s a broad term. So everything from cost to, the Affordable Care Act, to what’s going on with Medicare, all kinds of different things involving health care programs and insurance.

Emily in interview: So we were really excited to talk with you, because we wanted to cover, you know, all the changes to the marketplace plans, that you’ve been writing about. And, it just so happens that I need to enroll in a marketplace plan.

Julie Appleby: So let’s give you kind of the rundown. There’s like, there’s kind of like two things going on here. One of them is that just premiums are going up as they do every year. Although this year it’s bigger than it’s been since 2018. So the median increase nationwide, and this is according to some data research by KFF, is about 18%. So that’s a big jump, right? 

Emily in interview: Yeah. Yeah. In your reporting you called it a double whammy. Rates are going up, enhanced subsidies are probably going away. 

Julie Appleby: Right. That’s the second half of the double whammy.

Dan: OK, breaking in here– gonna do this a couple of times for Obamacare vocabulary. Emily just mentioned an important term, went by kinda fast: enhanced subsidies. Obamacare has always included subsidies for most people — that’s part of the “Affordable” part of Affordable Care Act. But for lots of people, Obamacare policies still were… pretty expensive!

So, in 2021 — like, as part of a COVID recovery package — Congress added extra subsidies for Obamacare policies: Enhanced subsidies. 

Julie Appleby: Basically, they made the coverage more generous on both ends of the income spectrum. In fact, I think I was looking at some statistics this morning and something like, 80% of people who have coverage right now have a plan that’s $10 a month or less.

Dan: These are folks with lower incomes — where paying sixty or eighty dollars a month is a big bite. With “enhanced” subsidies, that became ten dollars — or even zero.

But people with higher incomes also got help. Before the enhanced subsidies, people with incomes above a certain level didn’t get ANY subsidy. People called it an “income cliff.”

For the last four years these enhanced subsidies, kind of erased that cliff. If your income was higher, you just paid a percentage of your income. Enhanced subsidies picked up the rest.

But the enhanced subsidies weren’t permanent. They’ll expire at the end of this year, unless Congress extends them. Otherwise… 

Julie Appleby: people who make more than the four times the federal poverty level will not qualify for any help with their premiums under the Affordable Care Act. There will be that cliff.

Emily in interview: Right, right. 

Dan: And it turns out Emily is basically standing on that cliff. She shows Julie the numbers.

Emily: We found this calculator from KFF that attempts to show the changes in premiums if the subsidies expire. And maybe I’ll just share my screen and we can look at – we can look at what I’m looking at.

Okay, you guys see KFF? Maybe just reload and I can enter some Emily figures in here. So, they ask you about where you live and your yearly household income. 

Dan in interview: what’s the amount that you’ve entered as income?

Emily in interview: I have entered $63,000. And it says, without enhanced subsidies, you will likely lose financial help. Because my income is 418% of the federal poverty level.

Dan: Oy. a little more Obamacare vocabulary. First: Federal poverty level. Four times that level is where you fall off the income cliff, no subsidies. 400 percent. And the calculator – which we should say, is a year out-of-date, so the numbers aren’t precise, but they give us an idea– that calculator says Emily’s at 418.

And next:  Obamacare plans come in different “levels,” like Olympic medals: Bronze, Silver, Gold… Bronze plans are the cheapest, and cover the least. 

If Emily got a subsidy, the calculator says a silver plan would be like 400-and some dollars a month, but it says Emily wouldn’t GET a subsidy, so… 

Emily in interview: It would be about $880 a month for a silver plan, or $675 a month for a bronze plan. So for me, that is stressful to read. 

Julie Appleby: That’s a lot of money. 880 bucks a month. So you’re in the situation where you don’t get any, subsidies because your income is over that amount. But I played around with one of these calculators too when I wrote a story recently. And I also plugged in somebody, let’s say who’s earnings are kind of at the lower end of the income scale, say just over 150% of the federal poverty level. So they’re still gonna pay more. They’re, it’s gonna go from paying sort of a national average of about $2 a month to 72 bucks a month, or $864 a year. And remember, this is somebody who’s making 23,000 a year. So $864 is a lot of money. 

Dan in interview: Emily, can you put that calculator back up on the screen for us?

Emily in interview: Sure can.

Dan in interview: The scary calculator. I mean, what would happen if your income were just a little bit lower? If you just shave $3,000 from your income, what does it look 

Emily in interview: So maybe like 60? 

Julie Appleby: I bet you could even shave a little bit less. Why didn’t you make it 62?

 (Sfx: Buzzer) 

Dan: How about 61? What does 61 do for us?

Emily in interview: Can I get a 61 

(SFX: Buzzer) 

 Dan: how about $60,500?

 (SFX: Buzzer) 

Dan in interview: I feel like this is like an auction reverse.

Julie Appleby: in reverse.

Emily in interview: I know this is like the auction from hell

Dan in interview: Yeah, we’re, we’re lowering your income. So let’s keep going. $60,200,

 (SFX: Ding!) 

Dan in interview: That is it. Holy crap it’s a giant cliff. It’s a $5,000 cliff

Dan: Breaking in one last time:  Five thousand dollars is how much money Emily might save on Obamacare premiums if her income stays below that 400 percent line.  Put another way: It’s how much more she’d have to pay if she steps over that cliff.

Dan in interview: Julie, what does that look like to you, seeing that?

Julie Appleby: I think this also, this illustrates a lot of things. I mean, people are gonna have to keep in mind that cliff for next year if these tax credits aren’t extended. This is a projection, this is what you think you’re going to earn next year. So that’s one thing that to keep in mind, okay? And something could happen. Emily could, I don’t know, maybe she wins the lottery or she goes to the casino and wins a bunch of money and that puts her over. 

Emily in interview: Or offers me, you know, a freelance job that’s really interesting. It doesn’t pay that much, but just puts me over, you know? 

Dan in interview: You have to say, I’m sorry, that freelance job is gonna cost me more than $5,000 to accept.

Dan: So, Emily: listening back to that conversation now. What are you feeling?

Emily: I mean, I was trying to stay calm but internally I was freaking out. As Gen Z likes to say, I was crashing out.

Dan: It was really emotional. We both needed time to cool off, just to put this story together.

Emily: Yeah, this situation is stressful. I don’t know for sure how much money I’m even going to make next year. And it feels kind of weird to put all this out here. I don’t know how any of this sounds to other people. Because maybe it sounds like 400% of the federal level is a lot of money. And in some parts of the country it definitely is. But I live in New York City. So my income doesn’t go that far. And that $880 bucks a month we were talking about? That’s actually a big hit. 

Dan: Yeah and — not to pile on, but: the data behind the calculator where we got that number, 880 — that’s last year’s data.  So it doesn’t include the big premium increases that Julie was writing about. The actual amount you’d  be paying every month would be bigger. And you looked up the deductible: more than four thousand dollars. 

Emily: Right, which I won’t have lying around at the beginning of next year either. Yeah so honestly, all of it still makes me want to scream. 

Dan: Yeah, and you’re a case study for a LOT of people. Julie read us a really sobering number, where one consulting group estimated that with this double-whammy Obamacare enrollment could drop by like half or more. 

And, in fact, one of the reasons insurers say they’re raising prices this year is– without the enhanced subsidies, they figure a lot of healthy people will just opt out. 

Emily:  I can see why people don’t sign up. I mean,  I don’t have that choice. But in order to get a subsidy, I’d have to lower my income, and to a very specific number – which is less than I live on now. And watch it to make sure I don’t take in a penny more. 

Dan: While still paying hundreds of dollars a month for Obamacare – even with a subsidy.

Emily: And look. This is a thing a lot of people do. All the time. –intentionally limit their income to qualify for assistance.. To keep Medicaid, people skip out on jobs, careers, marriage. 

 So my situation is NOT unique. It’s definitely not the worst.

Dan: You’re our in-house case study. You can’t stand in for everybody.

I mean, just to add one more wrinkle: If you didn’t live in a super-expensive city, your premiums would actually be lower..

I used that calculator to look up what you’d pay for a silver plan in … Chicago, like where I live? Way, way cheaper. Like, unsubsidized? A lot less than a New York plan *with* a subsidy. I’m just saying.

Emily: That’s… wild. No shade on Chicago But I don’t think I’m ready to make a long distance  move for health insurance yet.

Dan: I’m just saying… 

Emily: But while we’ve been looking ahead to 2026 insurance, I’ve actually had a more-immediate decision to make.

Dan: Right.

Emily: LIke I said before, I had insurance through my old employer. But that’s ending. While we were doing this story, I had to figure out health insurance for the last three months of 2025.

Dan: You ended up getting some help from a real expert.

Emily: I sure did.

Dan: And: I called up An Arm and a Leg’s insurance broker.

Because like we said: If Emily’s a case study, so am I. We’re so small, and I’m the only one here who’s needed health insurance from this tiny little enterprise. Now, things are a little different.

What we’ve learned, and what’s next. That’s just ahead.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists — like Julie Appleby — do amazing work. We’re honored to be their colleagues.

Emily: Julie Appleby left me with a little advice: Connect with an ACA navigator.

Dan: Navigators: These are folks who can guide you through the process of signing up for Obamacare. They’re not brokers, they don’t make a commission. They’re paid by the government. 

Emily: But they’re not government employees — local organizations work on government-funded contracts.

Dan: Which makes sense– Obamacare plans themselves are basically local: The menu of plans to pick from, they don’t just vary from state to state: They can be different from one county to another.

Emily: And I wanted a little perspective on how the whole navigator program works.

Dan: And it turns out: We know someone at the organization that coordinates all the navigators in New York state.

Elisabeth Benjamin: My name is Elizabeth Benjamin. I’m Vice President for Health Initiatives at the Community Service Society of New York.

Dan: We’ve spoken with Elisabeth before — a bunch of times — about her work pushing hospitals in NY to quit suing people over medical debt.

And yes, it turns out her shop also runs the network of navigators throughout New York.

Emily: But when we talked, it turned out, her connection to the navigator program is a little different than I’d expected.

Elisabeth Benjamin: I don’t, you know, run it day to day, but I, myself do help people individually enroll. Because it’s really important to understand what people are experiencing, what their concerns are. I have like a small group of people that I help every year, Lots of friends, children.

Emily in interview: Oh, that’s awesome. Okay. Yeah, I bet you’re like a great like auntie to have..

Elisabeth Benjamin: You know, people that turn 26 and the parents are like, I know, please, will you help me?

Emily: She was like: Look, everybody needs help.

Elisabeth Benjamin: The bottom line is, you know, it isn’t for the faint of heart. It is hard to work through these websites. I mean, they are as user friendly as possible, but there’s like little kind of little moguls that you have to kind of ski over and it’s easy to kind of miss a mogul and faceplant, and we don’t want that to happen.

Emily: And when I told her about how my story fits into this episode, she was immediately like.

Elisabeth Benjamin: Oh, well, I can help you.

Emily: Not with my whole 2026 dilemma: there’s just no information about 2026 plans out there yet. But for my immediate question — what do I do about the rest of 2025 – she was like, I’m pretty free tomorrow.

Elisabeth Benjamin: You can tape your enrollment.

Emily in interview: Oh my gosh, that would be amazing.

Dan: Seriously amazing. I mean, it sounded like good tape, which we always like. 

But also — we talked that day, you and me: You were really weighing some big decisions. 

Emily: I mean one was: Do I sign up for Obamacare for the rest of the year, or do I stay on my old employer’s plan?

Because a law called Cobra means they have to allow me to buy in — but I’d have to pay the whole monthly premium, which was SUPER high. More than a thousand dollars.

So Obamacare was looking good. Those extra subsidies are still in place through the end of the year.

Dan: There was a downside.

Emily: Yeah — starting a brand-new plan would mean starting with a brand new deductible– money I’d have to pay out of pocket before the new insurance kicked in for most things.

Dan: Those can be like thousands of dollars. 

Emily: Yeah, but then there was an amazing surprise: In New York, where I live, a new state law means that all Obamacare plans include insulin with no copay. Even if you haven’t paid out and hit your deductible. That’s a deal I’ve *never* gotten from any insurance, ever.

AND this deal included other diabetes supplies — like my continuous glucose monitor. That stuff can be hugely expensive.

So my thinking was like: I’ll grab the cheapest Obamacare plan– and get all my diabetes supplies — and I’ll try not to go to the doctor for the rest of the year. 

Elisabeth Benjamin: Okay, so ready?

Emily in interview: I’m ready.

Emily: The next morning, I showed up at Elisabeth Benjamin’s apartment.

Elisabeth Benjamin: All right. So Emily, here you are, you’re on my dashboard. Oh, wait, here I can make this easier for you. Let’s do the big screen. Okay. 

Emily: Elisabeth started walking me through the application.  Name, date of birth, address… pretty routine to start. 

Elisabeth Benjamin: That’s your phone number…

Emily: And at this stage I’m wondering if I should’ve just done it all myself and left poor Elisabeth alone.

But after a while — once we started actually looking at plans, I was like: Oh wow. Elisabeth was able to like really zip through things. It was a whole vibe.

Elisabeth Benjamin: Hold on one second. That’s not, that’s not important I wanna see if this is in network…

Emily: And she spotted things I would have totally missed.

Elisabeth Benjamin: So this is kind of an interesting plan. ’cause you would be able to go to a doctor or a specialist before the deductible.

Dan: Wait, you could do a doctor visit before you spent that deductible? That’s a thing?

Emily: Yeah, in that one plan, I guess? But even Elisabeth had to really dig to figure that out. 

Elisabeth Benjamin: Like see, it’s sort of a little frustrating because you wouldn’t, you couldn’t really tell that from this. This is why it’s helpful to have a navigator

Emily: I mean, super-helpful: With Elisabeth’s help, I got a plan 

Elisabeth Benjamin: and you’re done. 

Emily: where OK, I can’t actually SEE a doctor before the deductible. Not in person. But I CAN do telehealth. So if god forbid I get some kind of weird infection, I could get a prescription. Oh, and my actual doctor, like my endocrinologist, is covered. And the deductible is much, much lower than the other plans I’d been looking at. I mean, it’s still scary as hell, but HALF as scary-as-hell?

Dan: And the only catch is: You have to do this all over again in November or December. Except then — unless Congress extends the extra subsidies — you may be looking at much higher monthly payments.

Emily: Right. Actually, let’s come back to me in a minute. Because the good news in my case: At least I’ll be able to get Elisabeth’s help again. Like, she offered to, which was so nice. But also: even if she’s super-busy, I’ll be able to talk to another navigator. Because I live in New York.

Dan: Yeah. This is one of the things we learned from Elisabeth. It goes back one of the reasons we wanted to talk with her in the first place. Because there’s another big change with Obamacare this year: the federal government is cutting funding for navigators by like 90 percent. We wanted to hear from Elisabeth — how is that gonna affect her group’s work.

Emily: And — this was a surprise: She said it won’t affect her work at all– because New York navigators are funded by the state government. Turns out the same thing is true for about half the states. But I talked with Elisabeth’s counterpart in a state where that is not the case. 

Nicholas Riggs: We are not gonna be able to reach the number of people we did before. That’s just reality. You can’t do more with less. People will lose their coverage because of this.

Emily: That’s Nicholas Riggs. He runs the NC Navigator Consortium.

Nicholas Riggs: We cover all 100 counties. We’re the only navigator entity in North Carolina.

Emily: He says a big piece of their work is actually outreach– finding people who may not know they can get this kind of help.

Nicholas Riggs: You know, there’s no list of the uninsured.

Emily: And they don’t just help people pick Obamacare plans– they help people sign up for Medicaid. A 90 percent budget cut hits all of that. He says they’re looking for more volunteer navigators, but it won’t be the same as having experienced staff. 

Nicholas Riggs: What you’re losing is institutional knowledge. Volunteer navigators are great. But sometimes it takes a few years to really get a handle on some more complex cases.

Dan: I mean, Emily — you experienced first hand how big a deal it was to hae, like,  a real expert walk you through this process.

Emily: Elisabeth spent almost an hour with me!

Dan: A lot of people won’t have access to that kind of help. It’s one more crummy thing we’re trying to help people plan for. You found a map that shows which states fund their own navigators. We’ll post a link — so people can see what the deal is in their state.

And Emily, let’s come back to you for a minute: You’re lucky to have access to the world’s greatest navigator, but unless Congress extends the enhanced subsidies, that next conversation with her is gonna be a lot tougher.

Emily: I mean, unless I get another job with health insurance first. 

Dan: So, about that: While you were having your first conversation with Elisabeth, I was talking with An Arm and a Leg’s health insurance broker, Kurt Kaufman.

Because I was like: What can I do to make it possible for Emily to stick around?

I asked Kurt, could we set things up for Emily to buy into An Arm and a Leg’s plan? Like, at all?

Our insurance is from Blue Cross Blue Shield of Illinois. Could it cover Emily in New York? He was like

Kurt K: Yeah, that’s fine.

Dan: Then she,

Kurt K: a hundred percent.

Dan: She could be insured on our Illinois based plan, 

even though she’s in New York.. Is that right?

Kurt K: All day long.

Dan: All day long,

Kurt K: yep., 

Oh, yeah.

Dan: So I was like: Um, how much would it COST?

He said, based on your age — insurance gets more expensive as you get older — like, five, six hundred.

Emily: That’s a LOT less than what the scary calculator said I’d pay for a Silver plan with no subsidies. That was showing like nine hundred dollars.

Dan: Yeah. I mean: These are 2025 numbers, just like everything else we’ve been looking at. Everything in 2026 is gonna be higher. But it seems like An Arm and a Leg gets a better deal than you’d get with Obamacare. However, there’s a but. You’d need to be full-time.

Emily: Aha!

Dan: Yeah. I mean we’ve got you at 20 hours a week.

Emily: Yeah.

Dan: I was like Oh my god. I’d have to DOUBLE that? But Kurt was like: Actually, no. The way insurance looks at it, if you were working an average of 30 hours a week, then you could qualify.

Kurt K: She could be meeting that definition of quote unquote full-time employee.

Dan:  Which, you know, isn’t in my budget for next year– and I’m still working to make sure some other parts of our scrappy little budget get funded– but it’s not DOUBLE. I’m starting to think about it– like, a stretch goal. I mean, I’d LOVE to have more of your time. I dunno.

Emily: I mean I like the idea a lot! But there are just a lot of unknowns, right?

Dan: Yeah, here’s where we’ve landed: You’ve got health insurance lined up for the rest of 2025. And after that, there’s so much we don’t know. Will I find more money? Will you take another job? 

And: Will Congress extend the enhanced subsidies? When we first started working on this story, over the summer, experts were like, “That’s not gonna happen.”

But in the last few weeks, SOME Republicans have been proposing it. We definitely don’t know — and it’s nothing we can count on.

It’s all, honestly, a little scary.

Emily: Honestly, more than a little.

Dan: BUT: We know more than we did. We’ve started really confronting the scary numbers and the unknowns. You’ve taken a practice run at picking insurance.

Emily: That was actually kind of a big thing.

Dan: It was, right?  And: I’ve started thinking about stretch goals.

We’re more prepared.

And — here was the point of doing this whole case study– I HOPE we’ve just helped a lot of other people get more prepared, to start planning. 

We’ll keep you posted on how things go for us. Some updates will show up in our First Aid Kit newsletter. 

If you’re not getting First Aid Kit, go check it out. 

Emily: While we were reporting this story, we published a guide there: Get ready, emotionally and financially, for 2026 health insurance.

Dan:  It has links to resources we talked about here, and we’ll have more in this week’s First Aid Kit. 

What you wanna do is go tor at Arm and a Leg show dot com, slash, first aid kit.

You’ll find the whole archive there — including notes about honestly, some extremely exciting projects that Arm and a Leg listeners are doing — and how you can pitch in. 

We’ll be back with another podcast episode in a few weeks. Till then, take care of yourself.

Emily: This episode of An Arm and a Leg was produced by me, Emily Pisacreta 

Dan: and me, Dan Weissmann. 

Emily: With help from Janmaris Perez and Lauren Gould.

Dan: And edited by Ellen Weiss.

Dan: Adam Raymonda is our audio wizard. Claire Davenport is our engagement producer.

Dan: Our music is by Dave Weiner and Blue Dot Sessions.

Dan: Bea Bosco is our consulting director of operations.

Big thanks to Lynne Johnson, who just wrapped up her run as our operations manager. Lynne, your work has done SO much to make our work more sustainable. I can’t thank you enough.

Dan: An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism.

Dan: Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show.

Dan: An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

Dan: And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

Dan: They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.Dan: Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, “First Aid Kit.” You can also follow the show on Facebook, Instagram, LinkedIn, and Bluesky. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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.

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In their series “Health Care Hustlers,” Bloomberg reporters Zachary Mider and Zeke Faux revealed how this couple and thousands of other people signed up for health plans by unknowingly agreeing to work fake “jobs.”  

Mider and Faux join “An Arm and a Leg” host Dan Weissmann to peel back the surprising layers of this story, from a TV-sitcom-writer-turned-investor who masterminded the idea to the legal gray area that allows these plans to proliferate.

Credits

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

Dan: Hey there—

This story’s outline may sound familiar, but what’s underneath — what we unravel here: It’s a new kind of thing. And it’s weird. 

And it could become huge.

So: A couple from New York, Sarah and Joe Strohmenger started new businesses, so they needed to buy their own health insurance for the first time..

And Sarah says the New York state marketplace, with Obamacare plans, seemed a little risky: If they got a subsidy, and then their new businesses did well, they might have to pay that subsidy back.

Sarah Strohmenger: As new business owners, we had not a clue of how much we were gonna make in the year.

So we were nervous about. How much we were gonna have to back pay. 

Dan: Looking elsewhere seemed like a cautious thing to do. Google led them to a site that offered quotes for insurance policies — just enter your phone number. They started getting calls from telemarketers, a lot of them, and eventually they picked a plan one of them offered. 

Sarah and Joe thought they were being reasonably careful. After all, Insurance is a regulated business. 

Sarah Strohmenger: We’re thinking it’s monitored. We had no clue that this was kind of like a free for all.

Dan: So as you’ve probably already guessed: Pretty quickly, and very painfully, Sarah and Joe figured out that they’d been hustled. 

But it took a pair of reporters from Bloomberg News to uncover the nature of that hustle. 

Zach Mider: There’s this kind of new breed of people offering health plans to the public that are not, um, not insurance companies at all, 

Dan: That’s one of those Bloomberg reporters, Zach Mider. As Zach and his reporting partner Zeke Faux revealed, this telemarketer had — on paper — made Joe an employee of a company he’d never heard of until those reporters told him about it.

And according to the legal theory underneath all of this, making Joe a certain kind of employee allowed the salesman to sell Joe an insurance plan so skimpy that— as Zach and Zeke’s story says — it would “normally be illegal.”

Zach Mider says these kinds of plans currently operate in a legal grey area, with nobody regulating it — not states, not the feds. 

Zach Mider: So it really is just kind of this weird legal vacuum where, you know, market actors are free to kind of jump in and start trying to do this.

Dan: Which, Zach says, they seem to be doing, more and more. 

Zach Mider: It looks like the numbers are shooting up

Dan: In their Bloomberg story, Zach and Zeke cite hundreds of complaints to the FTC from people who were sold these kinds of health plans.

They also write about meeting the guy who seems to have invented these plans — a former TV sitcom writer who they say actually believes he’s solving an important problem.

Their reporting — in a series called “Health Care Hustlers” — shows something else too: 

How each hustle gets created by a chain of legally-distinct operators — some of them truly operating completely independently of each other — and how, by being just one link in a chain, each operator can say:

“I was just doing a totally legit thing. It’s not my fault if some other guy is shady.”

Basically: These stories are showing us, more clearly than I’ve ever seen, what we’re up against when we take a call from somebody who says they’ve got a great insurance plan for us.

And it’s a totally wild ride. Here we go.

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

To start, here’s how bad things got for Sarah and Joe Strohmenger.

As they knew: They needed good health insurance. They’ve got pre-existing conditions.

For instance, Joe takes medicine that Sarah says costs 1500 dollars a month. And he’s got a benign brain tumor and has a doctor monitoring it. 

Sarah Strohmenger: That doctor was the most important doctor because it’s a doctor you can’t afford without health insurance.

Dan: Sarah says the monitoring includes periodic bloodwork and MRIs.

So she says when they were picking this plan, they asked about the doctor, about the tests, about the medicine, all their providers.

She says the sales rep for this plan told them, Yes. That is all covered.

Sarah Strohmenger: You know, it sounded great, covered everything that we needed.

Dan: Joe and Sarah paid about 87 hundred dollars upfront— a discount for a full year’s coverage. 

But Sarah says once they tried actually using the plan, things went south. She says their pharmacist told her Joe’s medicine wasn’t covered, and Joe’s doctor said his visits weren’t covered either.

And she says bills arrived that she did not expect.

Sarah Strohmenger: We were getting blood work bills back in the mail, for like $4,000 at a pop at a time, 3000.

Dan: According to the Bloomberg story, Joe called the company they’d bought the policy from— and reached a guy who said upgrading their plan would fix everything. They ultimately paid 20 thousand dollars for insurance that still didn’t cover what they needed.

Sarah says she thinks they also ended up on the hook for 10 to 15 thousand dollars in medical bills. 

Sarah Strohmenger: Within like six months, we stopped going to doctors.

Dan: They couldn’t afford to.

Sarah Strohmenger: We just were like, if we end up in the hospital, we’re basically screwed, you know? So Joe stopped going to all of his doctor’s appointments, he stopped taking his medication, and it was bad.

Dan: Meanwhile, Sarah says they also complained to state regulators about the company that sold them this policy.

The regulators wrote back, saying: We’ve never licensed or approved this entity. So… sorry. Sarah was like, Wait, WHAT? 

Sarah Strohmenger: I lived in a paradox that I didn’t know existed for a year. My mind was blown. 

Dan: I’m telling you — it’s REALLY weird. I’ve seen the letter, that’s what it says. And no: It’s not like there’s some other state office Sarah was supposed to write to. I checked.

Sarah says she and Joe took legal action against the marketing company, but they haven’t recovered any money. She says they paid off all the bills. And she says they signed up for a plan on New York’s Obamacare marketplace, which has been covering what they need. 

But she never understood what the heck had happened — the nature of the hustle — until she sent her story as a tip to Bloomberg News, and Zach Mider got in touch.

As it happened, he’d been digging into exactly this kind of hustle. 

Which has, I have to say, just an amazing number of layers and twists. Starting here:

When Zach looked at Sarah and Joe’s insurance cards, he noticed something that they had missed.

The name of a GROUP at the top — like as if this was a group plan, like you’d get from your job. 

And that was a key to the whole arrangement. That group — Outreach Data Partners Limited Partnership — is not an insurance company.

As Zach puts it, their legal stance is: They haven’t sold insurance to Sarah and Joe — or anybody else. That’s not the relationship.

Zach Mider: They’re claiming they have an employer-employee relationship with the people who buy health plans from them, and therefore, all of the state insurance laws don’t apply. 

Dan: Now, first: It’s actually true that for most people who get health benefits from their employer — like two-thirds — state insurance laws don’t apply. Lots of employers operate plans regulated by the federal Department of Labor.

Which Zach says is how Outreach Data Partners set up the plan Sarah and Joe bought.

All of which was news to Sarah and Joe.

Zach Mider: They just thought they were buying health insurance. 

Dan: And if they’re workers here, what was the JOB supposed to be?

Zach Mider: Yeah, that’s a great question. So, there is some work that is supposed to be done.

Dan: OK, strap in: Zach says to start with, in theory, the company gives you a special browser to use on your phone.

Zach Mider: The idea is if you want to go do something on the internet, you use this special browser and they’re collecting data about people’s browsing habits which then they can turn around and sell that information to advertisers.

Dan: So that’s the “job”: By using this browser, you’re producing value for the company— you’re working for them. Joe and Sarah told Zach they never got any special browser. And of course there’s another thing they might have expected to get from a job, ANY job: A paycheck.

And here’s how Zach says that absence gets explained.

Zach Mider: These data companies have been described to me as sort of, they’re startups, right?

Dan: And here’s where the full name of this company comes into play: ?Outreach Data Partners Limited Partnership. On paper, Joe and Sarah aren’t mere employees, they’re … limited partners— part owners. But in a company that hasn’t started making money yet. 

Zach Mider: Maybe they have a millionth share of the company. And so if the company starts making a lot of money, they will get a check. 

Dan: I don’t think Joe and Sarah are holding their breath for a check from Outreach Data Partners.

According to the Bloomberg story the company doesn’t have a public-facing website, and LinkedIn doesn’t list any employees. But the story also says that in a government filing the company claims 4,800 workers.

Zach and Zeke checked out the company’s headquarters: Box 371 at a UPS store in an Atlanta strip mall — between a dry cleaner and a Vietnamese restaurant. 

They found more than a dozen other companies using the same mailbox as their address — companies with names like Consumer Data Partners. All told, their story says these companies claim more than 30,000 employees.

And when Zach and Zeke started calling people connected to those companies, they ended up talking with the guy who seems to have invented what they call this fake-jobs healthcare setup.

A guy named Bill Bryan.

Zach Mider: Bill Bryan, was a pretty successful sitcom writer in the eighties and nineties. He wrote for Night Court

Judge from Night Court: What’s up Mac?

Mack from Night Court: A little case of disturbing the piece at a Star Trek convention, sir.

Zach Mider: And Coach

Craig Nelson: I didn’t lose the game. The team lost the game. I didn’t.

Zach Mider: And he wrote for a bunch of others. And then he does some real estate deals. He gets involved in some other investments. He ends up being a fairly wealthy guy and looking for new things to invest in, and comes across the idea of doing something with health plans.

Dan: ?Zach says, the idea was this: Obamacare had imposed standards on a lot of health insurance. Minimum stuff that had to be covered. Hospitalization. Mental health services. Prescription drugs. But covering all that stuff is expensive. It means premiums can be high, even with subsidies. And deductibles can be super-high: Thousands of dollars.

So Bill Bryan thought… 

Zach Mider: maybe if there was a way of designing a product that was legal. That covered less stuff than Obamacare, but still gave people what they wanted. You know? Um, it’s a free country. Maybe people should be able to decide what kind of healthcare they wanna buy and not have to meet all these minimum standards that maybe they’re not interested in.

Dan: So the plan that Sarah and Joe got sold, Zach says it does not meet those minimum standards. He says it covers like three doctor visits a year, a couple of lab services, and not a lot else.

Zach Mider: No coverage for hospitalization, no cover for emergency room visits. There is a prescription or there is a pharmacy benefit, but it only covers generics. 

Dan: Zach says Bill Bryan really thinks: that’s a product somebody might prefer to an Obamacare plan with a high deductible. Under the Affordable Care Act, you can’t sell that product as insurance. Actually, if you have a lot of employees, you can’t offer it to them either. 

But as a health-insurance law expert at Georgetown told me: You could maybe offer it to OWNERS of your company.

So by making people like Joe and Sarah LIMITED PARTNERS, maybe you could offer them this kind of super-stripped-down health plan legally.

Zach says: Bill Bryan thinks of this as a way to fix a problem he sees with Obamacare: Full coverage is too expensive for some people. 

Zach Mider: He’s a very smart guy, and so over the years he’s had to fight a lot for this, and I think that’s only kind of strengthened his conviction that it would be a corrective to the Obamacare system to have something that’s more affordable and more accessible for people to get.

Dan:Of course, that’s not what Joe and Sarah wanted – price wasn’t their top concern. They needed insurance that covered their providers, their treatments, their tests, their meds. That’s what they thought they were paying for.

I asked Zach and Zeke, what does Bill Bryan say about the kind of thing that happened to Joe and Sarah? 

Zach Mider: So it, it’s really important to point out here that like Bill Bryan didn’t sell the plan to Joe and Sarah. You know, he doesn’t do the call centers, right? These salespeople are all kind of independent operators who are essentially just selling this stuff for a commission. And so, he certainly doesn’t defend anybody misleading a customer.

Dan: According to Bloomberg’s story, Bryan said he had cut ties with the agency that sold Joe and Sarah their plan — years ago. 

And when he was told that the agency had sold the couple one of his plans much more recently, Bryan said, “That is absolutely news to me. I just don’t have anything more to say about any of these motherfuckers.” 

Zeke Faux: When we were talking with Bryan, though…

Dan: That’s Zach’s reporting partner, Zeke Faux.

Zeke Faux: …he and his colleagues were pretty evasive about exactly how these plans are sold.

Dan: Zeke says the way the plans are sold — specifically, the big commission rates for salespeople — was one of the reasons he and Zach got interested in this story in the first place.

Zeke Faux: Basically, the percentage of whatever the customer’s paying that is going to the salesman and the various middlemen involved is so high that it’s kind of hard to imagine that the customer could be getting a good deal. 

Dan: Even if the plan was cheap. Zach had pulled some data, crunched some numbers. The Bloomberg story says— at least in some cases— all those commissions and fees added up to 74 percent of what people like Joe and Sarah paid for these plans.

Zach Mider: If a person’s paying a dollar almost 74 cents is gonna go to commission to other various middlemen and whatever and only 26 cents is left for actually going into the pool from which medical care is paid out of. 

Dan: 26 cents for medical care. So, just to compare. Obamacare requires insurance plans to spend at least 80 cents of every dollar on medical care.

Everything else — your sales operation, all your admin costs — including the people who deny claims— and your CEO’s pay, and your profits — has to come out of that remaining 20 cents. 

With Bill Bryan’s plans, Zach’s numbers show that ratio can get almost flipped: 26 cents for medical care. 74 cents for commissions, fees, everything else

Zeke says: They brought these issues up to Bill Bryan. 

Zeke Faux: And when we tried to ask about that, Bryan and his colleagues pleaded ignorance, as if it was not really their business how the salesmen got paid.

Dan: And this is a big, big theme in this story: There’s no SINGLE entity doing all of this. It’s a chain of different players, and each one can blame the others.

Bill Bryan blamed the sales outfit for what happened to Joe and Sarah. 

And that company? Their CEO told Zach and Zeke that Outreach Data Partners screwed up, denying claims for the Strohmengers that should’ve been paid. And as the Bloomberg story reports: Bill Bryan dismissed that notion.

But there are more links in this chain than that. For instance, Outreach Data Partners — the company that theoretically made Joe and Sarah limited partners?

Bill Bryan does not run it. He doesn’t run ANY of the companies that employ 30,000 people from a mailbox in an Atlanta strip mall.

Which isn’t to say that he has nothing to do with them. That’s next.

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues.

So, Bill Bryan seems to be the mastermind behind what Bloomberg calls these 30,000 fake-jobs, and the health plans they offer.

But no, he doesn’t run the data companies behind those jobs. That would be illegal. 

Zach Mider: The data companies themselves wouldn’t be allowed under federal labor law to turn a profit on these health plans.

Dan: I mean, that sounds like a good law: Your boss isn’t supposed to make money by selling you a health plan. 

Zach Mider: So it’s all very segregated. They’re very careful to say these data companies are separate from us. The data companies are employing these people and they are sponsoring these health plans. And Bill Bryan’s role is he runs a series of vendors which provides services to the data companies.

Dan: Services like … running a health plan! Which, for a normal company, is a normal arrangement.

Remember how we said: Lots of employer health plans — ones tied to normal jobs— are exempt from state insurance laws?

The way those plans are set up, the employer normally hires a vendor — typically a big insurance company, like Blue Cross or Aetna — to run their health plan.

These data companies, instead of hiring Aetna to administer a health plan — for their 30 thousand “limited partners” — they’re hiring a company that Bill Bryan happens to run.

Zach Mider: I think he’s done a pretty good job of keeping these things formally separate, right? So he’s not formally in control. He doesn’t own the data companies, doesn’t formally direct their activities.

Dan: But Zach says: Bill Bryan seems to have had a hand in getting them set up. So they could offer health plans. That he could run.

Zach Mider: I think it’s fair to say that this was his and his partner’s idea, this whole kind of construct. But he’s tried pretty hard to, as a formal matter, make it compliant with federal labor law.

Zeke Faux: I feel like we should call the data companies and be like, hey, I can see that you have a lot of complaints about your health plan. It might be hurting recruiting. You know, would you like to switch to Aetna? Then we could find out if, uh — how independent they are.

Dan: That’s Zeke again, and yeah: He and Zach wrote in their story that they found HUNDREDS of complaints to the Federal Trade Commission, and the Better Business Bureau, and Apple’s App store about health plans tied to fake jobs.

A graphic that goes with their story shows dozens of quotes, like: This whole thing feels like a big scam that I fell for.

And: I can’t imagine I am the only person who has been lied to and basically stolen from.

And: Stay away at all costs.

Which raises a big question: Is any of this really legal? Isn’t there someone regulating it?

Zach says Bill Bryan wants answers to those questions too. 

Seven years ago, a data company the Bloomberg story describes as “allied with Bryan” went to the Labor Department for clarification— and validation. Basically, they said:

Zach Mider: We want you to sign off on this and confirm to everyone in the marketplace that this is legit. That these are real employees, these limited partner employees who are downloading the web browser are real employees, and that therefore we can sell ’em, these health plans without any problem. And the Department of Labor when push came to shove said, no, these aren’t employees. You’re just trying to sell insurance.

Dan: Bryan’s allies went to court to fight back. 

Zach Mider: And they’re still fighting over it all these many years later. That was 2018 when they were first trying to get this opinion. And um, now it’s 2025 and it’s still unresolved. 

Dan: ?Here’s what’s happened so far: A district judge ruled against the Labor Department, calling its opinion “arbitrary and capricious.” An appeals court later agreed with that conclusion, but sent the case back to the district court to reconsider other details, including: what should happen next.

Zach Mider: So the way it stands, it’s really in a kind of strange limbo, where the Department of Labor really doesn’t get to say, these are legit, or these are not while we wait for the litigation to play out. But it does open the door for other people like Bill Bryan to come into the marketplace and start selling this kind of stuff. 

Dan: And it looks like they have. The Bloomberg story has a chart, showing the number of households enrolled in “fake jobs” plans. After the appeals court ruled against the labor department, the numbers more than doubled.

And meanwhile, NOBODY is regulating these plans. They’re not traditional insurance plans, so state insurance departments don’t have jurisdiction. So with the federal case on hold, people like Sarah and Joe have no one to turn to.

In a letter to the editor that Bloomberg published, Bill Bryan blames what happened to people like Sarah and Joe on the Labor Department, for not validating his model.

“If the department stepped up and played its proper role,” he wrote, “the fraud reported in your story could have very well been prevented.”

He added: “At a minimum, it would give victims someplace to seek recourse.”

So: everybody’s got somebody else to blame. 

Which is one of the themes that connects Bill Bryan’s story with a totally WILD tale that Zeke traced to Florida. One that doesn’t start out sounding like it has anything to do with health insurance.

In 2024, he writes, “if you were poor and online, certain ads were everywhere you looked.”

These ads featured celebrity deepfakes — promising 6 thousand four hundred dollars, if you call a certain phone number. 

Zeke Faux: I mean, it looks like it’s Taylor Swift, and she’s saying…

Fake Taylor Swift: Remember those stimulus checks? Well, there’s a new thing going viral. 

Zeke Faux: Or it’s Dr. Phil and he’s saying..

Fake Dr. Phil: They’re giving out $6,400 to anyone who makes the call 

Zeke Faux: Or Andrew Tate saying…

Fake Andrew Tate: If you don’t act now, you’re basically throwing away $6,400. That’s just stupid.

Zeke Faux: And these ads didn’t even, they might briefly mention health insurance or maybe they don’t say health insurance at all.

Dan: But if you called that number, you’d end up talking with someone ready to sign you up for health insurance. 

Sign you up so quickly that… you might not have any idea that’s what had just happened. 

Or, for that matter, that no, you would not be getting 64 hundred bucks to spend.

This story goes in some WILD directions, but here’s how Zeke describes the connection with the fake-jobs saga. 

Zeke Faux: in reporting both of these stories, I think what we learned is that there is kind of a subculture of call center operators who have turned what seems like a pretty boring business selling health insurance into a get rich quick kind of operation.

Dan: The call centers, the telemarketers. That’s the connection— Bloomberg paired these stories under the heading “Health Care Hustlers.”And those hustlers are always looking for a new angle. 

Which is to say: Zeke and Zach’s stories reinforce a big Arm and a Leg rule: 

If the internet leads you to a phone call with someone who says they’ve got a GREAT health insurance deal for you… be very, very suspicious.

And a lot of people will be looking for deals on health insurance. 

During the Biden Administration, Congress added more-generous subsidies to Obamacare plans, which made them more affordable. 

Unless Congress re-ups them soon— which seems unlikely— those extra subsidies will expire this year. 

People will look for alternatives, and these call centers will offer them.

In a way, it’s back to the future: 

The first Trump Administration loosened certain rules, making it easier to sell short-term plans that didn’t meet Obamacare standards. Zeke says he reported on the results back then.

Zeke Faux: I spoke with people who had bought these plans and then had medical emergencies and been stuck with 50 or a hundred thousand dollar bills, so we’ll be — we’re kinda watching to see what new products emerge or what these call centers start selling. 

Dan: And meanwhile, just — look:  Don’t buy insurance over the phone from somebody you’ve never met. Don’t bother with google. Healthcare dot gov. That’s basically it. 

What you’ll find there, I’m not saying you’ll love it. It’s probably gonna cost more than you want to pay, and deductibles will likely be high. 

But even though subsidies for Obamacare plans aren’t AS generous this year, they still exist. And these policies are regulated. Anything else… like Sarah Strohmenger said, it’s a free-for-all. And there are some hustlers out there. 

Meanwhile: the Trump Administration and Congress have both set up changes to the ACA marketplaces — administrative hassles that will make it harder to get, and keep, your coverage.

The time to start planning for it is now. And we’re gonna have some help for you, starting with next week’s First Aid Kit newsletter. 

My colleague Claire Davenport has been digging into those changes, what they mean for all of us, and how we can start preparing. 

You can sign up on our website at armandalegshow dot com, slash, first aid kit.

By the way: We just launched a new version of our website — with a brand new feature: Starter Packs. 

Here’s where we bring together our best reporting on questions you need answers to, like: How do I shop for health insurance? 

We’ll have a link wherever you’re listening, 

and we’ll be back with a new episode in a few weeks.

Until then, take care of yourself.

This episode of An Arm and a Leg was produced by Emily Pisacreta and me, Dan Weissmann — with help from Lauren Gould—

And edited by Ellen Weiss.

Claire Davenport is our engagement producer. 

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.

Bea Bosco is our consulting director of operations.

Lynne Johnson is our operations manager.

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism.

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show.

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support.

Thanks! And thanks for listening.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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.

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This story can be republished for free (details).

Host Dan Weissmann and producers Emily Pisacreta and Claire Davenport share tips from a retired hospital manager who now helps seniors find the right Medicare plans, a pharmaceutical sales rep, an employee benefits adviser, and a battle-worn hospital caseworker. Each brings surprising, maybe even lifesaving, information to the table.

Explore the full crowdsourced series, including five installments of the “First Aid Kit” newsletter: The Prescription Drug Playbook.

Credits

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

Dan: Hey there. Let’s meet Jeanne Chamberlin from North Carolina. She regularly talks with folks who take like 15 different meds every day. 

Jeanne Chamberlin: You are like, oh my gosh. And literally the retail costs are $20,000 a month. 

Dan: Jeanne’s an expert, twice over. Since retiring from a career managing hospitals and medical groups, she’s been helping her fellow seniors figure out how to manage what they pay for health care — as a county-level volunteer coordinator for a program called SHIP. 

Jeanne: And SHIP stands for Seniors Health Insurance Information Program. 

Dan: Actually in some cases it stands for State Health Insurance Assistance Program. 

Whatever you wanna call it — It’s a federally funded program that helps seniors with all things Medicare. Every state has its own version of SHIP. 

During the busy season — that’s in the fall, when people can pick new insurance for the coming year– Jeanne says she and her team speak to more than a hundred people a week. 

And one thing that comes up in basically ALL of those conversations: Can I change things to get my meds for less next year? 

She says one year, her team added up the impact of those conversations. Half of the people changed plans, and on average, they saved 300 dollars. Not bad… 

Jeanne: But there were many, many people who saved a thousand, 2000, even $10,000 by changing from one Medicare plan to another based entirely on the cost of their drugs. 

Dan: Jeanne’s gonna tell us how she helps people get those kinds of savings– with strategies that aren’t just for people on Medicare. 

And Jeanne is just one person who wrote to us when we asked for you, our listeners, to tell us about your tactics and tricks for dealing with the high cost of prescription drugs.

The result: two podcast episodes– this is number two — and four installments of our First Aid Kit newsletter. 

In this episode, we’re gonna hear from Jeanne and three other *incredible* sources who came to us with crucial insider knowledge. Knowledge that — now they we have it– we have to share with you. 

Jeanne’s gonna help us get set up. She’s gonna share what she tells those seniors, and how it can apply to anyone, at any age. 

… Then, a pharma insider is gonna air an open secret. 

An employee benefits advisor — a kind of scout for deals — will tell us where she’d send someone struggling to pay for meds. 

Finally, we’ll meet a battle-worn hospital caseworker. And beyond the specific tip she wrote in with, her work – and life story – are gonna bring us some deeper perspective. 

These people kick ass. 

And for all their advice, there is, of course, a BIG caveat: 

like we said last episode — your mileage will vary. There is no one solution for everyone. This is a set of patches, workarounds, bandaids. 

To be honest, a lot of them are actually weird byproducts of the profit-making machine. Which is a big reason they’re so patchy and unreliable. 

We deserve SO much better. But in the meantime, we can help each other. That’s what this project is about. Including the four newsletter installments I mentioned. And we’ll link to those from wherever you’re listening — so: you don’t need a pencil and paper here. We’ve got you. 

Our hope is that you walk away from all of this armed with a *little* more knowledge that could help you or someone you care about get the meds they need. A kind of leg up. An Arm and a Leg-leg-up. 

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann– I’m a reporter, and I like a challenge. So the job we’ve chosen on this show is to take one of the

most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful. 

So, first: Jeanne wrote to us about what she knows from helping people enroll in Medicare. But she also had an instructive personal story to share. Because even experts have to scramble sometimes. 

A while ago, when Jeanne’s husband had a gut infection, he got prescribed two antibiotics. His insurance coverage meant one was gonna cost him thirty bucks. But the other one? His plan didn’t cover it And… . 

Jeanne: It was $1,200. For a 14 day supply it was just obscenely expensive. 

Dan: So immediately, Jeanne says she went into problem solving mode. And her order of operations provides a great template for any of us. 

Step one: Google for discounts. Just taking a quick first pass at the kind of thing we talked about in our last episode. Maybe that’s GoodRx. Maybe that’s a coupon from the drug maker. Results for Jeanne: Not great. 

Jeanne: I could get it down to $800. It’s like, still, you’re like $800. Really? 

Dan: So, on to step two: Tell your provider there’s a problem and ask for advice. 

Jeanne: We went back to the doctor and said, is there something else that you know you can do? 

Dan: Jeanne was thinking: Maybe the doc could recommend another antibiotic — one that insurance would cover. Or help them fight her husband’s insurance to get this drug covered. 

But actually, the doc’s proposal was much simpler. 

Jeanne: She said just take the other one. 

Dan: Just take the one Jeanne’s husband could get for thirty bucks. Skip the second drug. 

Jeanne: So he did, and he was fine!

Dan: END OF STORY. In this case. It’s not always that easy. But the moral is: ASK. If your insurance covers a different drug, your doc can tell you if it’s a good bet for you. If not… well… we’ll come back to other ways your doc could help. 

But right now let’s move on to the biggest, most valuable advice Jeanne gives to seniors– and that applies to everybody. 

Especially anybody with meds they’re taking long term, like blood pressure or cholesterol meds, or whatever. 

And the advice is this: Look ahead, every year. 

In the fall, when it’s time to sign up for next year’s insurance plan: Get a look at the list of which drugs your insurance will cover, and how much they expect you to pay for them. It’s called the formulary. 

Because even if you don’t change anything about your insurance, your insurance could change the formulary. That can happen to anybody. 

Jeanne sees it all the time with seniors, when their plans reboot at New Year’s. 

Jeanne: People come in in January and this happens every year, and say, I just went to the pharmacy and. They want $300 for my medicine. And last year, or last month in December, it was $30. 

Dan: These folks didn’t plan to change anything about their insurance — but their insurance plan changed on them– and stopped covering a drug they’ve been taking. Now they’re getting charged sticker price. 

And Jeanne’s like, ‘Man, I wish you’d have come to see us during the fall sign-up– open enrollment.’ 

Jeanne: We could have probably found a plan that covered that drug still.. 

Dan: Now, it’s true that folks on Medicare tend to have more choices than the rest of us here. In Medicare, drug coverage is its own separate plan — called Part D — and seniors in Jeanne’s county have more than a dozen to pick from. 

If you get insurance from work — and maybe there’s just one plan — this thing of looking ahead is maybe even more important.

At some point, maybe a couple months before the new year, you should get a chance to see that next year’s formulary 

And it could say, “Hey, your drug is gonna be more expensive for you next year” 

That’s your cue to start problem-solving right away. Get a plan in place before that new price kicks in. 

Step one: Check: Can you find discounts online that make this drug affordable? Cool. 

No? Time to get in touch with your provider’s office: start tapping their expertise. 

Jeanne: The provider normally has a lot of people with your condition and probably prescribes this medication a lot. 

Dan: And so, if your insurance company says they’ve got some other drug you could take, one they’ll pay for– your provider will know: could that drug work for you? 

And if you’ve got a choice of plans — but they all require a special approval process now for your drug — your provider will know: Is one of them more likely to actually issue that approval? 

Jeanne: Ask them about a plan where they have an easy time getting it approved for somebody with your condition where it always goes through. 

Dan: And that’s the plan you want to pick. And, speaking of getting your insurance company’s approval: 

We’re about to move from Jeanne’s advice– plan ahead, get your provider to help — to the next step. Because you can’t plan everything. Sometimes you get sick, with something new. No planning for that. 

And sometimes, your insurance is definitely not gonna say yes right away to the drug your doc thinks you need. And your doc thinks you need this particular drug. So, how ELSE can your provider help?

John: I work, uh — work for an industry with an approval rating below Congress. 

Dan: He’s a pharmaceutical sales rep! He asked us to keep his full name and employer confidential. 

He’s also an Arm and a Leg fan. 

John: I love it when, uh, I hear stories of average people just sticking it to the insurance company. It’s nice when the patient wins, cause they don’t get a lot of wins. 

Dan: We reached John in his primary office — also known as his car. 

When we asked listeners a few months ago to share lessons about getting prescription meds without paying an arm and a leg, he wrote right in with tips. 

And one, I love just for the attitude. Here’s John reading from the email he sent us: 

John: Step therapies. Uh, denials and price at pharmacy should be viewed as suggestions. 

Dan: Suggestions. Perfect. The other is much more specific. As a salesman, a big part of John’s job is prepping doctors for the fights they’re gonna have with insurance companies, to get approvals for drugs. He does that because approvals for them mean sales for John. 

Of course, approvals take time. 

John: But one thing that you know doesn’t care about time is diseases. 

The disease of Crohn’s or Bipolar disorder, whatever, isn’t like, look, I’ll hold off on affecting you until this prior authorization is done. 

Dan: So here’s John’s advice: while you’re fighting for that approval– pushing back on the insurance company’s “suggestion” that you try something else– Ask your provider if they can get free samples from the pharma company — from a rep like him.

John: And the provider hopefully will say, yeah, let me call the rep and we’ll leave some at front for you. 

Dan: Actually, your provider may already have some on hand. A study from a few years ago found that TWO THIRDS of primary-care practices had CLOSETS of pharmaceutical samples. Which, wow. 

So, let’s address something big: Like John joked about as we introduced him, pharma sales reps are NOT generally looked upon as model citizens. 

The rap is: Some of them use less-than-scrupulous tactics to encourage doctors to prescribe expensive drugs… even to patients who might not get extra benefit from a specific drug. Or, in the case of opioids — which got pushed really hard — might cause harm. And free samples are part of that process. 

So, some providers won’t meet with sales reps at all. Some health systems don’t allow any of their staff to meet with them. 

But you don’t have to approve of how pharmaceutical companies do their business to take advantage of John’s suggestion. And neither does your doctor. 

John says, to get free samples, your doctor might not even need to talk to anyone. 

They can just make a request online, at the manufacturer’s website. John says it definitely happens. 

John: So even with providers or doctors that I’ve never seen in my nine years, I know that they’ve gotten samples before. 

Dan: But here too, there will be limits. 

John: Some manufacturers don’t even do samples. So it really varies a lot. Dan: But a lot of these samples do exist — 

And the idea of using them as a stopgap while you fight to get your insurance to pay for the meds you need — I had never thought of it until we asked you, our listeners, for your tips.

And you also sent us this: Could a local clinic supply the meds you need for a price you can actually afford? That’s next.. 

This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists do amazing work. We’re honored to be their colleagues. 

OK, a whole new kind of expert here. Like Jeanne, who we heard from earlier. Cristy Gupton also lives in North Carolina. She works as an independent employee benefits designer. You’re probably like, what the hell is that? Here’s how she describes her work. 

Cristy Gupton: Imagine you’re a kid in high school, in shop class, and your teacher puts an old engine on the table, and says, take it apart and put it back together again and make sure it works. 

Dan: Except, the machine is a health benefit program for workers. And– back to the shop-class metaphor — Cristy says she’s the real gear-head in the room . 

Cristy Gupton: By the time I put the engine back together, it works twice as good, but at half the cost. 

Dan: Cristy says she does it by ditching expensive, off-the-shelf parts — standard insurance policies from big companies — for custom solutions. It’s a WHOLE THING, and super-interesting, and worth going into. 

For now, she’s got one big tip that *some* of us could use to get access to meds at super-low prices. Basically it’s this: Look for a community health center that offers a sliding scale. They can get drugs at extremely low prices, through a federal program called 340B. 

How low? 

Cristy Gupton: The drug Humira is one of the most prescribed drugs in America. And the list price is probably somewhere in the neighborhood of 5,000 a month. But a 340B covered entity could purchase it for a penny. 

Dan: So we checked, and actually: Humira’s list price isn’t 5,000 dollars. It’s 7,000 dollars. But YES, a 340B clinic can get it for a penny. Now, they don’t get every drug that cheap, but..

And look: although this is all very much worth knowing about, it’s not guaranteed to work for you. 

340B is complicated in all kinds of ways. Here’s my colleague Emily Pisacreta asking Christy about it. 

Emily: Help me understand what 340B is. 

Cristy Gupton: I’ll give you my best, um, like only know enough to be dangerous answer. 

Dan: After checking some actual experts, here’s what we think you need to know: 

A federal law from the 1990s — section 340B of that law — basically requires drug-makers to give some hospitals and health centers that serve low-income folks super-duper discounts on meds. 

Those discounts don’t always get passed along to patients. The feds say hospitals and clinics can take a profit, to subsidize their other work . 

But the rules say: community health centers DO need to make drugs affordable to people with lower incomes. Specifically, to people who make less than two times the federal poverty level. 

For 2025, that’s just over 64 thousand dollars for a family of four. Not a lot. 

But it’s a lot of people: More than 28 percent of Americans qualify. And some clinics may have sliding scales for people with higher incomes than that. 

So: There’s a search tool. We’ve got a link wherever you’re listening to this. Find a clinic in your area, call them, and see what the deal is. 

One last thing to know: You’ve gotta actually be a patient at the clinic in order to use this program. And actually, if you meet the income requirements, all the clinic’s services are gonna be super-subidized. 

But if you don’t want to engage too deeply with the clinic– don’t want to switch over all your care to a new team — Cristy says, in her experience, you may not have to.

Cristy Gupton: It can be as loose as they just have a virtual visit. I mean, that’s pretty simple. 

Dan: Again, we’ve got a link to the search tool for finding a health center near you. Which of course…near you… not everybody is gonna have. Your mileage may vary, literally. But is it worth checking? Yeah, I think so. 

OK we’ve thrown a LOT at you. I know, I know. And we do have one more set of expert tips. From someone we are really glad to have met. So here’s Erika — and her expertise is part of a lifelong project. 

Erika: You know, as a child with Type one diabetes, I had a very dysfunctional household and I had to take care of myself from a very young age. I have learned that the skills that I developed as a child with a chronic illness are transferable into a career to help people be taken care of. 

Dan: So now, she works as a patient navigator– a kind of case worker, at a hospital in rural Oregon. 

When my colleague Emily talked with Erika, they bonded a little. 

Emily: I live with Type One Diabetes and I really wish that I had had a patient navigator, um, when I was diagnosed. 

Erika: Yeah, I wish I had me as a patient navigator too. 

Dan: Most of the patients Erika does work with are managing chronic conditions and other serious health problems, under tough circumstances. 

Erika: For example, let’s say a patient has an amputation and they’re told on discharge to keep it elevated and keep it clean. Well if they’re living in their car, that can be a challenge. So in that case, case management would try to find them a hotel for a couple weeks. 

Dan: And of course, one of the most common problems she tackles: helping people get their meds at prices they can afford. 

Erika: There are weeks where that’s all I’ll do.

Dan: For insured patients, Erika he starts with drugs-and-insurance 101: Helping them figure out which drugs their insurance covers, at what price to them, and coaching them before they call their insurance company. 

Erika:I offer to be on the call with them if they want. And I will tell you right now that we’re gonna be on hold with that insurance company for 30 minutes 

Dan: Yeah, that sounds familiar. Also, for some patients on Medicaid, Erika runs interference with bureaucracies. 

And, when there’s no way that insurance will make the right drugs affordable for her patients– including folks with no insurance at all– Erika helps them explore one of the options she wrote in to us about. 

“Patient Assistance Programs” based on income. Some are from manufacturers, others come from private foundations. 

Erika: It’s such a matter of somebody knowing who to ask and where to get the stuff. 

Dan: And there are websites to find this kind of thing — we’ve got links and guides for you — and she says the applications aren’t complicated. 

But the people she works with, they need extra help. 

Erika: A lot of my patients don’t even know how to use a computer or to get onto the internet, or they don’t have smart phones, they just have cell phones. So a lot of them, I meet with them. I take my laptop, and we do an online application. I help them fill it out. 

Dan: And then hope it works. Some programs only give out so much assistance per year, so not everybody gets help. 

Erika: It’s a frustrating fight. I feel bad that people have to wage this, you know, to get what they need to be healthy. It’s, it’s not like people are asking for BMW or new clothing. People are asking for, oftentimes medications they need to keep themselves alive. It’s, it’s like asking for oxygen. Like what if you were told you you couldn’t afford oxygen? That’s the way people feel sometimes.

Dan: And that’s why, even though Erika wrote to us about practical specifics, it’s her approach, her presence that we especially wanted to share with you. 

Erika: I advised all my patients to get a tattoo that says, be persistent. I mean, seriously, I don’t expect them to get tattoos. But as a patient who manages a chronic condition, you just have to be. 

Dan: Oh yeah. The ongoing burden of dealing with all this, it’s a bear. And it came up again and again when you wrote in to us. 

Erika: Yeah. Stress management, whew. 

Dan: For Erika’s patients, and for herself too. 

Erika: I have to remember to like, stop, step away, do some breathing. And these are things I teach to my patients a little bit too. Like, okay, let’s stop and do some breathing together on the phone. Okay. 

Dan: She calls her strategy “self compassion.” It’s about helping people see how much they’re already doing. 

Erika: I encourage people to take a moment and appreciate that about yourself. Okay? you’ve been on the phone with your insurance company for 30 minutes. 

You’re trying to get this done. You really need to appreciate that you’re doing that for your health. For your health. Feel good about that, at least. 

Dan: You are taking time to listen to this podcast. We are here, right now, together, doing our best. 

For the practical lessons — all the things to try, that may or may not work — we’ve done our best to write them down for you, and organize them so they’re useful, in our First Aid Kit newsletter. Four installments. 

You can find those newsletters — and these episodes — at Arm and a Leg show, dot com, slash, drugs. 

That’s the address where we first asked you to share what you’d learned by walking through this maze. Now we’re inviting you to come and see what we’ve learned from you.

Arm and a Leg show dot com, slash drugs. There’ll be a link wherever you’re listening to this. 

And you’ll find one more thing there, too. 

To honor the endless and ridiculous process that we sometimes have to go through to get our medicines… my colleague Claire Davenport, who has led the reporting for so much of this series, made an endless and ridiculous song. Well, with the help of an AI. Stay tuned after the credits for a little taste of that. 

We’ll be back with a new episode in a few weeks. 

Till next time, take care of yourself. 

This episode of An Arm and a Leg was produced by Emily Pisacreta and Claire Davenport with help from me, Dan Weissmann, and Lauren Gould. 

And edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Weiner and Blue Dot Sessions. 

Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s the editorial liaison to this show. 

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. 

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support. 

And NOW….a little treat. 

So: At one point, we were like, “What if we could make like a jingle to help people remember all the tactics we’re talking about?” 

But when our producer Claire tried actually writing one, with AI supplying the melody and the band — it just kinda showed us how endless and ridiculous the list actually is. 

And we found that just adorable. Here’s how it starts… 

AI Song: I am a prescription – medication. And as you might know, I’m Expensive in this nation. Getting me can be confusing. And often quite scary. Since when it comes to meds. The prices can vary. Luckily, there’s some tricks you can try. When you’re in this situation and the price is high… 

Dan: Alright, I think you get the idea — and if you want more, it’s all at Arm and a Leg show dot com, slash, drugs. Along with these podcast episodes and First Aid Kit newsletter installments, and everything we hope you’ll actually find useful. Thanks.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

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

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

USE OUR CONTENT

This story can be republished for free (details).

Dozens of listeners responded with their stories, including Bob, who is being identified only by his first name to guard his family’s privacy and whose daughter has epilepsy. When Bob changed jobs, the price tag for his daughter’s medication went through the roof. In this first installment of a two-part series, “An Arm and a Leg” shares lessons from Bob’s experience navigating a maze of pharmacies and insurance companies to get his daughter the medicine she needs.

Credits

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

Dan: Hey there. 

When I tell friends that we’ve been working on a series about how to pay less for prescription drugs, I find myself telling them about a guy named Cole Schmidtknecht. 

In January of last year, Cole went to a Walgreens in Appleton, Wisconsin, to get refills on the medication he used to control his asthma. 

He’d been taking it for years, and he expected to pay about seventy bucks. 

But — this is all according to a lawsuit filed by Cole’s folks– the pharmacy said his insurance didn’t cover his medicine anymore. He’d have to pay more than 500 dollars. 

He left without it. 

A few days later, he had a massive asthma attack. He died after a few days on life support. He was 22 years old. 

In their lawsuit, Cole’s folks say the pharmacist at Walgreens could’ve told him right then and there about comparable drugs his insurance would’ve paid for. 

This is the kind of information we all need, all deserve. 

In surveys, a quarter of Americans say they’ve skipped taking meds in the past 12 months because of cost. 

And maybe we can put a little dent in that. 

Because there are actually a lot of things to know, and a lot of things– a lot of strategies we can try when it looks like our medicine is gonna cost an arm and a leg. 

Over the last few months, you’ve actually been helping us learn about more of these strategies, and here we’re gonna start tying those lessons together. 

Back in February, we asked you, our listeners, to tell us how you’ve managed when your prescriptions got really expensive.

And we heard back from a LOT of you. 

Person 1: We went to go pick up the prescription and we were like, holy moly, that is so expensive. 

Person 2: We’ve been given estimates of $30,000 a dose 

Person 3: The pharmacist would burst out laughing every time I showed up 

Dan: And … you told us what you did next. The strategies you learned for fighting back, and sometimes winning. 

A lot of those strategies, we knew about. Some, we were like, whoa, that’s a new one on us! 

I mean, with all of this, there’s no guarantee that your particular problem has a good solution. 

Our whole system sucks. These are patches, workarounds. 

Cole’s dad– he now works full time trying to change the whole system of how we get charged for meds. Which is a must– and is gonna be a long haul. 

But in the meantime, these patches and workarounds — honestly, they can really help a lot of people. 

So here’s what we’re gonna do. 

We’re gonna break down what we’ve learned into chunks you can digest, and share. We’re gonna take TWO episodes of this show to do it. 

And we’re NOT expecting you to take out a pen and paper: We’re gonna share everything in writing, in our First Aid Kit newsletter. Including stuff that doesn’t fit on the podcast. 

It’ll take four installments. I’m telling you, there’s a lot. 

Meanwhile, we’re starting here with one guy’s story– a listener named Bob. 

Bob’s journey is going to help us show you — well, the journey. How the trial and error works. The obstacles.

And we’ll show you the strategies Bob worked to get through those obstacles. Including a tool he developed, that we’re gonna share with you. 

And I’ve got some help telling Bob’s story. Our producer Claire Davenport did most of the reporting for this episode. Hey, Claire! 

Claire: Hi, Dan! 

Dan: You’re gonna tell us Bob’s story, and then at some points, we’ll zoom out — like tour guides, pointing out the big lessons 

Claire: Yep! I’m super excited to get into it. 

Dan: Let’s go. 

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

Okay Claire, where should we start with Bob’s story? 

Claire: First, let’s meet Bob. He’s got a lot going on… 

Bob: Between me and my wife, we have five kids and uh, three dogs, and two cats and two lizards. 

Claire: Did you ever anticipate you’d be a dad to so many, Bob: Nobody plans to have many kids, Claire. 

Claire: By the way, Bob asked us just to use his first name for privacy reasons. But we’ve checked out his story — he sent us lots of documentation. 

Bob’s journey here begins in 2019 — the first day of high school for his daughter, Mary. 

After she got home, he wanted to hear how it went, so he called her.

Bob: We were talking and, I would say she’s being a little spacey, but, uh, talking to a 14-year-old on a cell phone, right? 

And, and I’ll never forget this, she, we were talking and all of a sudden she said, the ceiling looks so funny. 

And then, um, and then she was sort of gone. 

Claire: At first, he assumed Mary had just set the phone down — maybe to talk with one of her sisters. 

Bob: I text her mom and say, Hey, I was talking to our oldest daughter, and, uh, she just sort of disappeared now she’s not answering the phone. Can you go check on her? 

And I still get even choked up talking about this. But, I get a text back in about two minutes saying she’s unconscious. 

Claire: They end up calling an ambulance. Bob is scared. 

Bob: All kinds of thoughts were running through my mind in terms of what could possibly have happened here. Epilepsy was not one of them. 

Claire: Epilepsy. It’s a condition that causes seizures. And Mary was having one while her dad was on the phone with her. 

Mary and her folks worked with a pediatric neurologist. They started trying out different medications and dosages. 

Bob: We were told, we’re going to figure out what the right medications are for her. This is gonna be a process. 

Claire: And it was. It took years of trial and error: they had to experiment with different drug combinations. 

Finally they landed on the right mix. That mix included a drug called Clobazam. Bob: And that seemed to be the magic bullet 

Claire: A magic bullet with a reasonable price tag.

Bob: the three drugs she was on were well under a hundred dollars for all three of them together 

and she went over a year without a seizure. 

(beat) 

Bob: And then I changed jobs. 

Claire: Which had an unexpected consequence. As Bob learned when it was time to refill Mary’s prescription for Clobazam. 

Bob was used to paying around 15 dollars. 

Bob: This time the pharmacist comes out and says, Hey, your, your Clobazam is gonna be $500. 

Claire: Ok, so…Dan, let’s take a step back. Bob changed jobs, and suddenly Mary’s Clobazam is $500. Because… 

Dan: Bob’s new job meant… a new insurance plan for the family. And… 

Claire: Every insurance plan has its own list of how much you pay for which drugs. And which drugs they don’t cover at all. That list is called “the formulary.” 

Dan: That list, that formulary, is based in part on business deals that plans and drug-makers hash out behind closed doors. 

Claire: So when you change jobs, change insurance: the difference between what’s on one formulary and what’s on the next: It can be… 

Dan: unpredictable at best. 

And even if you don’t change jobs, your job may change your insurance plan. That happens a lot. 

Claire: And even if your insurance plan doesn’t change, that plan’s formulary can change from year to year.

Dan: So, Claire, this seems like the first big lesson from Bob’s story — the first big obstacle: The deal can change on you. And MAYBE, in this new deal, your insurance offers another drug they say is just as good. 

But it may not be just as good for YOU. That’s a thing. 

Claire: And it was definitely a thing for Bob and his daughter Mary. Remember, they had spent YEARS of trial and error, finding the perfect regimen. 

Just switching to whatever random thing the insurance company approves, that’s not on the table. 

So first, Bob thinks, hey maybe there was just some kind of mistake here. New insurance company, right? Maybe the pharmacy got confused. Bob calls his insurance just to ask, and they’re like: 

Bob: Oh, well that medication, , is only covered for a certain type of, of epilepsy 

Claire: Which isn’t the type they think Mary has. They’re not gonna cover it. So, now we have arrived at the point where Bob busts out his first big strategy: Haggling with his insurance. They’ve said “no,” but that doesn’t mean he has to accept this as their final answer. 

Dan: Yep, we heard from so many people — have heard over the years: This is a whole dance, a whole fight. 

Claire: Yep, and Bob’s gonna take us through it. In fact, in this very same phone call where his insurance company said they wouldn’t cover Mary’s Clobazam, they basically invited him to this dance. They said: 

Bob: Well, there’s a prior authorization that can be filled out. We’ll send that to your doctor. 

Dan: There’s a prior authorization for that! We’ll send that to your doctor!” The way Bob says that, it sounds like the insurance person was so cheerful. Making things sound so easy. 

But prior authorization…

Claire: That’s a hurdle, a hoop for Bob — and Mary’s doctor — to jump through. 

Dan: This will be familiar to a lot of folks already, but: Prior authorization… PRIOR: 

Claire: Before the insurance company will pay for Mary’s Clobazam, Dan: They have to AUTHORIZE it. 

Claire: her doctor has to make a case that she needs this particular treatment — and the insurance company has to decide the argument is good enough. 

Dan: We see it all the time. 

Claire: Bob isn’t thrilled by this requirement. 

Bob: Seems unnecessary. This is a, you know, board certified pediatric neurologist who’s been seeing this patient for years. 

Claire: And who took her through a whole long trial-and-error process to find the right meds. 

Dan: Because of Bob’s confidentiality, his insurance company said they couldn’t respond directly to his story — fair enough. But a lot of the time, Insurance companies say: Hey, we’re just discouraging waste with these prior authorizations! Sometimes doctors do just prescribe an expensive thing, when something cheaper would be just as good. Okay. 

But a lot of patients say, like Bob would: My doctors and I had already DONE all this checking. 

Claire: Bob gets form sent in, but now he’s got another problem. The insurance company needs time to evaluate the prior authorization. And Mary needs her drugs right now. 

Bob: She starts to panic a little bit of like, Hey, I, I need my medication. If I miss a couple doses, I could have a seizure. 

Dan: That’s a bad problem.

Claire: Luckily: Bob found a way to get Mary’s Clobazam for less than five hundred dollars a week. We’ll get into that a little later. 

But for now, just to note: It’s lucky he found that workaround. Because when Bob calls to check on the prior authorization– PA for short– Well, here’s how he says the conversation went… 

Bob: ‘Yes, we got the PA information. It was denied.’ 

‘It was denied? What, uh, why was it denied?’ 

‘Oh, well, again, it looks like it’s only approved for this one particular type of epilepsy.’ 

Claire: Which was just what they’d said before. Bob gets ready to appeal. 

And he says this is getting to him. When we talked, he mentioned a lesson from this show: 

Bob: I think you guys recommend this of like not losing your cool with the customer service people, in the insurance companies. 

Dan: We do. Everybody says: It really helps. 

Claire: And everybody knows. It’s not actually always possible. Here’s what happened the next time Bob calls his insurance. 

Bob: They asked me, oh, how’s your daughter doing? And I just remember saying like, you don’t care how my daughter’s doing. She’s terrified. She’s gonna be walking to class and have a seizure because she doesn’t have the medication. So don’t give me this BS about how’s my daughter doing. 

Dan: Bob seems like a pretty level-headed guy. 

Also — we’ve kind of withheld this until now– but Claire, you told me Bob works in health care, so he knows a little more about this world than most of us do. Insurance, appeals.

He’s got the advantage, in terms of keeping his cool, of not being in totally foreign terrain. 

Claire: Yep, and he says he recovered his cool pretty quickly. 

Bob: I pulled back at when I realized what I was doing. Like this isn’t this person’s fault. They’re just probably reading a script. 

Dan: But this is kind of the lesson here: No matter what kind of advantages you have, this stuff is so frustrating. Anybody can lose their cool. The key — and maybe we should do a whole show on this — is recovering. Because you’re gonna have to get up and go again. 

Claire: Yeah, and we’re just getting to the most frustrating part. Dan: Right. 

Claire: After more than a month– and two rounds of appeals– Bob says Mary’s Clobazam finally gets approved. 

Dan: And this is the frustrating part because… 

Claire: Insurance will cover it now. But they tell him his share is going to be $150. Remember, Bob said under his old insurance, it used to only cost $15. 

Bob: So 10 times the price now, plus the price you know, of the other medications she’s on. 

Dan: Yep. All this waiting, all this fighting, everything. And it’s ten times more than he used to pay under his old insurance. 

Claire: It’s less bad– this insurance originally was gonna make him pay more than 500 bucks. But yeah. Not great. 

Dan: But Claire: this is not the end of Bob’s story, right? 

Claire: Not even close. 

Bob: What this sparked us to do is to look at, well okay, if it’s not going to get approved, what are the other options?

Claire: We’ll get into those options– after the break. 

Dan:This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health issues in America. Their reporters win all kinds of awards every year. We are honored to work with them. 

So, Bob has worked the strategy of Haggling With His Insurance. And he won. Kind of. Except that winning still leaves him paying ten times more than he used to. 

Claire: Yes, and now he’s going to work a whole different strategy: Ignoring his insurance. Because there can be better deals elsewhere. Bob starts with GoodRx. 

Dan: Lots of people know it — it’s a website where you tell them what drug you need, and they’ll show you deals — discounts — at local pharmacies. 

Which does not always work. Saving 50 percent on a thousand dollar drug does not make it affordable. I know people who get mad when you mention it. 

Claire: Bob says he got mad because of who recommended it to him: a rep from his insurance company. 

Bob: Like you’re my insurance company. Why? You’re, that’s what I pay you for. 

Claire: Right? he pays them premiums so he can pay less for health care, including medicine. But he didn’t write it off. And he says now, it was actually useful: even though he knew about GoodRx before, he wouldn’t have thought to go there. 

Bob: like I almost, and this is gonna sound crazy, but I almost thought of GoodRx as like Medicaid. Like, I think I thought of it as like, oh, well that’s what you use if you don’t have insurance. 

Dan: Interesting! And in one sense, he wasn’t wrong: When you use a GoodRx discount, you can’t use your insurance too. But it turns out, even when you have insurance, GoodRx can be worth looking at.

Claire: Yes, and here’s what makes Bob’s story stand out — the reason we wanted to really dig in. It’s what he did next. Because he didn’t just look at GoodRx. He started exploring a whole world of options. Actually, worlds. 

One is the world of sites LIKE GoodRx. 

Dan: Ooh, I’m googling “sites like GoodRx” — here’s SingleCare, RxSaver, BuzzRx… 

Claire: Yep, and for any given drug, each of these sites may show you different prices. So now that he was looking at this world, he started mapping it. 

Bob: I created this spreadsheet that had each of those options, the different medications and then the different pharmacies and where we could kind of get the best price for things. 

Claire: And: Once Bob started looking at THIS outside-insurance world, started exploring others. Like Cost Plus Drugs. 

Bob: And –What was really sort of eye-opening to me is they did so much better than our insurance company did. 

Dan: We should really talk about Mark Cuban Cost Plus Drugs, to use its full name. It’s pretty different. 

Claire: Right. The celebrity owner. 

Dan: Mark Cuban is basically famous for being rich. Like he owns the Dallas Mavericks basketball team. 

Claire: And he’s spent 15 years on the reality show Shark Tank. [THEME] 

Dan: It’s like American Idol for startups. People pitch their business to investors who might offer to buy in, on camera. 

TV announcer: Mark Cuban has just made the largest offer in Shark Tank history.

Mark Cuban: Lemme ask you a question. If I offered you $30 million for the company, would you take it? 

Claire: All of that, but the celebrity factor isn’t really what makes Cost Plus different: The company buys meds direct from manufacturers, and adds 15 percent to their wholesale cost. 

Dan: Plus shipping fees, and five bucks for “pharmacy labor”. Claire: Bob added CostPlus to his spreadsheet. And he liked what he saw. Bob: It’s very transparent and super low cost. 

Claire: He asked Mary’s doctors to transfer two of Mary’s prescriptions. 

Dan: But not all of them. Cost Plus doesn’t carry everything. For one thing, they mostly only carry generic drugs. 

Claire: And — what matters in Bob’s case: they don’t carry controlled substances. Nobody sells them online because it’s illegal to ship them. And Mary’s Clobazam? It’s a type of controlled substance: They’re called Benzos. 

Dan: Like Valium and Xanax. 

Claire: So for Clobazam, the best price he can find is 85 bucks, using GoodRx at Walmart. 

Dan: A LOT less than his insurance was gonna have him pay. go spreadsheet! Head to WalMart, use GoodRx there. 

Claire: Just one thing: Mary’s off at college now, and there’s no Walmart right nearby. And Mary, doesn’t drive. 

Bob: Well, she has epilepsy. She can’t have a driver’s license, so it’s uh, she can’t drive anywhere. Right? We had a Walmart near our house at home. I’m two and a half hours away from her. 

Claire: And he says he made the drive.

Dan: Dad of the decade. For ALL of this. Bob fought down the insurance companies. He shopped around. He made the spreadsheets. And he made a bunch of round trips to his daughter’s college. 

Claire: Yeah, Bob rules. But he’s not exactly happy about all of it. 

Bob: I pay an insurance company every month outta my paycheck for prescription drug benefit that I don’t feel like I get, right? Like I’m having to go outside of that in order to get them the medications that are nothing special. Like, clobazam has been on the market since like the seventies. 

Dan: Yeah, fair. 

Claire: But he may be game to take the win on that Dad of the Decade award. 

Bob: Would say I did a magnificent job of, you know, staying, staying calm, and hiding that stress from Mary 

Mary: I assumed he was gonna figure it out. Um.. [laughs] Bob: Total confidence in me, right? [laughs] 

Dan: That’s Mary? 

Claire: That’s her. 

Dan: OK, so let’s review these lessons: Yes, you can fight your insurance, but you may get a better deal going outside of it. All of which suck — this was a LOT of work, and not a total victory — but is better than NOT knowing any of this. 

Claire: Yes. And this story ends up going full circle. Back to the first lesson. The deal can change on you. For worse. Or for better. 

Bob changed jobs again recently — so, new insurance. 

And actually, it’s good this time! Under Bob’s new insurance, Mary’s clobazam is … back to 15 dollars. 

Which she learned when she went to pick it up recently.

Mary: I was like, this is amazing. Definitely a weight lifted off my chest when I saw a two digit number. 

Dan: And speaking of how the deal can change on you… this reminds me: went looking at GoodRx recently, and saw a new price for Mary’s Clobazam there, too. 

Claire: Yes. The lowest price on GoodRx is now: Thirty dollars, at a CVS she can walk to. 

I showed the current GoodRx prices to Bob and Mary, and what struck Mary at first was this: how different the prices at different pharmacies were. 

GoodRx said CVS had Clobazam for 30 dollars but… 

Mary: It said Walgreens was like over $300.over. It was like 300 and then everything else is between 25 and 35, maybe 40, but I don’t understand that. 

Dan: I KNOW! Man, I had this exact experience a few years ago. I was like, WHY ARE THESE SO DIFFERENT? 

I ended up learning about companies called pharmacy benefit managers or PBMs. They’re the ones that actually decide which drugs our insurance covers, and how much we pay for them. 

We did a WHOLE episode about them (it was SOO complicated, but I learned a huge amount) 

Claire: So we are NOT gonna get into here, but we’ll leave a link in the show notes in case people want to nerd out. 

Because today we’re just looking at how to get things to work better for YOU. 

So: Mary was curious about the 300 Walgreens price from GoodRx. And by the way, she’s also furious with the whole system. 

But here’s one thing she was filing away: She could now use GoodRx to get Clobazam for 30 dollars at CVS.

Mary: It was not like that a couple years ago. And it is reassuring to know, like, if I show up and it’s, you know, $150, there are places that would have a price I could actually afford. 

Dan: Let’s take that glass half full and add a little bit to it. Because in addition to their story, Bob gave us one more thing: His spreadsheet. And we’ve been adding to it. 

Claire: Yep. We’ve got a template you can download — it’s in the show notes for this episode, and it’s in our First Aid Kit newsletter. And in addition to GoodRx, and some similar sites, and CostPlus, we’re adding lines where you can log prices from a world Bob didn’t explore. 

Dan: I mean, he’s just one guy. 

Claire: So, one thing we’re adding: ordering from pharmacies outside the U.S. 

Drug prices are lower basically everywhere else, and some pharmacies in Canada will ship to the U.S. To avoid shady internet stuff, a tool called Pharmacy Checker will steer you to ones that are above board. 

Dan: Another addition: Manufacturer coupons. SOMETIMES, especially with brand-name drugs, pharma companies offer coupons that can make drugs affordable. 

Claire: There are a lot of caveats with those too. 

Dan: Oh man, tell me about it. But not right now. There are TOO MANY possible workarounds, too many caveats, for any one person to keep in mind. That’s why we are doing this across two episodes and FOUR installments of our First Aid Kit newsletter. 

It’s all exhausting, and there’s no guarantees. But it’s all worth knowing. And with help from Bob, and a lot of listeners who chimed in, we are boiling things down and putting them in forms we hope you’ll find useful. 

As always, DEFINITELY please let us know how the stuff we provide can be even better. 

You can find the First Aid Kit newsletter at arm and a leg show dot com, slash first aid kit. New installments there every week. We’ll have a link wherever you’re listening to this.

And in our next episode, we’ll dive into some tips that really surprised us, from folks who do this kind of thing for a living. 

Erika: I guess in my heart of hearts, I want everyone to be taken care of. Dan: For now, Claire: Thank you so much for bringing us Bob’s story. Claire: My pleasure! 

Dan: And we’ll be back with the second episode in this series in a few weeks. Till then, take care of yourself. 

This episode of An Arm and a Leg was produced by Claire Davenport with help from me, Dan Weissmann, and Emily Pisacreta. And our new intern: Welcome Lauren Gould! It was edited by Ellen Weiss. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Weiner and Blue Dot Sessions. 

Bea Bosco is our consulting director of operations. 

Lynne Johnson is our operations manager. 

An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism. 

Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show. 

An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station. And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor. 

They allow us to accept tax-exempt donations. You can learn more about INN at INN.org. 

Finally, thank you to everybody who supports this show financially. You can join in any time at arm and a leg show, dot com, slash: support.

Thanks! And thanks for listening.

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

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, First Aid Kit. You can also follow the show on Facebook and the social platform X. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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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.

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