The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.

During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.

Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.

Then the bill came.

The Medical Procedure

An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.

The Final Bill

$340, which included $120 for vision testing and $100 for optic nerve imaging.

The Billing Problem: Vision Coverage vs. Medical Coverage

Tuszynski’s UnitedHealthcare Medicare Advantage plan declined to pay for her eye appointment. “The member has no out of network benefits,” the company’s denial letter said.

Tuszynski felt like she was seeing double. How could an eye doctor be in-network and out-of-network at the same time? She said she sent the insurer a screenshot of its own webpage showing the clinic listed as in-network.

She said that after she complained, UnitedHealthcare representatives explained that the eye clinic was in-network under her vision plan, so her policy would cover the clinic’s services related to glasses or contact lenses. But they said the clinic was not in-network for her medical insurance plan, and glaucoma treatment is considered a medical issue.

Tuszynski was baffled that care for a patient’s eyes would not be covered by vision insurance. She said she didn’t realize that insurers can have contracts with eye clinics to provide some services but not others.

UnitedHealthcare spokesperson Meg Sergel said such arrangements are common, including with non-Medicare insurance provided by employers or purchased by individuals. “I looked up my eye doctor, and it’s the same thing,” she said in an interview with KFF Health News.

Sergel said she understood how a customer could mistakenly think vision insurance would cover all care for the eyes. She said UnitedHealthcare recommends that before undergoing treatment, patients ask care providers whether they are in-network for specific services.

Otherwise, she said, to know whether a test or treatment is covered by vision insurance, “you’d have to read the nitty-gritty” of a policy.

Leaders at Steinhauer Family Eye Clinic, where Tuszynski saw the optometrist, declined to comment.

Casey Schwarz, senior counsel for education and federal policy at the nonprofit Medicare Rights Center, said such complications frequently come up when Medicare Advantage members try to use their insurance at eye clinics or dental offices.

The federal government pays insurers to run Medicare Advantage plans for people who choose them instead of traditional Medicare. More than half of Medicare beneficiaries sign up for the private plans. Many offer routine vision and dental coverage that isn’t included with traditional Medicare.

“We hear from people who choose these plans because of those supplemental benefits, but there is not a lot of transparency around them,” Schwarz said.

The Resolution

After receiving the rejection letter, Tuszynski repeatedly contacted UnitedHealthcare to question the decision and filed an appeal with the company. Then, she said, she called a Medicare hotline to complain to federal officials. She also wrote to KFF Health News, which asked the insurer about the case.

UnitedHealthcare eventually agreed to cover the bill as if the service had been in-network. “In good faith, we made an exception,” Sergel said. However, Tuszynski was warned that if she received medical care from the clinic again, it would not be covered, because the clinic remains out-of-network for such services, Sergel said. “It doesn’t sound like that pleased her.”

Tuszynski confirmed that she is not pleased.

She said she lost sleep over the dispute and felt that it shouldn’t have taken so much effort to obtain a fair outcome. “It’s just been a horrible, difficult whirlwind,” she said.

The Takeaway

Schwarz said regulators should require insurance companies to clearly explain to customers and care providers how different procedures and services will be covered under vision, dental, and health plans. “They’re tricky,” she said.

In an ideal world, Schwarz said, Medicare would consider things like dental cleanings, eye checkups, and hearing aids as basic health care that would be covered in the same way as other medical care. But until that happens, she said, patients with any doubt should call their insurers beforehand to check whether services will be covered.

Tricia Neuman, a senior vice president with KFF, a health information nonprofit that includes KFF Health News, noted that Medicare’s website now includes a tool that can help people determine whether their doctors participate in a Medicare Advantage plan.

“This is helpful and a step forward, but information about provider networks is not always correct,” Neuman said. “Errors can come at a cost to enrollees, unless they are willing and able to take on their insurer.”

Tuszynski worked for 30 years as a secretary in hospitals and at doctors’ offices, so she’s familiar with billing issues, she said. “If I can’t sort through all this, how can anybody else do it?”

She knows her $340 bill was much smaller than the medical debts many other people face. But she said it was a serious amount of money to her, and she was glad she objected to the insurer’s contention that the bill shouldn’t be covered.

“I have a strong feeling about right and wrong — and this is just wrong,” she said.

For 2026, she decided to shift out of her Medicare Advantage plan. She now is enrolled in traditional Medicare, plus a supplemental plan to help with copays and other costs. She pays $184 a month for that plan, compared with paying no separate premium for her old Medicare Advantage plan.

Now she won’t have to worry about private insurers’ limited networks of contracted care providers, she said. Her glaucoma treatment will be covered at the Madison eye clinic.

However, she no longer has insurance coverage for eyeglasses, just a discount plan if she buys glasses from certain stores. She used her Medicare Advantage insurance to buy new glasses shortly before switching. “Hopefully, those will last me a while,” she said.

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

Millions of Americans are facing dramatically higher health insurance premium payments due to the Jan. 1 expiration of enhanced Affordable Care Act subsidies. But much of Washington appears more interested at the moment in culture war issues, including abortion and gender-affirming care.

Meanwhile, at the Department of Health and Human Services, personnel continue to be fired and rehired, and grants terminated and reinstated, leaving everyone who touches the agency uncertain about what comes next.

This week’s panelists are Julie Rovner of KFF Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• Congress remains undecided on a deal to renew enhanced ACA premium subsidies, as it is on spending plans to keep the federal government running when the existing, short-term plan expires at the end of the month. While some of the bigger appropriations hang-ups are related to immigration and foreign affairs, there are also hurdles to passing spending for HHS.
• ACA plan enrollment is down about 1.5 million compared with last year, with states reporting that many people are switching to cheaper plans or dropping coverage. Enrollment numbers are likely to drop further in the coming months as more-expensive premium payments come due and some realize they can no longer afford the plans they’re enrolled in.
• A key Senate health committee on Wednesday hosted a hearing on the abortion pill mifepristone, focused on the safety concerns posed by abortion foes — though those concerns are unsupported by scientific research and decades of experience with the drug. Many abortion opponents are frustrated that the Trump administration has not taken aggressive action to restrict access to the abortion pill.
• As the Trump administration moved this week to rehire laid-off employees and abruptly cancel, then restore, addiction-related grants, overall government spending is up, despite the administration’s stated goal of saving money by cutting the federal government’s size and activities. It turns out the churn within the administration is costing taxpayers more. And new data, revealing that more federal workers left on their own than were laid off last year, shows that a lot of institutional memory was also lost.

Also this week, Rovner interviews KFF Health News’ Elisabeth Rosenthal, who created the “Bill of the Month” series and wrote the latest installment, about a scorpion pepper, an ER visit, and a ghost bill. If you have a baffling, infuriating, or exorbitant bill you’d like to share with us, you can do that here.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The New York Times’ “E.P.A. to Stop Considering Lives Saved When Setting Rules on Air Pollution,” by Maxine Joselow.

Alice Miranda Ollstein: ProPublica’s “After Sowing Distrust in Fluoridated Water, Kennedy and Skeptics Turn to Obstructing Other Fluoride Sources,” by Anna Clark.

Joanne Kenen: The New Yorker’s “What ‘The Pitt’ Taught Me About Being a Doctor,” by Dhruv Khullar.

Anna Edney: MedPage Today’s “Worried About Liability After CDC Vaccine Changes? You Shouldn’t Be,” by Joedy McCreary.

Also mentioned in this week’s podcast:

• The Washington Post’s “A Majority in Name Only? House Republicans Are Barely Hanging On,” by Paul Kane.
• HealthAffairs’ “National Health Care Spending Increased 7.2 percent in 2024 as Utilization Remained Elevated,” by Mica Hartman, Anne B. Martin, David Lassman, and Aaron Catlin.
• Politico’s “Lawsuit Dismissed After Trump Admin Quietly Restored Tens of Millions to Planned Parenthood,” by Alice Miranda Ollstein.
• JAMA’s “The US Food and Drug Administration’s Regulation of Mifepristone,” by Sophie Dilek, Joanne Rosen, Anna Levashkevich, Joshua M. Sharfstein, and G. Caleb Alexander.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello from KFF Health News and WAMU public radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 15, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go. 

Today, we are joined via video conference by Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Rovner: Alice [Miranda] Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi, everybody. 

Rovner: Later in this episode, we’ll have my interview with KFF Health News’ Elisabeth Rosenthal, who reported and wrote the latest “Bill of the Month,” about an ER trip, a scorpion pepper, and a ghost bill. But first, this week’s news. Let’s start this week on Capitol Hill, where both houses of Congress are here and legislating. This week alone, the Senate rejected a Democratic effort to accept the House-passed bill that would renew for three years the Affordable Care Act’s expanded subsidies — the ones that expired Jan. 1.  

The Senate also turned back an effort to cancel the Trump administration’s regulation covering the ACA, which, although it has gotten far less attention than the subsidies, would also result in a lot of people losing or dropping health insurance coverage.  

Meanwhile, in the House, Republicans are struggling just to keep the lights on. Between resignations, illnesses, and deaths, House Republicans are very nearly — in the words of longtime Congress watcher Paul Kane of The Washington Post — a [majority] in name only, which I guess is pronounced “MINO.” Their majority is now so thin that one or two votes can hand Democrats a win, as we saw earlier this week in a surprise defeat on an otherwise fairly routine labor bill. Which brings us to the prospects for renewing those Affordable Care Act subsidies. When the dust cleared from last week’s House vote, 17 Republicans joined all the House’s Democrats to pass the bill and send it to the Senate. But it seems that the bipartisan efforts in the Senate to get a deal are losing steam. What’s the latest you guys are hearing? 

Ollstein: Yeah, so it wasn’t a good sign when the person who has sort of come out as a leader of these bipartisan negotiations, Ohio Sen. Bernie Moreno, at first came out very strong and said, We’re in the end zone. We’re very close to a deal. We’re going to have bill text. And that was several days ago, and now they’re saying that maybe they’ll have something by the end of the month. But the initial enthusiasm very quickly fizzled as they really got into the negotiations, and, from what my colleagues have reported, there’s still disagreements on several fronts, you know, including this idea of having a minimum charge for all plans, no zero-premium plans anymore, which the right says is to crack down on fraud, and the left says would really deter low-income people from getting coverage. And there, of course, is, as always, a fight about abortion, as we spoke about on this podcast before. There is not agreement on how Obamacare currently treats abortion, and thus there can be no agreement on how it should treat abortion. 

And so the two sides have not come to any kind of compromise. And I don’t know what compromise would be possible, because all of the anti-abortion activist groups and their allies in Congress, of which there are many, say that the only thing they’ll accept is a blanket national ban on any plan that covers abortion receiving a subsidy, and that’s a nonstarter for most, if not all, Democrats. So I don’t know where we go from here. 

Rovner: Well, we will talk more about both abortion and the ACA in a minute, but first, lawmakers have just over two weeks to finish the remaining spending bills, or else risk yet another government shutdown. They seem to [be] making some headway on many of those spending bills, but not so much on the bill that funds most of the Department of Health and Human Services. Any chance they can come up with a bill that can get 60 votes in the Senate and a majority in the much more conservative House? That is a pretty narrow needle to thread. I don’t think abortion is going to be a huge issue in Labor, HHS, because that’s where the Hyde Amendment lives, and we usually see the Hyde Amendment renewed. But, you know, I see a lot of Democrats and, frankly, Republicans in the Senate wanting to put money back for a lot of the things that HHS has cut, and the House [is] probably not so excited about putting all of that money back. I’m just wondering if there really is a deal to be had, or if we’re going to see for the, you know, however many year[s] in a row, another continuing resolution, at least for the Department of Health and Human Services. 

Ollstein: Well, you’re hearing a lot more optimism from lawmakers about the spending bill than you are about a[n] Obamacare subsidy deal or any of the other things that they’re fighting about. And I would say, on the spending, I think the much bigger fights are going to be outside the health care space. I think they’re going to be about immigration, with everything we’re seeing about foreign policy, whether and how to put restraints on the Trump administration, on both of those fronts. On health, yes, I think you’ve seen efforts to restore funding for programs that was slashed by the Trump administration, and you are seeing some Republican support for that. I mean, it impacts their districts and their voters too. So that makes sense. 

Kenen: We’ve also seen the Congress vote for spending that the administration hasn’t been spent. So Congress has just voted on a series of things about science funding and other health-related issues, including global health. But it remains to be seen whether this administration takes appropriations as law or suggestion. 

Rovner: So while the effort to revive the additional ACA subsidies appears to be losing steam, there does seem to be some new hope for a bipartisan health package that almost became law at the end of 2024, so 13 months ago. Back then, Elon Musk got it stripped from the year-end spending bill because the bill, or so Musk said, had gotten too big. That health package includes things like reforms for pharmacy benefits managers and hospital outpatient payments, and continued funding for community health centers. Could that finally become law? That thing that they said, Oh, we’ll pass it first thing next year, meaning 2025. 

Edney: I think it’s certainly looking more likely than the subsidies that we’ve been talking about. But I do think we’ve been here before several times, not just at the end of last year — but, like with these PBM reforms, I feel like they have certainly gotten to a point where it’s like, This is happening. It’s gonna happen. And, I mean, it’s been years, though, that we’ve been talking about pharmacy benefit manager reforms in the space of drug pricing. So basically, you know, from when [President Donald] Trump won. And so, you know, I say this with, like, a huge amount of caution: Maybe. 

Rovner: Yeah, we will, but we’ll believe it when … we get to the signing ceremony. 

Ollstein: Exactly. 

Rovner: Well, back to the Affordable Care Act, for which enrollment in most states end today. We’re getting an early idea of how many people actually are dropping coverage because of the expiration of those subsidies. Sign-ups on the federal marketplace are down about 1.5 million from the end of last year’s enrollment period, and that’s before most people have to pay their first bill. States that run their own marketplaces are also reporting that people are dropping coverage, or else trying to shift to cheaper plans. I’m wondering if these early numbers — which are actually stronger than many predicted, with fewer people actually dropping coverage — reflect people who signed up hoping that Congress might actually renew the subsidies this month. Since we kept saying that was possible. 

Ollstein: I would bet that most people are not following the minutiae of what’s happening on Capitol Hill and have no idea the mess we’re in, and why, and who’s responsible. I would love to be wrong about that. I would love for everyone to be super informed. Hopefully they listen to this podcast. But you know, I think that a lot of people just sign up year after year and aren’t sure of what’s going on until they’re hit with the giant bill.  

Rovner: Yeah. 

Ollstein: One thing I will point out about the emerging numbers is it does show, at least early indications, that the steps a lot of states are taking to make up for the shortfalls and put their own funding into helping people and subsidizing plans, that’s really working. You’re seeing enrollment up in some of those states, and so I wonder if that’ll encourage any others to get on board as well. 

Kenen: But … I think what Julie said is it’s … the follow-up is less than expected. But for the reasons Julie just said is that you haven’t gotten your bill yet. So either you haven’t been paying attention, or you’re an optimist and think there’ll be a solution. So, and people might even pay their first bill thinking that there’ll be a solution next month, or that we’re close. I mean, I would think there’d be drop-off soon, but there might be a steeper cliff a month or two from now, when people realize this is it for the year, and not just a tough, expensive month or two. So just because they’re not as bad as some people forecast doesn’t say that this is going to be a robust coverage year. 

Edney: And I think, I mean, they are the whole picture when you’re talking about who’s signing up, but a lot of these people that I’ve read about or heard about are on the radio programs and different things are signing up, are drastically changing their lives to be able to afford what they think might be their insurance. So how does that play out in other aspects? I think will be .. of the economy of jobs, like, where does that lead us? I think will be something to watch out for too. 

Rovner: And by the way, in case you’re wondering why health insurance is so expensive, we got the 2024 national health spending numbers this week, and total health expenditures grew by 7.2% from the previous year to $5.3 trillion, or 18% of the nation’s GDP [gross domestic product], up from 17.7% the year before. Remember, these are the numbers for 2024, not 2025, but it makes it pretty hard for Republicans to blame the Affordable Care Act itself for rising insurance premiums. Insurance is more expensive because we’re spending more on health care. It’s not really that complicated, right? 

Kenen: This 17%-18% of GDP has been pretty consistent, which doesn’t mean it’s good; it just means it’s been around that level for many, many, many years. Despite all the talk about how it’s unsustainable, it’s been sustained, with pain, but sustained. $5.7 trillion, even if you’ve been doing this a long time … 

Rovner: It’s $5.3 trillion. 

Kenen: $5.3 trillion. It’s a mind-boggling number. It’s a lot of dollars! So the ACA made insurance more — the out-of-pocket cost of insurance for millions of Americans, 20-ish million — but the underlying burden we’ve not solved the — to use the word of the moment, the “affordability” crisis in health care is still with us and arguably getting worse. But like, I think we’re sort of numb. These numbers are just so insane, and yet you say it’s unsustainable, but … I think it was Uwe’s line, right? 

Rovner: It was, it was a famous Uwe Reinhardt line. 

Kenen: No, it’s sustainable, if we’re sustaining it at a high — in economically — zany price.  

Rovner: Right. 

Kenen: And, like, the other thing is, like, where is the money? Right? Everybody in health care says they don’t have any money, so I can’t figure out who has the $5 trillion. 

Rovner: Yeah, well, it’s not … it does not seem to be the insurance companies as much as it is, you know, if you look at these numbers — and I’ll post a link to them — you know, it’s hospitals and drug companies and doctors and all of those who are part of the health care industrial complex, as I like to call it. 

Kenen: All of them say they don’t have enough.  

Rovner: Right. All right. So we know that the Affordable Care Act subsidies are hung up over abortion, as Alice pointed out, and we know that the big abortion demonstration, the March for Life, is coming up next week, so I guess it shouldn’t be surprising that Senate health committee chairman and ardent anti-abortion senator Bill Cassidy would hold a hearing not on changes to the vaccine schedule, which he has loudly and publicly complained about, but instead about the reputed dangers of the abortion pill, mifepristone. Alice, like me, you watched yesterday’s hearing. What was your takeaway? 

Ollstein: So, you know, in a sense, this was a show hearing. There wasn’t a bill under consideration. They didn’t have anyone from the administration to grill. And so this is just sort of your typical each side tries to make their point hearing. And the bigger picture here is that conservatives, including senators and the activist groups who are sort of goading them on from the outside — they’re really frustrated right now about the Trump administration and the lack of action they’ve seen in this first year of this administration on their top priority, which is restricting the abortion pill. Their bigger goal is outlawing all abortion, but since abortion pills comprise the majority of abortions these days, that’s what they’re targeting. And so they’re frustrated that, you know, both [Robert F.] Kennedy [Jr.] and [Marty] Makary have promised some sort of review or action on the abortion pill, and they say, We want to see it. Why haven’t you done it yet? And so I think that pressure is only going to mount, and this hearing was part of that. 

Rovner: I was fascinated by the Louisiana attorney general saying, basically, the quiet part out loud, which is that we banned abortion, but because of these abortion pills, abortions are still going up in our state. That was the first time I think I’d heard an official say that. I mean that, if you wonder why they’re going after the abortion pill, that’s why — because they struck down Roe [v. Wade] and assumed that the number of abortions would go down, and it really has not, has it? 

Ollstein: That’s right. And so not only are people increasingly using pills to terminate pregnancies, but they’re increasingly getting them via telemedicine. And you know, that’s absolutely true in states with bans, but it’s also true in states where abortion is legal. You know, a lot of people just really prefer the telemedicine option, whether because it’s cheaper, or they live really far away from a doctor who is willing to prescribe this, or, you know, any other reasons. So the right — you know, again, including senators like Cassidy, but also these activist groups — they’re saying, at a bare minimum, we want the Trump administration to ban telemedicine for the pills and reinstate the in-person dispensing requirement. That would really roll back access across the country. But what they really want is for the pills to be taken off the market altogether. And they’re pretty open about saying that.  

Rovner: Well, rather convenient timing from the Journal of the American Medical Association this week, which published a peer-reviewed study of 5,000 pages of documents from the FDA that found that over the last dozen years, when it comes to the abortion pill and its availability, the agency followed the evidence-based recommendations of its scientists every single time, except once, and that once was during the first Trump administration. Alice, is there anything that will convince people that the scientific evidence shows that mifepristone is both safe and effective and actually has a very low rate of serious complications? There were, how many, like 100, more than 100 peer-reviewed studies that basically show this, plus the experience of many millions of women in the United States and around the world. 

Ollstein: Well, just like I’m skeptical that there’s any compromise that can be found on the Obamacare subsidies, there’s just no compromise here. You know, you have the groups that are making these arguments about the pills’ safety say very openly that, you know, the reason they oppose the pills is because they cause abortions. They say it can’t be health care if it’s designed to end a life, and that kind of rhetoric. And so the focus on the rate of complication … I mean, I’m not saying they’re not genuinely concerned. They may be, but, you know, this is one of many tactics they’re using to try to curb access to the pills. So it’s just one argument in their arsenal. It’s not their, like, primary driving, overriding goal is, is the safety which, like you said, has been well established with many, many peer-reviewed studies over the last several years. 

Rovner: So, in between these big, high-profile anti-abortion actions like Senate hearings, those supporting abortion rights are actually still prevailing in court, at least in the lower courts. This week, [a lawsuit filed by the American Civil Liberties Union and the National Family Planning and Reproductive Health Association against the Trump administration was quietly dropped after the administration also quietly gave Planned Parenthood and other family planning groups] back the Title X family planning money that was appropriated to it by Congress. That was what Joanne was referring to, that Congress has been appropriating money that the administration hasn’t been spending. But this wasn’t really the big pot of federal money that Planned Parenthood is fighting to win back, right?

Ollstein: It was one pot of money they’re fighting to win back. But yes, the much bigger Medicaid cuts that Congress passed over last summer, those are still in place. And so that’s an order of magnitude more than this pot of Title X family planning money that they just got back. So that aside, I’ve seen a lot of conservatives conflate the two and accuse the Trump administration of violating the law that Congress passed and restoring funding to Planned Parenthood. This is different funding, and it’s a lot less than the cuts that happened. And so I talked to the organizations impacted, and it was clear that even though they’re getting this money back, for some it came too late, like they already closed their doors and shut down clinics in a lot of states, and they can’t reopen them with this chunk of money. This money is when you give a service to a patient, you can then submit for reimbursement. And so if the clinic’s not there, it’s not like they can use this money to, like, reopen the clinic, sign a lease, hire people, etc.  

Rovner: Yeah. The wheels of the courts, as we have seen, have moved very slowly. 

OK, we’re going to take a quick break. We will be right back. 

So while abortion gets most of the headlines, it’s not the only culture war issue in play. The Supreme Court this week heard oral arguments in a case challenging two of the 27 state laws barring transgender athletes from competing on women’s sports teams. Reporters covering the argument said it seemed unlikely that a majority of justices would strike down the laws, which would allow all of those bans to stand. Meanwhile, the other two branches of the federal government have also weighed in on the gender issue in recent weeks. The House passed a bill in December, sponsored by now former Republican congresswoman Marjorie Taylor Greene that would make it a felony for anyone to provide gender-affirming care to minors nationwide. And the Department of Health and Human Services issued proposed regulations just before Christmas that wouldn’t go quite that far, but would have roughly the same effect. The regulations would ban hospitals from providing gender-affirming care to minors or risk losing their Medicare and Medicaid funding, and would bar funding for gender-affirming care for minors by Medicaid or the Children’s Health Insurance Program. At the same time, Health and Human Services Secretary Kennedy issued a declaration, which is already being challenged in court, stating that gender-affirming care, quote, “does not meet professionally recognized standards of health care,” and therefore practitioners who deliver it can be excluded from federal health programs. I get that sports team exclusions have a lot of public support, but does the public really support effectively ending all gender-affirming care for minors? That’s what this would do. 

Edney: Well, I think that when a lot of people hear that, they think of surgery, which is the much, much, much, much, much less likely scenario here that we’re even talking about. And so those who are against it have done an effective job of making that the issue. And so there … who support gender-affirming care, who have looked into it, would see that a lot of this is hormone treatment, things like that, to drugs …  

Rovner: Puberty blockers! 

Edney: … they’re taking — exactly — and so it’s not, this isn’t like a permanent under-the-knife type of thing that a lot of people are thinking about, and I think, too, talking about, like mental health, with being able to get some of these puberty blockers, the effect that it can have on a minor who doesn’t want to live the way they’ve been living, so it’s so helpful to them. So I think that there’s just a lot that has, you know, there’s been a lot of misinformation out there about this, and I feel like that that’s kind of winning the day. 

Kenen: I think, like, from the beginning, because, like, five or six years ago was the first time I wrote about this. The playbook has been very much like the anti-abortion playbook. They talk about it in terms of protecting women’s health, and now they’re talking about it in protecting children’s health. And, as Anna said, they’re using words like mutilation. Puberty blockers are not mutilation. Puberty blockers are a medication that delays the onset of puberty, and it is not irreversible. It’s like a brake. You take your foot off the brake, and puberty starts. There’s some controversy about what age and how long, and there’s some possible bone damage. I mean, there’s some questions that are raised that need to be answered, but the conversation that’s going on now — most of the experts in this field, who are endocrinologists and psychologists and other people who are working with these kids, cite a lot of data saying that not only this is safe, but it’s beneficial for a kid who really feels like they’re trapped in the wrong body. So you know, I think it’s really important to repeat … the point that Anna made, you know, 12-year-olds are not getting major surgery. Very few minors are, and when they are, it’s closer … they may be under 18, it’s rare. But if you’re under 18, you’re closer to 18, it’s later in teens. And it’s not like you walk into an operating room and say, you know, do this to me. There’s years of counseling and evaluation and professional teams. It really did strike a nerve in the campaign. I think Pennsylvania, in particular. This is something that people don’t understand and get very upset about, and the inflammatory language, it’s not creating understanding. 

Rovner: We’ll see how this one plays out. Finally, this week, things at the Department of Health and Human Services continues to be chaotic. In the latest round of “we’re cutting you off because you don’t agree with us,” the Substance Abuse and Mental Health Services Administration sent hundreds of letters Tuesday to grantees canceling their funding immediately. It’s not entirely clear how many grants or how much money was involved, but it appeared to be something in the neighborhood of $2 billion — that’s around a fifth of SAMHSA’s entire budget. SAMHSA, of course, funds programs that provide addiction and mental health treatment, treatment for homelessness and suicide prevention, among other things. Then, Wednesday night, after a furious backlash from Capitol Hill and just about every mental health and substance abuse group in the country, from what I could tell from my email, the administration canceled the cuts. Did they miscalculate the scope of the reaction here, or was chaos the actual goal in this?  

Edney: That is a great question. I really don’t know the answer. I don’t know what it could serve anyone by doing this and reversing it in 24 hours, as far as the chaos angle, but it does seem, certainly, like there was a miscalculation of how Congress would react to this, and it was a bipartisan reaction that wanted to know why, what is it even your justification? Because these programs do seem to support the priorities of this administration and HHS. 

Rovner: I didn’t count, but I got dozens of emails yesterday.  

Edney: Yeah. 

Rovner: My entire email box was overflowing with people basically freaking out about these cuts to SAMHSA. Joanne, you wanted to say something? 

Kenen: I think that one of the shifts over — I’m not exactly sure how many years — 7, 8, 9, years, whatever we’ve been dealing with this opioid crisis, the country has really changed and how we see addiction, and that we are much more likely to view addiction not as a criminal justice issue, but as a mental health issue. It’s not that everybody thinks that. It’s not that every lawmaker thinks that, but we have really turned this into, we have seen it as, you know, a health problem and a health problem that strikes red states and blue states. You know, we are all familiar with the “deaths of despair.” Many of us know at least an acquaintance or an acquaintance’s family that have experienced an overdose death. This is a bipartisan shift. It is, you know, you’ve had plenty of conservatives speaking out for both more money and more compassion. So I think that the backlash yesterday, I mean, we saw the public backlash, but I think there was probably a behind-the-scenes — some of the “Opioid Belts” are very conservative states, and Republican governors, you know, really saying we’ve had progress. Right? The last couple of years, we have made progress. Fatal overdoses have gone down, and Narcan is available. And just like our inboxes, I think their telephones, they were bombarded.  

Rovner: Yeah. Well, meanwhile, several hundred workers have reportedly been reinstated at the National Institute of Occupational Safety and Health — that’s a subagency of CDC [the Centers for Disease Control and Prevention]. Except that those RIF [reduction in force] cancellations came nine months after the original RIFs, which were back in April. Does the administration think these folks are just sitting around waiting to be called back to work? And in news from the National Institutes of Health, Director Jay Bhattacharya told a podcaster last week that the DEI-related [diversity, equity, and inclusion] grants that were canceled and then reinstated due to court orders are likely to simply not be renewed. And at the FDA, former longtime drug regulator Richard Pazdur said at the J.P. Morgan [Healthcare] Conference in San Francisco this week that the firewall between the political appointees at the agency and its career drug reviewers has been, quote, “breached.” How is the rest of HHS expected to actually, you know, function with even so much uncertainty about who works there and who’s calling the shots? 

Ollstein: Not to mention all of this back and forth and chaos and starting and stopping is costing more, is costing taxpayers more. Overall spending is up. After all of the DOGE [Department of Government Efficiency] and RIFs and all of it, they have not cut spending at all because it’s more expensive to pay people to be on administrative leave for a long time and then try to bring them back and then shut down a lab and then reopen a lab. And all of this has not only meant, you know, programs not serving people, research not happening, but it hasn’t even saved the government any money, either. 

Kenen: Like, you know, the game we played when we were kids, remember, “Red Light-Green Light,” you know, you’d run in one direction, you run back. And if you were 8 years old, it would end with someone crying. And that’s sort of the way we’re running the government these days [laughs]. The amount of people fired, put on leave. The CDC has had this incredible yo-yoing of people. You can’t even keep track. You don’t even know what email to use if you’re trying to keep in touch with them anymore. The churn, with what logic? It’s, as Alice said, just more expensive, but it’s, it’s also just … like you can’t get your job done. Even if you want a smaller government, which many of conservatives and Trump people do, you still want certain functions fulfilled. But there’s still a consensus in society that we need some kind of functioning health system and health oversight and health monitoring. I mean, the American public is not against research, and the American public is not against keeping people alive. You know, the inconsistency is pretty mind-boggling. 

Edney: Well, there’s a lot of rank-and-file, but we’re seeing a lot of heads of parts of the agencies where, like at the FDA, with the drug center, or many of the different institutes at NIH that really don’t have anyone in place that is leading them. And I think that that, to me, like this is just my humble opinion, is it kind of seems like the message as anybody can do this part, because it’s all coming from one place. There’s really just one leader, essentially, RFK, or maybe it’s Trump, or they want everyone to do it the way that they’re going to comply with the different, like you said, everyone wants research, but I, Joanne, but I do think they only want certain kinds of research in this case. So it’s been interesting to watch how many leaders in these agencies that are going away and not being replaced. 

Rovner: And all the institutional memory that’s walking out the door. I mean, more people — and to Alice’s point about how this hasn’t saved money — more people have taken early retirement than have been actually, you know, RIF’d or fired or let go. I mean, they’ve just … a lot of people have basically, including a lot of leaders of many of these agencies, said, We just don’t want to be here under these circumstances. Bye. Assuming at some point this government does want to use the Department of Health and Human Services to get things done, there might not be the personnel around to actually effectuate it. But we will continue to watch that space. 

OK, that’s this week’s news. Now we will play my “Bill of the Month” interview with Elisabeth Rosenthal, and then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast Elisabeth Rosenthal, senior contributing editor at KFF Health News and originator of our “Bill of the Month” series, which in its nearly eight years has analyzed nearly $7 million in dubious, infuriating, or inflated medical charges. Libby also wrote the latest “Bill of the Month,” which we’ll talk about in a minute. Libby, welcome back to the podcast. 

Elisabeth Rosenthal: Thanks for having me back. 

Rovner: So before we get to this month’s patient, can you reflect for a moment on the impact this series has had, and how frustrated are you that eight years on, it’s as relevant as it was when we began? 

Rosenthal: We were worried it wouldn’t last a year, and here we are, eight years later, still finding plenty to write about. I mean, we’ve had some wins. I think we helped contribute to the No Surprises Act being passed. There are states clamping down on facility fees, you know, and making sure that when you get something done in a hospital rather than an outpatient clinic, it’s the same cost. The country’s starting to address drug prices. But, you know, we seem to be the billing police, and that’s not good. We’ve gotten a lot of bills written off for our individual patients. Suddenly, when a reporter calls, they’re like, Oh, that was a mistake or Yeah, we’re going to write that off. And I’m like, You’re not writing that off; that shouldn’t have been billed. So sadly, the series is still going strong, and medical billing has proved endlessly creative. And you know, I think the sad thing for me is our success is a sign of a deeply, deeply dysfunctional system that has left, as we know, you know, 100 million adult Americans with medical debt. So we will keep going until it’s solved, I hope. 

Rovner: Well, getting on to this month’s patient, he gives new meaning to the phrase “It must have been something I ate.” Tell us what it was and how he ended up in the emergency room. 

Rosenthal: Well, Maxwell [Kruzic] loves eating spicy foods, but he’s never had a problem with it. And suddenly, one night, he had just excruciating, crippling abdominal pain. He drove himself to the emergency room. It was so bad he had to stop three times, and when he got there, it was mostly on the right-lower quadrant. You know, the doctors were so convinced, as he was, that he had appendicitis, that they called a surgeon right away, right? So they were all like, ready to go to the operating room. And then the scan came back, and it was like, whoops, his appendix is normal. And then, oh, could he have kidney stones? And it’s like no sign of that either. And finally, he thought, or someone asked, Well, what did you eat last night? And of course, Maxwell had ordered the hottest chili peppers from a bespoke chili pepper-growing company in New Mexico. They have some chili pepper rating of 2 million [Scoville heat units], which is, like, through the roof, and it was a reaction to the chili peppers. I didn’t even know that could happen, and I trained as a doctor, but I guess your intestines don’t like really, really, really hot stuff. 

Rovner: So in the end, he was OK. And the story here isn’t even really about what kind of care he got, or how much it cost. The $8,000 the hospital charged for his few hours in the ER doesn’t seem all that out of line compared to some of the bills we’ve seen. What was most notable in this case was the fact that the bill didn’t actually come until two years later. How much was he asked to pay two years after the hot pepper incident? 

Rosenthal: Well, he was asked to pay a little over $2,000, which was his coinsurance for the emergency room visit. And as he said, you know, $8,000 … now we go, well, that’s not bad. I mean, all they did, actually, was do a couple of scans and give him some IV fluids. But in this day and age, you’re like, wow, he got away — you know, from a “Bill of a Month” perspective, he got away cheap, right? 

Rovner: But I would say, is it even legal to send a bill two years after the fact? Who sends a bill two years later? 

Rosenthal: That’s the problem, like, and Maxwell — he’s a pretty smart guy, so he was checking his portal repeatedly. I mean, he paid something upfront at the ER, and he kept thinking, I must owe something. And he checked and he checked and he checked and it kept saying zero. He actually called his insurer and to make sure that was right. And they said, No, no, no, it’s right. You owe zero. And then, you know, after like, six months, he thought, I guess I owe zero. But then he didn’t think about it, and then almost two years later, this bill arrives in the mail, and he’s like, What?! And what I discovered, which is a little disturbing, is it is not, I wouldn’t say normal, but we see a bunch of these ghost bills at “Bill of the Month,” and in many cases, it’s legal, because of what was going on in those two-year periods. And of course, I called the hospital, I called the insurer, and they were like, Yeah, you know, someone was away on vacation, and someone left their job, and we couldn’t … you know, the hospital billed them correctly. And the hospital said, No, we didn’t. And they were just kind of doing the usual back-end negotiations to figure out what a service is worth. And when they finally agreed two years later what should be paid, that’s when they sent Maxwell the bill. And the problem is, whether it’s legal really depends on your insurance contracts, and whether they allow this kind of late billing. I do not know to this day if Maxwell’s did, because as soon as I called the insurer and the hospital, they were like, Never mind. He doesn’t owe anything. And you know, as he said, he’s a geological engineer. He has lots of clients, and as he said, you know, if I called them two years later and said, Whoops, I forgot to bill for something, they would be like, Forget it! you know. So I do think this is something that needs to be addressed at a policy level, as we so often discover on “Bill of the Month.” 

Rovner: So what should you do if you get one of these ghost bills? I should say I’m still negotiating bills from a surgery that I had six months ago. So I guess I should count myself lucky. 

Rosenthal: Well, I think you should check with your insurer and check with the hospital. I think more with your insurer — if the contract says this is legal to bill. It’s unclear to me, in this case, whether it was. The hospital was very much like, Oh, we made a mistake; because it took so long, we actually couldn’t bill Maxwell. So I think in his case, it probably was in the contract that this was too late to bill. But, you know, I think a lot of hospitals, I hate to say it, have this attitude. Well, doesn’t hurt to try, you know, maybe they’ll pay it. And people are afraid of bills, right? They pay them.  

Rovner: I know the feeling. 

Rosenthal: Yeah, I do think, you know, they should check with their insurer about whether there’s a statute of limitations, essentially, on billing, because there may well be and I would say it’s a great asymmetry, because if you submit an insurance claim more than six months late, they can say, Well, we won’t pay this. 

Rovner: And just to tie this one up with a bow, I assume that Maxwell has changed his pepper-eating ways, at least modified them? 

Rosenthal: He said he will never eat scorpion peppers again. 

Rovner: Libby Rosenthal, thank you so much. 

Rosenthal: Oh, sure. Thanks for having me. 

Rovner: OK, we’re back, and now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us off this week? 

Edney: Sure. So my extra credit is from MedPage Today: “Worried About Liability After CDC Vaccine Changes? You Shouldn’t Be.” I appreciated this article because it answered some questions that I had, too, after the sweeping change to the childhood vaccine schedule. There was just a lot of discussions I had about, you know, well, what does this really mean on the ground? And will parents be confused? Will pediatricians — how will they be talking about this? You know, will they stick to the schedule we knew before? And there was an article in JAMA Perspectives that lays out, essentially, to clinicians, you know, that they should not fear malpractice .. issues if they’re going to talk about the old schedule and not adhere to the newer schedule. And so it lays out some of those issues. And I thought that was really helpful. 

Rovner: Yeah, this was a big question that I had, too. Alice, why don’t you go next? 

Ollstein: Yeah, so I have a piece from ProPublica. It’s called “After Sowing Distrust in Fluoridated Water, Kennedy and Skeptics Turn to Obstructing Other Fluoride Sources.” So this is about how there’s been this huge push on the right to end public water fluoridation that has succeeded in a couple places and could spread more. And the proponents of doing that say that it’s fine because there are all these other sources of fluoride. You can get a treatment at the dentist, you can get it in stuff you buy at the drugstore and take yourself. But at the same time, the people who arepushing for ending fluoridated public drinking water are also pushing for restricting those other sources. There have been state and federal efforts to crack down on them, plus all of the just rhetoric about fluoride, which is very misleading. It misrepresents studies about its alleged neurological impacts. But it also, that kind of rhetoric makes people afraid to have fluoride in any form, and people are very worried about that, what that’s going to do to the nation’s teeth? 

Rovner: Yeah, it’s like vaccines. The more you talk it down, the less people want to do it. Joanne. 

Kenen: This is a piece by Dhruv Khullar in The New Yorker called “What ‘The Pitt’ Taught Me About Being a Doctor,” and it was really great, because there’s certain things I think that we who — like, I don’t know how all of you watch it — but like, there’s certain things that didn’t even strike me, because I’m so used to writing about, like, the connection between poverty, social determinants of health, and, like, of course, people who come to the ED [emergency department] have, you know, homelessness problems and can’t afford food and all that. But Dhruv talked about how it sort of brought that home to him, how our social safety net, the holes in it, end up in our EDs. And he also talked about some of it is dramatized more for TV, that not everybody’s heart stops every 15 minutes. He said that sort of happens to one patient a day. But he talked about compassion and how that is rediscovered in this frenetic ED/ER scene. It’s just a very thoughtful piece about why we all love that TV show. And it’s not just because of Noah Wyle. 

Rovner: Although that helps. My extra credit this week is from The New York Times. It’s called “E.P.A. to Stop Considering Lives Saved When Setting Rules on Air Pollution,” by Maxine Joselow. And while it’s not about HHS, it most definitely is about health. It seems that for the first time in literally decades, the Environmental Protection Agency will no longer calculate the cost to human health when setting clean air rules for ozone and fine particulate matter, quoting the story: “That would most likely lower costs for companies while resulting in dirtier air.” This is just another reminder that the federal government is charged with ensuring the help of Americans from a broad array of agencies, aside from HHS — or in this case, not so much.  

OK, that’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. We also had help this week from producer Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, at kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can find me still on X @jrovner, or on Bluesky @julierovner. Where are you folks hanging these days? Alice. 

Ollstein: Mostly on Bluesky @alicemiranda and still on X @AliceOllstein. 

Rovner: Joanne. 

Kenen: I’m mostly on Bluesky or on LinkedIn @JoanneKenen. 

Rovner: Anna. 

Edney: Bluesky or X @annaedney. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

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Treatment for a Florida Medicaid enrollee’s heart attack cost nearly $78,000 — about as much as surgery for an uninsured Montana woman’s broken arm.

In 2025, these patients were among the hundreds who asked KFF Health News to investigate their medical bills as part of its “Bill of the Month” series.

Insured and uninsured. Job-based and government-funded. Comprehensive and short-term. Part of a sharing ministry. So many people with different health insurance situations asked the same questions: Why do I owe so much? And how am I going to afford it?

As millions of Americans grapple with the rising cost of health insurance next year, the “Bill of the Month” series is approaching its eighth anniversary. Our nationwide team of health reporters has analyzed almost $7 million in medical charges, more than $350,000 of that this year.

Of this year’s 12 featured patients, five had their bills mostly or fully forgiven soon after we contacted the provider and insurer for comment.

Our mission, though, is to empower every patient with the information needed to understand, manage, and — if push comes to shove — fight their own medical bills. Here are our 10 takeaways from 2025.

1. Most insurance coverage doesn’t start immediately. Many new plans come with waiting periods, so it’s important to maintain continuous coverage until the new plan kicks in. One exception: If you lose your job-based coverage, you have 60 days to opt into a COBRA policy. Once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.

2. Check out your coverage before you check in. Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and cancer screenings. Call your insurer — or, for job-based insurance, your human resources department or retiree benefits office — and ask whether there are exclusions for the care you need, including per-day or per-policy-period caps, and what you can expect to owe out-of-pocket.

3. “Covered” does not mean insurance will pay, let alone at in-network rates. Carefully read the fine print on network gap exceptions, prior authorizations, and other insurance approvals. The terms may be limited to certain doctors, services, and dates.

4. Get a cost estimate in writing for nonemergency procedures. If you object to the price, negotiate before undergoing care. And if you’re uninsured and receive a bill that’s $400 or more than the estimate, the federal Centers for Medicare & Medicaid Services has a formal dispute process.

5. Location matters. Prices can vary depending on where a patient receives care and where tests are performed. If you need blood work, ask your doctor to send the requisition to an in-network lab. A doctor’s office connected to a health system, for instance, may send samples to a hospital lab, which can mean higher charges.

6. When admitted, contact the billing office early. If possible, when you or a loved one has been hospitalized, it can help to speak to a billing representative. Ask whether the patient has been fully admitted or is being kept under observation status, as well as whether the care has been determined to be “medically necessary.” And while there may be no choice about taking an ambulance, if a transfer to another facility is recommended, you can ask whether the ambulance service is in-network.

7. Ask for a discount. Medical charges are almost always higher than what insurers would pay, because providers expect them to negotiate lower rates. You can, too. If you’re uninsured or underinsured, you may be eligible for a self-pay or charity care discount.

8. There’s help available for Medicaid patients. If you get a bill you don’t think you should owe, file a complaint with your state’s Medicaid program and, if you have one, your managed-care plan. Ask whether there is a caseworker who can advocate on your behalf. A legal aid clinic or consumer protection firm specializing in medical debt can also help file complaints and communicate with providers.

9. Your elected representatives can help, too. While a call from a state or federal lawmaker’s office may not get your bill forgiven, those officials often have an open line of communication with insurance companies, local hospitals, and other major providers — and advocating for you is their job.

10. When all else fails … you can write to “Bill of the Month”!

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Maddie McGarveyParker Michels-BoyceSophie ParkJim VondruskaJeremy Wade ShockleyRachel Woolf

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

Kruzic was seen immediately because hospital staff members were pretty sure he had appendicitis. They inserted an IV, called a surgeon, and sent him off for a scan to confirm the diagnosis.

But the scan showed a perfectly normal appendix and no problems in his abdomen. Doctors racked their brains for other possible diagnoses. Could it be a kidney stone? Gallstones? Here was a 37-year-old man in agony, but nothing really fit.

Then, someone asked what Kruzic had eaten the night before. He said he’d consumed tacos with some hot sauce that he’d made from a kind of scorpion pepper, grown from seeds he ordered from a chile pepper research institute.

The peppers measure over 2 million Scoville heat units on the spiciness scale, he noted, compared with a jalapeño at up to 8,000 or a habanero at 100,000 to 350,000.

The peppers are among “the world’s hottest, incredibly hot,” Kruzic said. “Delicious.” He loves spicy food and had never had a problem with it, but apparently this was just too much burn for his digestive system.

Kruzic spent much of the night on a gurney in the ER. After about four hours, the pain decreased, and he was sent home with medicine to treat nausea and vomiting.

Then the bill came — about two years later.

The Medical Procedure

Kruzic underwent blood work and a CT scan of his abdomen during his ER visit for acute abdominal pain.

Consuming very spicy foods can cause painful inflammation and irritation of the digestive system. The discomfort typically resolves on its own.

The Final Bill

$8,127.41, including $5,820 for the CT scan. Kruzic paid $97.02 during his visit to the hospital, which was in-network under his insurance. After insurance payments and discounts, he owed $2,460.46 — the remainder of the $1,585.26 he owed toward his plan’s deductible and $972.22 he owed in coinsurance.

The Problem: Ghost Bills From Visits Past

This September, Kruzic received a bill for his pepper-induced ER visit in 2023.

Unfortunately for patients, there are no uniform rules for timely billing.

Anticipating a bill, Kruzic repeatedly checked the hospital’s online portal, as well as that of his insurer, UnitedHealthcare. He noted that the insurer said the claim had been processed shortly after his treatment. For about eight months, he kept checking the hospital portal’s billing section, which indicated he owed “$0.” He called UnitedHealthcare, and Kruzic said a representative assured him that if the hospital said he owed nothing, that was the case.

It is unclear what caused the nearly two-year delay. At least part of the problem seems to have involved protracted disagreements between the insurer and the hospital over how much his visit should have cost.

Lindsay Radford Foster, a spokesperson for CommonSpirit Health, the hospital system, said in a statement to KFF Health News: “United Healthcare, the insurer responsible for the medical claim, underpaid the account based on the care provided. As a result, CommonSpirit contacted UnitedHealthcare’s Payer Relations Department to rectify the underpayments.”

Asked why it had taken two years, she cited a reorganization at UnitedHealthcare and a change in the insurer’s representative assigned to the case.

But UnitedHealthcare contested that view. “This was paid accurately,” said Caroline Landree, a spokesperson for the insurer.

But those explanations don’t satisfy Kruzic, a geological consultant: “Receiving a bill two years after the service wouldn’t fly in any other industry. We could never contact a client two years after we completed a project and say, ‘By the way, we missed this charge.’”

“How could this be considered anything but surprise billing?” he added.

The federal No Surprises Act doesn’t protect against all types of medical bills that patients find surprising. It primarily protects patients from out-of-network charges when they visit an in-network hospital, or in an emergency.

But in medical billing, what’s legal and what’s reasonable are two very different issues.

“The bill certainly sounds outrageous,” said Maxwell Mehlmen, co-director of the Law-Medicine Center at the Case Western Reserve University School of Law. “The question is whether it’s legal.”

That, he said, “is a matter of state law and the terms of the insurance policy and the agreement between the hospital and the insurer.”

In Colorado, there are extensive regulations about how long health care providers have to file a claim and bill a patient. For instance, claims for Medicaid patients must be filed within 120 days from the date of service. For patients with private insurance, the terms may be outlined in their insurers’ contracts with individual providers.

If a hospital submitted a proper claim and the provider and insurer were working out payment in good faith, then a patient can be billed for their share of the costs years later.

The Resolution

Within hours of KFF Health News contacting the hospital’s media relations department for this article, Kruzic got a call from a hospital executive telling him his bill had been adjusted to zero.

Blaming administrative changes at the insurer, Radford Foster of CommonSpirit said that UnitedHealthcare had taken so long to properly pay the bill that the hospital couldn’t collect from the patient. She said that Kruzic’s statement balance “was to be adjusted to zero, but due to a clerical error, a statement was sent to the patient in error.”

UnitedHealthcare’s Landree said that “given the significant delay, we are addressing this issue directly with the physician’s office.”

“Mr. Kruzic will not be responsible for any additional costs related to this bill,” she said.

The Takeaway

KFF Health News’ “Bill of the Month” series receives complaints every year about ghost bills — bills that arrive long after a service is rendered.

Sometimes it’s because the insurer and hospital are haggling over payment, and the patient’s responsibility — usually a percentage of that number — can’t be calculated until the dispute is resolved. Other times, insurers audit old bills and, determining they overpaid, try to claw back the money, resulting in the patient (or even the patient’s surviving spouse) being billed for the difference.

For now, the legality of billing long after treatment depends primarily on the fine print of insurance contracts.

An insurer’s word that a claim has been “processed” doesn’t mean that the insurer has agreed to pay and that the billing is resolved. It could also mean that the insurer balked at the bill or completely denied payment.

As for Kruzic and his affinity for hot peppers? He said he still loves spicy food, but in his cooking, “I will not use scorpion peppers again.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).

The enhanced premium tax credits that since 2021 have helped millions of Americans pay for insurance on the Affordable Care Act marketplaces will expire Dec. 31, despite a last-ditch effort by Democrats and some moderate Republicans in the House of Representatives to force a vote to continue them. That vote will happen, but not until Congress returns in January.

Meanwhile, the Department of Health and Human Services canceled a series of grants worth several million dollars to the American Academy of Pediatrics after the group again protested HHS Secretary Robert F. Kennedy Jr.’s changes to federal vaccine policy.

This week’s panelists are Julie Rovner of KFF Health News, Lizzy Lawrence of Stat, Tami Luhby of CNN, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• The House on Wednesday passed legislation containing several GOP health priorities, including policies that expand access to association health plans and lower the federal share of some Affordable Care Act exchange marketplace premiums. It did not include an extension of the expiring enhanced ACA premium tax credits — although, also on Wednesday, four Republicans signed onto a Democratic-led discharge petition forcing Congress to revisit the tax credit issue in January.
• In vaccine news, the American Academy of Pediatrics spoke out against the federal government’s recommendation of “individual decision-making” when it comes to administering the hepatitis B vaccine to newborns — and HHS then terminated multiple research grants to the AAP. Meanwhile, the Centers for Disease Control and Prevention is funding a Danish study of the hepatitis B vaccine in West Africa through which some infants will not receive a birth dose, a strategy that critics are panning as unethical.
• Also, a second round of personnel cuts at the Department of Veterans Affairs is expected to exacerbate an existing staffing shortage and further undermine care for retired service members.
• The FDA is considering rolling back labeling requirements on supplements — a “Make America Health Again”-favored industry that is already lightly regulated.
• And abortion opponents are pushing for the Environmental Protection Agency to add mifepristone to the list of dangerous chemicals the agency tracks in the nation’s water supply.

Also this week, Rovner interviews Tony Leys, who wrote the latest “Bill of the Month” feature, about an uninsured toddler’s expensive ambulance ride between hospitals.

Plus, for a special year-end “extra-credit” segment, the panelists suggest what they consider 2025’s biggest health policy themes: 

Julie Rovner: The future of the workforce in biomedical research and health care. 

Lizzy Lawrence: The politicization of science. 

Tami Luhby: The systemic impacts of cuts to the Medicaid program. 

Alice Miranda Ollstein: The resurgence of infectious diseases. 

Also mentioned in this week’s podcast:

• The Washington Post’s “American Academy of Pediatrics Loses HHS Funding After Criticizing RFK Jr.,” by Lena H. Sun and Paige Winfield Cunningham.
• MedPage Today’s “FDA Vax Chief Jumped the Gun on Claims of Kid Deaths From COVID Shots,” by Jeremy Faust.
• The Washington Post’s “VA Plans To Abruptly Eliminate Tens of Thousands of Health Care Jobs,” by Meryl Kornfield, Hannah Natanson, and Lisa Rein.
• NBC News’ “FDA Says It May Relax Warning Label Rule for Dietary Supplements,” by Berkeley Lovelace Jr.
• Politico’s “New Anti-Abortion Campaign Takes Aim at EPA Drinking Water Rules,” by Alice Miranda Ollstein and Ariel Wittenberg.
• The Washington Post’s “What Happened When Dr. Oz Took Charge of a Wonky Health Agency,” by Paige Winfield Cunningham.
• Politico’s “Dr. Oz Makes His Mark,” by Joanne Kenen.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, from KFF Health News and WAMU Public Radio in Washington, D.C., and welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Dec. 18, at 10 a.m. As always, news happens fast, and things might have changed by the time you hear this. So, here we go. 

Today, we are joined via video conference by Tami Luhby of CNN. 

Tami Luhby: Hello. 

Rovner: Alice Ollstein of Politico. 

Alice Miranda Ollstein: Hi, there. 

Rovner: And I am pleased to welcome to the podcast panel Lizzy Lawrence of Stat News. Lizzy, so glad you’ll be joining us. 

Lizzy Lawrence: Thanks so much for having me. I’m excited. 

Rovner: Later in this episode, we’ll have my interview with Tony Leys, who reported and wrote the latest KFF Health News “Bill of the Month” about yet another very expensive ambulance ride. But first, this week’s news. 

Well, remember when House Speaker Mike Johnson complained during the government shutdown that the issue of the additional ACA [Affordable Care Act] subsidies expiring was a December problem? Well, he sure was right about that. On Wednesday, the House, along party lines, passed a bill that Republicans are calling the “Lower Healthcare Premiums for All [Americans] Act,” which actually doesn’t, but we’ll get to that in a moment. Notably, not part of that bill was any extension of the enhanced tax credits that now are going to expire at the end of this year, thus doubling or, in some cases, tripling what many consumers who get their coverage from the ACA marketplaces will have to pay monthly starting in January. Speaker Johnson said he was going to let Republican moderates offer an amendment to the bill to continue the additional subsidies with some changes, but in the end, he didn’t. 

So, four of those Republicans, from more purple swing districts worried about their constituents seeing their costs spike, yesterday signed on to a Democratic-led discharge petition, thus forcing a vote on the subsidies, although not until Congress returns in January. Before we get to the potential future of the subsidies though, Tami, tell us what’s in that bill that just passed the House. 

Luhby: Well, there are four main measures in it, but none of them, as you say … they will lower potentially some premiums for certain people, but they’re really a bit of a laundry list of Republican favorite provisions. 

So, one of the main ones is association health plans. They would allow more small businesses — and, importantly, the self-employed — to band together across industries. This could lower health insurance premiums for some people, but these plans also don’t have to adhere to all of the ACA protections and benefits that are offered. So, it may attract more healthier people or be more beneficial for healthier people, but not for everyone, for sure. 

There are some PBM, pharmacy benefit manager, reforms. They would have to provide a little more information to employers about drug prices and about the rebates they get, but it may not really have … the experts I spoke to said it’s really just tinkering around at the edges and may not be that consequential. 

Rovner: And it’s not even as robust a PBM bill as Republicans and Democrats had agreed to last year … 

Luhby: Exactly. 

Rovner: … that Elon Musk got struck at the last minute because the bill was too long. 

Luhby: Exactly, it’s a narrower transparency. There are narrower transparency provisions. It would also, importantly, refund the cost-sharing provisions. And remember, there are two types of subsidies in the Affordable Care Act. There are the premium subsidies, which is what everyone is talking about, the enhanced premium subsidies. But these are cost-sharing reductions that lower-income people on the exchanges receive to actually reduce their deductibles and their copayments and coinsurance, their out-of-pocket expenses. 

President [Donald] Trump, during his first term, in an effort to weaken the Affordable Care Act, ended the federal funding for these cost-sharing subsidies, but the law requires that insurers continue to provide them. So what the insurers did was they increased the premiums of the “silver” plans in order to make up some of the difference, but those silver plans, remember, are tied to … the cost of those silver plans are what determines the premium subsidies that people get. So, basically, by refunding or by once again funding these cost-sharing subsidies, insurers will lower the premiums for those silver plans, which will, in turn, lower the premium subsidies that the government has to pay and save the government money. 

The people in silver plans probably won’t be affected as much, but what happened after Trump ended the cost-sharing subsidy funding is that with these increased premium subsidies that are tied to the silver plans, a lot of people were able to buy “gold” plans. They were able to buy better plans for less because they got bigger premium subsidies, or they were able to buy “bronze” plans for really cheap. So basically, this provision will end, will reduce the premium assistance that people get, and it’ll effectively raise premium payments for people in a lot of plans, which will make it more difficult for them. 

Rovner: Which was a wonderful explanation, by the way, of something that’s super complicated. 

Luhby: Thank you. 

Rovner: But I’ve been trying to say it basically moves money around. It takes money that had been … it lowers how much the federal government will have to pay, while at the same time loading that back onto consumers. 

Luhby: Right. 

Rovner: So, hence my original statement that the “Lower Premiums for All” Act doesn’t lower premiums for all. So, this is … 

Luhby: No, there’ll be a lot of people in gold and bronze and “platinum” plans who will be paying a lot more, or they’ll have to, if they’re in gold, they may have to shift to silver, which means they’ll just be paying more out-of-pocket when they actually seek care. 

And then there’s a fourth provision that’s not as consequential: It’s called choice plans. It’s to help employers give … it’s to make it easier for employers to give money to people to buy coverage on the exchanges. 

Rovner: Yeah, which I think nobody disagrees with. But Alice, there’s another even catch to the cost-sharing reductions, which is that it’s only for states that ban abortion or that don’t ban abortion. Now I forget, which is it? 

Ollstein: So, it’s, yeah. So the great compromise of the Affordable Care Act was that it’s up to states whether to allow, require, or prohibit plans on the Obamacare exchanges from covering abortion. And as states do, they went in different directions, so about half ban it and about the other half, it’s 50-50 on requiring abortion coverage and just allowing it, leaving it up to individual plans. And so yes, this provision sought to penalize states that allowed abortion. And so, it’s expanding the definition of the Hyde Amendment from where it was before, basically saying if any federal funding is going to a plan that uses other money to pay for abortion, then that counts as funding abortion, even though the money is coming out of different buckets. 

And so, this has been a big fight on Capitol Hill this year. And as I wrote yesterday, it’s nowhere near being resolved. I mean, even if lawmakers were going to come together on everything else related to the subsidies, which they are not, the abortion debate was still in the way as an impediment, including in the Senate as well. 

Rovner: Yeah. So, what are the prospects for these additional subsidies? And I should go back and reiterate that what Tami and I were talking about were the original tax credits that were passed with the Affordable Care Act, not the enhanced ones, the bigger tax credits that are expiring at the end of the year. So, Republicans have now forced this vote, so we know that the House is going to vote on extending these subsidies — in January, after they’ve expired, which is a whole issue of complication itself. But I mean, is there any prospect for a compromise here? Might they go home and get enough pushback from constituents who are seeing their costs go up so much they’re going to have to drop their insurance that they might change their minds? 

Ollstein: Well, Democrats and advocacy groups are trying to ramp up that pressure. We’ve been covering some ad campaigns and efforts. Democrats are holding town halls in Republican districts where the representatives are not holding town halls to shine a light on this. They’re highlighting the stories of individual, sympathetic-character folks who are having their premiums go way up. 

So, there were press conferences just this week I saw with retirees and people who are on Social Security Disability and small-business owners and single parents, and it’s not hard to find these stories; this is happening to tens of millions of people. And so, I think this is going to be a major, major political message going into next year. Whether it’s enough to make Republicans who are still so ideologically opposed to the Affordable Care Act agree on some kind of an extension, that remains to be seen. And we really haven’t, despite the defection of a small handful this week in joining the Democrats on an extension — which was really notable and a sign that Speaker Johnson is not keeping his caucus in array. But the vote hasn’t happened yet, and we’ll see if spending time back in the districts over the holidays makes people more or less willing to compromise. It can go either way. 

Rovner: I saw a lot of people yesterday saying that, Well, even if the House were to pass the clean three-year extension of the enhanced subsidies — which is what’s in the Democrats’ bill — the Senate just voted on it last week and voted it down, so it wouldn’t have any chance. To which my response was, “Hey, Epstein files.” When the jailbreak happened in the House on that, the Senate voted, I believe, unanimously for it. So, things can change in the Senate. Sorry, Tami, I interrupted you; you wanted to say something. 

Luhby: No, I was just going to say that yes, things can certainly change and there have been surprises before, but this is obviously also not a new issue. I mean, the Democrats have been running ads, people have been speaking out. We have all been writing stories about the cancer survivors or cancer patients who may have to drop their coverage in the middle of their treatment because they can’t afford the new premiums, or all of these stories. So, none of this is new, but we’ll see. There’s obviously … what is somewhat new is the administration’s message on increasing affordability, and this is a huge affordability issue. So, maybe that will spur some change in votes or change in mindset. 

Rovner: Well, definitely a January story too. 

Well, moving on to this week in vaccine news, the Centers for Disease Control and Prevention has made it official — after being blessed by the acting director of the agency, who is neither a doctor nor a public health professional — the U.S. government is no longer recommending a birth dose of the hepatitis B vaccine, which by the way, has been shown to reduce chronic hepatitis B in children and teenagers by 99% since the recommendation was first issued in 1991. 

And merging two stories from this week, there’s also news about the American Academy of Pediatrics, which has been among the most vocal medical groups protesting the vaccine schedule changes. The AAP said the hepatitis B change will “harm children, their families, and the medical professionals who care for them.” And in a move that seems not at all coincidental, the Department of Health and Human Services on Wednesday terminated seven federal grants to the AAP worth millions of dollars, for work on efforts including reducing sudden infant deaths, preventing fetal alcohol syndrome, and identifying autism early. According to The Washington Post, which broke the story, an HHS spokesman said the grants were canceled because they “no longer align with the Department’s mission or priorities.” 

First, this is not normal. Second, however, it’s HHS in 2025 in a microcosm, isn’t it? Either get with the program or get out. Lizzy, you’re nodding. 

Lawrence: Absolutely. Yeah, I think this has become very commonplace in this administration. And also interestingly, yesterday, the HHS posted in the federal register that the CDC offered a $1.6 million grant to a group of Danish researchers who study in Guinea, West Africa, to run a placebo-controlled trial of hepatitis B vaccine for newborns. And so, we’re seeing an active removal of funds from the American Academy of Pediatricians [Pediatrics], and then giving funds now to research. And this is a research group actually that RFK Jr. has cited their studies before, they study overall health effects of vaccines. And so, it will be really interesting to see if this is a trend that continues, if they’re kind of … we already know that HHS, the CDC’s vaccine panel, there’s been discussions about making our vaccine schedule closer to Denmark’s. Now there’s this money being given to Danish researchers who align with the way that they think about vaccines is similar to Kennedy and to another official at FDA, called Tracy Beth Høeg, who is also on the CDC’s panel as the FDA representative. So, yeah. 

Rovner: And who is Danish, I believe. 

Lawrence: Yes, her husband is Danish, and so she lived in Denmark for many years. 

Rovner: I saw some scientists complain about that study in Guinea-Bissau, because they say it’s actually unethical to use a placebo to study the hepatitis B vaccine because we know that it works. So if you’re giving a placebo to children, you’re basically exposing them to hepatitis B.  

Lawrence: Right. 

Ollstein: Yeah. I saw that too. And a lot of folks were saying this would never be approved to be done in the U.S. And so, doing it in another country is reminding people of colonial experiments in medicine that were really unethical and subjected people to more risks than would be allowed here. And like you said, basically knowingly withholding something that is safe and effective and giving someone a placebo instead. 

Another issue I saw raised was that it is not a double-blind study; it is a single-blind study. And so, that allows for potential biases there as well. 

Lawrence: Right. And I was also seeing that the Guinea Ministry of Health is planning to mandate a universal hep B dose in 2027. 

Rovner: Oops. 

Lawrence: So, that’s a crazy … yeah, you have babies born before that year who are not given this dose, and then after … so yeah, it raises all kinds of ethical concerns, and it’s just remarkable that the government would just pull away and offer this money to them. 

Rovner: HHS in 2025. Specifically on the covid vaccine, there were two stories this week. One is a study in the Journal of the American Medical Association that found that pregnant women vaccinated against covid-19 are less likely to be hospitalized, less likely to need intensive care, and less likely to deliver early, if they can track the virus, than those who are unvaccinated. And over at MedPage Today, editor Jeremy Faust, who’s both a doctor and a health researcher, says that FDA vaccine chief Vinay Prasad overstated his case when he said the agency has found at least 10 children who’ve died as a result of receiving the covid vaccine. Turns out the actual memo from the scientists assigned to research the topic concludes the number is somewhere between zero and seven, and five of those cases have only a 50-50 chance of being related to the vaccine. This isn’t great evidence for those who want to stop giving the vaccine to children and pregnant women, I would humbly suggest. 

Lawrence: Right, right. Yeah, the memo that Vinay Prasad sent, which was immediately leaked, was remarkable in that it included no data backing up his claims. And this is a really tricky area, when I’ve talked to scientists at the agency who focus on these issues. I think sometimes it’s hard to say that there are cases that are very subjective, and so this is a discussion that needs to be handled delicately, and it’s a really severe claim to say that this has killed 10 children. And so, that discussion needs to be shared transparently and allow for experts to really weigh in. 

Rovner: Yeah. Well, another issue that’s going to bleed over into January. All right, we’re going to take a quick break. We will be right back. 

So in other administration health news, it appears, at least according to The Washington Post, that the on-again, off-again cuts to medical personnel at the Department of Veterans Affairs are on again. The Post is reporting that the VA is planning to eliminate up to 35,000 doctors, nurses, and support personnel. That’s on top of a cut of 30,000 people earlier in 2025. Altogether, it’s about a 10% cut in total. Apparently, most of the positions are currently unfilled, but that doesn’t mean that they’re unneeded, particularly after Congress dramatically expanded the number of veterans eligible for health benefits by passing the PACT Act during the Biden administration. That’s the bill that allowed people to claim benefits if they were exposed to toxic burn pits. What is this second round of cuts going to mean for veterans’ ability to get timely care from the VA? Nothing good, I imagine. 

Luhby: Well, I’ve been speaking over the past year or two to a VA medical staffer, who wishes to remain anonymous for obvious reasons. And one thing they told me is that their boss, who was also a medical practitioner, took one of the retirements, and that they have to now cover their boss’ shift. And they’ve asked if the boss is going to be replaced because they obviously can’t do two people’s jobs well, and they’ve been told that the boss will not be replaced. 

There’s also, on top of all of this, there’s a hiring freeze and there’s restrictions in hiring. So, it’s been very difficult for agencies, including the VA, including the medical personnel, to get new people. And again, the person I’ve spoken to said that the veterans are not getting the care, as good care as they were last year because this person just can’t do two people’s jobs. And it’s on the medical side, but the source also said that it’s throughout the hospital with the support staff and even the custodial staff. I mean, just … there’s a lot of unfilled positions that are affecting overall care.  

Rovner: I feel like a big irony here is that during the first Trump administration, improving care at the VA and lowering the wait times was a huge priority for President Trump, not just for the administration. He talked about it all the time. And yet, here he’s basically undoing everything that he did for veterans during the first administration. 

All right. Well, meanwhile, NBC is reporting that the FDA is considering rolling back the rule that requires dietary supplement makers to note on their labels that their products have not been reviewed by FDA for safety and efficacy. This was a compromise reached by Congress after a gigantic fight over supplements in 1994 — I still have scars from that fight — following a series of illnesses and deaths due to tainted supplements a couple of years before that. The idea was to let supplements continue to be sold without direct FDA approval, as long as customers were informed that they were not intended to “diagnose, treat, cure, or prevent any disease,” a phrase that I’m sure you’ve heard many times in commercials. Of course, diet supplements are practically an article of faith for followers of the “Make America Healthy Again” movement. I would assume that this is part of RFK Jr.’s vow to loosen what he has called the “aggressive suppression” of vitamins and dietary supplements. Lizzy, you’re nodding. 

Lawrence: Yeah, this is super interesting because this was one of the first things a year ago, when RFK was announced as the HHS secretary, when people were speculating on what some of his priorities would be, deregulating supplements was a big one. And so, I think this will be a really interesting space to watch and see. And it’s emblematic, too, of the uneven view of products regulated by the FDA, where there are some products where there’s … that RFK and other leaders at the FDA are super “pro” and well, we don’t actually need as much evidence here. And then others, like vaccines or SSRIs [selective serotonin reuptake inhibitors], where it seems that they want to really raise evidence standards, which is not how the FDA is supposed to work. It’s supposed to be dispassionately, with no bias, reviewing medical products. 

Rovner: And I would point out, in case I wasn’t clear before, that supplements are barely regulated now. Supplements are regulated so much less than most everything else that the FDA regulates. Sorry, Alice, you wanted to say something. 

Ollstein: Yeah. It also, I think, reveals an interesting public perception issue, where the message that a lot of people are getting is that the pharmaceutical industry is this big, bad, evil corporate thing that is out to harm you, and it has all these documented harms, whereas supplements are natural and wellness and seen as the underdog and the upstart. And I think people should remember that supplements are a huge corporate industry as well, and, like Julie and Lizzy have been saying, regulated a lot less than pharmaceuticals. So, if you’re taking a prescription drug, it’s been tested a lot more than if you’re taking a supplement. 

Rovner: Yeah, absolutely. So while most of the coverage of HHS in 2025 has been pretty critical, this week, two of our fellow podcast panelists, Joanne Kenen and Paige Winfield Cunningham, have stories on how the breakout star at HHS in this first year of Trump 2.0 turns out to be Dr. Oz. Apparently being an Ivy League-trained heart surgeon with an MBA actually does give you some qualifications to run the agency that oversees Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act. I think I noted way back during his confirmation hearings that he clearly already had the knack of how to deal with Congress: flatter them and take their parochial concerns seriously. That’s something that his boss, RFK Jr., has most certainly not mastered as of yet. And it turns out that Dr. Oz has both leadership and policy chops. Who could have predicted this going into this year? 

Luhby: Well, one thing that’s interesting is that we were all, I think, watching what Dr. Oz would do with Medicare and Medicare Advantage, because it’s obviously something that he had promoted on his shows. It’s something that the Biden administration was trying to crack down on. And it has been interesting that he has not been giving carte blanche to the insurers. He has been cracking down on them as well. I listened to a speech that he gave before the Better Medicare Alliance, which is the group that works with Medicare Advantage insurers. And he said basically, “You guys have to step up,” and so, it’ll be interesting to see going forward what additional measures they take. But yeah, he’s certainly not bending over to the insurers. 

Rovner: Yeah. I will say, like I said, I noticed from the beginning, from when he came to his confirmation hearing, that somebody had briefed him well. Apparently, according, I think it was in Joanne’s story, he’s been talking regularly to his predecessors from both parties about how to run the agency, which surprised me a little bit. I will be interested to see how this all progresses, but if you had asked me to bet at the beginning of the year of the important people at HHS who were running these agencies who would do the consensus best job, I’m not sure I would’ve had Dr. Oz at the top of my list. 

Luhby: Well, and one thing to also point out that was really interesting in Paige’s story, particularly, is that what we’ve been hearing at other agencies — the CDC, and across the Trump administration — that a lot of the political appointees are really at odds with the staff. They’re not communicating with the staff; there were concerns about that after the CDC shooting over the summer. And one thing that, obviously, Dr. Oz is very personable, he knows how to reach out to an audience. And in this case, his audience is also his staff. And it was notable that Paige detailed about how he really is interacting a lot with the staff. And I’m sure that’s obviously helping morale and helping the mission at CMS. Also, of course, it’s an agency that RFK has not focused on. 

Rovner: I say, what a shock, treating career staff with some respect, like they know what they’re doing. 

All right. Well, finally, we end this year on reproductive health, pretty much the same way we began it, with anti-abortion groups attacking the abortion pill, mifepristone. We know that despite the fact that abortion is now illegal in roughly half the states, the number of abortions overall has not fallen, and that is because of the easy availability, even across state lines, of medication abortion. Alice, you’ve got quite the story this week about an unusual way to go after the pill. Tell us about it. 

Ollstein: Yeah. So this is a trend I’ve been covering for the last few years, and it’s anti-abortion groups trying to use various environmental laws to achieve the ban on the pills that they want to achieve. And so, there’s been some various iterations of this over the years. The latest one is that groups are jumping on a EPA [Environmental Protection Agency] public comment process that’s going to kick off any day now. So, this is what the EPA does. Every few years, they update the list of chemicals that need to be tracked in water around the country. So this is a big deal. It costs a lot to track these chemicals. There can only be so many chemicals on the list. And these groups are trying to rally people around the country to demand that the EPA add mifepristone and its components to this list. 

Rovner: This is wastewater, right? Not drinking water? 

Ollstein: No, this is drinking water. 

Rovner: Oh, it is drinking water. 

Ollstein: There are other efforts to use wastewater laws to restrict abortion pills, yes. So we talked to scientists that say there is no evidence that mifepristone in the water supply is causing any harm whatsoever. On the other hand, there is tons of evidence of other chemicals, and so we have scientists in our story talking about how if they put mifepristone on this list, it would push out another more dangerous chemical from being on that list. 

So, just to zoom out a little bit, while this particular campaign tactic, whatever you want to call it, may not succeed, I think it’s part of a bigger project to sow doubt in the public’s mind about the safety of mifepristone in various ways. We’ve been seeing this all year, and for several years. But I think that this kind of gross-out factor of there’s abortions in the water! Even without scientific evidence of that, I think it contributes to the public perception. And KFF had some polling recently showing that doubt about the safety of the pills has increased over the past few years. And so, these kinds of campaigns are working in the court of public opinion, if not quite yet at federal agencies. 

Rovner: Another one we will be watching. All right, that is this week’s news. Now we’ll play my “Bill of the Month” interview with Tony Leys, and then we’ll come back and do our very special year-end extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ Tony Leys, who reported and wrote the latest KFF Health News “Bill of the Month.” Tony, welcome back. 

Tony Leys: Thanks for having me, Julie. 

Rovner: So, this month’s patient had a very expensive ambulance ride, alas, a story we’ve heard as part of this series several times. Tell us who he is and what prompted the need for an ambulance. 

Leys: He is Darragh Yoder, a toddler from rural Ohio. He had a bacterial skin infection called [staphylococcal] scalded skin syndrome, which causes blisters and swelling. His mom, Elisabeth, took him to their local ER, where doctors said he needed to be taken by ambulance to a children’s hospital in Dayton, about 40 miles away. They put in an IV and then put him in the ambulance. His mom went with and said the driver didn’t go particularly fast or use the siren, but did get them there in about 40 minutes. 

Rovner: But it still was an ambulance ride. So, how big was the bill? 

Leys: $9,250. 

Rovner: Whoa. Now, this family doesn’t have insurance, which we’ll talk about in a minute. So, it wasn’t an in- or out-of-network thing. Was this unreasonably high compared to other ground ambulance rides of this type? 

Leys: It’s really hard to say because the charges can be all over the place, is what national experts told me. But if Darragh had been on Medicaid, the ambulance company would’ve been paid about $610, instead of $9,200. 

Rovner: Whoa. So, what eventually happened with the bill? 

Leys: The company agreed to reduce it about 40% to $5,600 if the family would pay it in one lump sum. They did, they wound up putting it on a credit card, a no-interest credit card, so they could pay it off overtime. 

Rovner: Now, as we mentioned, this family doesn’t have insurance, but they belong to something called a health sharing ministry. What is that? 

Leys: Members pool their money together and basically agree to help each other pay bills. And they were thinking that that would cover maybe about three-quarters of what they owed, so … 

Rovner: Have they heard about that yet? 

Leys: I have not heard. 

Rovner: OK. So, what’s the takeaway here? I imagine if a doctor says your kid who has an IV attached needs to travel to another facility in an ambulance, you shouldn’t just bundle them into your car instead, right? 

Leys: I sure wouldn’t. Yeah, no. I mean, at that point, she felt like she had no choice. I mean, she did say if she would’ve just driven straight to the children’s hospital instead of stopping at the local hospital, they would’ve gotten there sooner than if once she stopped at the local hospital and they ordered an ambulance. So, that’s in retrospect what she wishes she would’ve done. But if they’d had insurance, the insurer would’ve presumably negotiated a lower rate, and they wouldn’t have had to do the negotiation themselves. 

Rovner: So, they are paying this off, basically? 

Leys: Yeah, they paid it in one lump sum, which is a stretch for them, but they felt like they had no choice. 

Rovner: All right. Tony Leys, thank you very much. 

Leys: Thanks for having me, Julie. 

Rovner: OK, we’re back. It’s time for our extra-credit segment. That’s usually where we each recognize a story we read this week we think you should read too. But since this is our last podcast of the year, I wanted to do something a little bit different. I’ve asked each of our panelists to take a minute or two to talk about what they see, not necessarily as the biggest single health story of the year, but the most important theme that we’ll remember 2025 for. Tami, why don’t you start us off? 

Luhby: OK. Well, I think that Medicaid has been a big issue in 2025 and will continue to be going forward. Among the most consequential health policies enacted this year were the sweeping Medicaid changes contained in the One Big Beautiful Bill [Act], which Congress passed over the summer. The legislation enacts historic cuts to [the] nation’s safety net, with the biggest chunk coming from Medicaid, which serves low-income Americans. It would slash more than $900 billion from Medicaid, according to the Congressional Budget Office. About 7.5 million more people would be uninsured in 2034 due to these Medicaid provisions. And most of that spike would come from Congress adding work requirements to Medicaid for the first time. We know that that happened in 2018, states were trying to do … well, the Trump administration allowed certain states to do that. It really only took effect in Arkansas, and about 18,000 people lost coverage within months from the work requirements, many of whom, the advocates say, many people are working, they’re going to get caught up in red tape. They’re either working or they’re eligible for exemptions, but they’ll get caught up in red tape. 

So, what the Big Beautiful Bill requires is in states that have expanded Medicaid, working-age adults without disabilities or [dependent] children under age 14 would have to work, volunteer, or attend school or job training programs at least 80 hours a month to remain eligible, unless they qualify for another exemption, such as being medically frail or having substance abuse disorder. The package also limits immigrants’ eligibility for Medicaid, requires enrollees to pay some costs, and caps state and local government provider taxes, which is a key funding source for states and which will have ripple effects across hospitals and across states in general. 

Now, what’s important to note is, most of these provisions haven’t taken effect yet. Most of them actually take effect after the midterm elections next year. So, they’ll be rolling out in coming years and the full impact is yet to come. 

Rovner: Alice. 

Ollstein: So, I have chosen the resurgence of infectious diseases that we are seeing right now. I think measles is really the canary in the coal mine. Because it’s so infectious, that’s what’s showing up first, but it’s not going to be the last infectious disease that the country had almost squashed out of existence that is now, as I said, resurging. And so, I think that a lot of different policies and trends are feeding into this. And I think we have the rollback of vaccine requirements at the state level, at the federal level. We have policies that deter people from seeking out testing and treatment, especially some of these anti-immigrant policies that we’re seeing. And then just cuts to public health and public health staff, cuts to surveillance, so it’s just harder to know where the outbreaks are happening and how bad they are. It’s hard to get reliable data on that. And so I think, yes, we’re seeing measles first, but now we are starting to see whooping cough, we’re starting to see some other things, and it’s really troubling, and it could have a political impact too. 

I have talked to a bunch of candidates who are running in next year’s midterms who say that they’re able to point to outbreaks right there in their state to say, “This is the consequence of Republican health policies, and this is why you should vote for me.” So, I would be keeping an eye on that in the coming year. 

Rovner: Lizzy. 

Lawrence: So, my chosen theme is the politicization of science. And my focus has been on the FDA as an FDA beat reporter, but there’s been the politicization of science in every agency. And this is something that used to be pretty taboo, right? I keep thinking these days about the [Barack] Obama HHS secretary, Kathleen Sebelius, and the legal and political repercussions she faced when she vetoed an FDA decision to make Plan B over-the-counter. And those days seem very far away, because now we’re seeing at the FDA speedier drug reviews being used as a bargaining chip in deals between the White House and companies in exchange for companies lowering their prices. 

At the FDA and CDC, you’re seeing skeptics or more political officials completely taking over operations, reopening debates on things like vaccines, antidepressants during pregnancy, RSV, monoclonal antibodies, based on thin or even really no or debunked evidence. 

You’re seeing the White House just today use CMS to pull funding from hospitals that perform gender-affirming surgeries. You’re seeing NIH [the National Institutes of Health] pull funding from research studies that go against Trump administration ideology. So, there’s really so many examples, too many to count, of political leaders wielding in power and trying to shape science to fit their agendas in the way that they see the world. 

And then I’d say that has a trickle-down effect to the way that everyday people think about science, and it calls everything into question and makes … People look to politicians and to the heads of public health agencies to tell them the truth. I mean, maybe not politicians, but it seems that doctors and medical experts’ voices are increasingly being drowned out by the political re-litigating of science that has been settled for a long time. So, I think this is a very important topic and one that I’ll keep watching closely in the next year. 

Rovner: Yep. So my topic builds on Lizzy’s. It’s how this administration is using a combination of personnel and funding cuts and new regulations to jeopardize the future of the scientific and health care workforce well into the future. The administration has frozen or terminated literally billions of dollars in grants from the National Institutes of Health and the National Science Foundation, not just causing the shutdown of many labs, but making students who are pursuing research careers rethink their plans, including those who are well into their graduate studies. Some are even going to other countries, which are happily poaching some of our best and brightest. 

And as we’ve talked about so many times before in this year’s podcast, the administration also seems intent on basically choking off the future health care workforce. The big budget bill includes caps on how much medical students can borrow in federal loans. That’s an effort to get medical schools to lower their tuition, but most observers think that’s unlikely to happen. The Education Department has decreed that those studying to be nurses, physician assistants, public health workers, and physical therapists are not pursuing a “profession,” thus also limiting how much they can borrow. And a new $100,000 visa fee is going to make it even more difficult for hospitals and clinics, particularly those in rural areas, to hire doctors and nurses from outside the U.S., at a time when international medical workers are literally the only ones working in many shortage areas. These are all changes that are going to have ramifications, not just for years, but potentially for generations. So, these are all themes that we will continue to watch in 2026. 

OK, that is this week’s show and our last episode for 2025. Thank you to all of you listeners for coming with us on this wild news ride. As always, thanks to our editor, Emmarie Huetteman, and this week’s producer-engineer, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me on X @jrovner, or on Bluesky @julierovner. Where are you guys hanging these days, Alice? 

Ollstein: Mostly on Bluesky @alicemiranda, and still on X @AliceOllstein. 

Rovner: Tami. 

Luhby: You could find me at cnn.com. 

Rovner: Lizzy. 

Lawrence: You can find me at Stat News, on LinkedIn at Lizzy Lawrence, on X @LizzyLaw_, and on Bluesky — and I forget my username, but I’m somewhere there. 

Rovner: Don’t worry about it. OK, we will be back in your feed in January. Until then, be healthy. 

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An online search of his symptoms suggested he had staphylococcal scalded skin syndrome, a serious bacterial infection. Yoder drove the toddler from their home in the small town of Mechanicsburg, Ohio, to the Mercy Health hospital in nearby Urbana.

Staff in the emergency room there quickly confirmed that Darragh had scalded skin syndrome and said he needed to be taken by a private company’s ambulance to Dayton Children’s, a hospital about 40 miles away.

“I asked them: ‘Can I take him? Can I drive him?’” Yoder said. “And they were like, ‘Oh, absolutely not.’”

So, Yoder and her son got into the ambulance, with Darragh strapped in his car seat. The ambulance driver didn’t turn on the siren or drive particularly fast, Yoder said. The trip took about 40 minutes, she said. “It was fairly straightforward transportation from Point A to Point B.”

Yoder had heard that ambulance rides can be pricey. But she didn’t know how much her son’s ride would cost.

Darragh was hospitalized for three days and recovered from the illness.

Then the bill came.

The Medical Procedure

During the ride, the ambulance crew monitored Darragh’s vitals and an intravenous line, inserted at the hospital, carrying fluids and antibiotics, but he received no other medical treatment, Yoder said.

The Final Bill

$9,250, which included a “base rate” charge of $6,600 for a “specialty care transport” and a mileage fee of $2,340, calculated at $60 for each of the ride’s 39 miles. It also included $250 for use of an intravenous infusion pump and $60 for monitoring Darragh’s blood oxygen.

The Problem: No Insurance, Few Protections

The children’s hospital charged only about $3,000 more for the toddler’s three-day stay than the ambulance company charged for the ride, Yoder said.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid, the public health program that covers low-income residents, or for the Ohio Children’s Health Insurance Program, which covers moderate-income kids.

The Yoders belong to a Christian health care sharing ministry, with members paying into a fund that helps reimburse them for medical bills.

Unlike health insurance, such arrangements do not offer members negotiated rates with ambulance companies or other medical providers. And there are no state or federal billing protections that would help an uninsured patient in Ohio with a ground ambulance bill.

The federal No Surprises Act protects those with insurance from large bills for air ambulance transportation provided outside their insurers’ network agreements. But ground ambulance services aren’t covered by the law — and even if they were, that wouldn’t have helped the Yoders, since they didn’t have insurance.

Patricia Kelmar, the senior director of health care campaigns for PIRG, a national advocacy group, said ambulance charges vary widely. She said she’s seen per-mile charges ranging from less than $30 to more than $80, as well as base rates that differ dramatically.

Some patients, such as those with traumatic injuries, need ambulances with highly trained staff and advanced medical equipment, Kelmar said, so it makes sense that those rides would be more expensive. But patients rarely are told what the ride will cost until they receive a bill.

Jennifer Robinson, a spokesperson for Mercy Health, said she couldn’t comment on a specific patient’s case but said the staff follows established medical standards. “When a patient requires a higher level of treatment, ambulance transfer between facilities is best practice to ensure appropriate care,” she said in an email to KFF Health News.

Kimberly Godden, a vice president for the ambulance company, Superior Ambulance Service, said a doctor at the first hospital requested a high-level transport for the patient, requiring specially trained staff.

“Our priority is always to ensure patients receive the highest-quality care when they need it most, and we respond to every call regardless of a patient’s ability to pay,” Godden said in an email. “Superior had the team and resources available to quickly and safely move the patient to the higher level of care they needed within the time frame set by the ordering physician.”

Godden said the company would offer a “charity care” rate to Yoder if the family qualified for it.

The Resolution

Yoder said she repeatedly discussed the bill with ambulance company representatives, including the option for charity care. They told Yoder the best deal they could offer was to reduce the total by about 40%, to $5,600, if the family paid it in a lump sum, she said.

After months of discussion, the family wound up agreeing to that deal, Yoder said. They put the charge on a new credit card, which gave them 17 months to pay it off with no interest.

They have agreed to payment plans with the two hospitals, which offered charity care discounts that dropped the bills to a total of about $6,800.

The Yoders expect the sharing ministry to reimburse them for about 75% of the payments they’re making to the hospitals and the ambulance service.

The Takeaway

Patients and their families should feel comfortable asking hospital staffers whether a recommended ambulance company is in their insurance network and how much the ride to another location will cost, said Kelmar, a national expert on such bills. “Shouldn’t the hospital know that?” she said. “I don’t think it’s that heavy of a lift.”

Kelmar said she doesn’t want to discourage people from taking an ambulance if a doctor says it’s necessary. Once consumers receive a bill for the service, she said, they often can negotiate the price down. It can help to look up what the ambulance service accepts as payment from government programs. Those rates are often much lower than the full-price charges patients see on a bill.

If the family had been covered by Ohio’s Medicaid program, the ambulance service would have been paid much less than it charged the Yoders. The public health program pays ambulance services a $413 base rate for “specialty care transports,” plus $5.05 per mile. Those rates would have added up to $609.95 for the transportation part of Darragh’s ambulance ride.

Yoder said she wishes she had driven Darragh straight to the children’s hospital. If she had skipped the local ER, she said, they would have arrived at the bigger hospital sooner and she would have saved thousands of dollars.

But she didn’t feel as if she had a choice about putting her son in the ambulance, she said. The doctor told her it was necessary, and the hospital staff had already inserted an intravenous line. “I wasn’t going to pull out his IV line and just leave,” she said.

Yoder said she remains uninsured because she hasn’t seen any private insurance options that suit her family’s circumstances. No matter who pays the ambulance bill, she thinks the charges were much too high. She understands that patients can often negotiate discounts, she said, “but you shouldn’t have to work so hard for it.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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The longest federal government shutdown in history is over, after a handful of House and Senate Democrats joined most Republicans in approving legislation that funds the government through January. Despite Democrats’ demands, the package did not include an extension of the expanded tax credits that help most Affordable Care Act enrollees afford their plans — meaning most people with ACA plans are slated to pay much more toward their premiums next year.

Also, new details are emerging about the Trump administration’s efforts to use the Medicaid program — for low-income and disabled people — to advance its immigration and trans health policy goals. And President Donald Trump has unveiled deals with two major pharmaceutical companies designed to increase access to weight loss drugs for some Americans.

This week’s panelists are Emmarie Huetteman of KFF Health News, Anna Edney of Bloomberg News, Shefali Luthra of The 19th, and Sandhya Raman of CQ Roll Call.

Panelists

Among the takeaways from this week’s episode:

• Though the shutdown deal did not include an extension of the enhanced ACA subsidies, it came with a plan for a Senate vote by next month — on what exactly, it is unclear. Senate Republicans appear to be coalescing around providing money via health savings accounts rather than through the subsidies, while House Republicans seem more fragmented. The clock is ticking; the existing credits expire on Jan. 1, and open enrollment has begun.
• Even as the Trump administration is likely to be tied up in court over its efforts to use Medicaid to crack down on health care for immigrants and trans people, they’ve had a real chilling effect. Immigrants, for instance, are skipping medical care, and hospitals are cutting back on offering gender-affirming care for trans people for fear of losing federal funding.
• Trump’s newly announced GLP-1 price deals could help Medicare enrollees afford the weight loss drugs, potentially opening up access to a new population of patients — and customers. And a steady stream of policy reversals, unexplained dismissals, and negative news coverage is leading to worries that the FDA’s credibility is being undermined by internal drama. Also in question is whether it’s interfering with the agency’s work. Drug companies would likely say yes, and some within the FDA are trying to combat these concerns.
• A major anti-abortion group is leaning into the current electoral moment, targeting key states and preparing for sizable political contributions ahead of next year’s midterm elections. Abortion opponents see an opportunity to capitalize on voters’ changing motivations and reposition themselves to fit into the post-Trump Republican Party.

Also this week, KFF Health News’ Julie Rovner interviews KFF Health News’ Julie Appleby, who wrote the latest “Bill of the Month” feature, about a doctor who became the patient after a car accident sent her to the hospital — and $64,000 into debt. Do you have an outrageous medical bill? Tell us about it!

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Emmarie Huetteman: KFF Health News’ “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance,” by Amanda Seitz.

Anna Edney: Bloomberg News’ “Bayer Weighs Roundup Exit as Cancer Legal Bill Nears $18 Billion,” by Tim Loh, Hayley Warren, and Julia Janicki.

Shefali Luthra: The 19th’s “Detransition Is Rare, but It’s Driving Anti-Trans Policy Anyway,” by Orion Rummler.

Sandhya Raman: BBC’s “Canada Loses Its Measles-Free Status, With US on Track To Follow,” by Nadine Yousif.

Also mentioned in this week’s episode:

• KFF’s “KFF Health Tracking Poll: Public Weighs in on Health Care Debate and Government Shutdown,” by Audrey Kearney, Alex Montero, Mardet Mulugeta, Ashley Kirzinger, and Liz Hamel.
• KFF Health News’ “Trump’s HHS Orders State Medicaid Programs To Help Find Undocumented Immigrants,” by Phil Galewitz.
• NPR’s “Trump Pushes an End to Medical Care for Transgender Youth Nationally,” by Selena Simmons-Duffin.
• Stat’s “FDA’s Top Drug Regulator Resigns Amid Investigation,” by Lizzy Lawrence and Adam Feuerstein.
• Stat’s “Under Vinay Prasad, Employees at a Key FDA Center Fear Speaking Out, Look for the Exits,” by Lizzy Lawrence.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]  

Emmarie Huetteman: Hello and welcome to “What the Health?” from KFF Health News and WAMU. I’m Emmarie Huetteman, a senior editor for KFF Health News, filling in for host Julie Rovner this week. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 13, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go. 

Today, we’re joined via video conference by Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning. 

Huetteman: Anna Edney of Bloomberg News. 

Anna Edney: Hi, everyone. 

Huetteman: And Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Huetteman: Later in this episode, we’ll have Julie’s interview with KFF Health News’ Julie Appleby, who wrote our latest “Bill of the Month” story about a doctor who became the patient after a car accident sent her to the hospital and $64,000 into debt. But first, this week’s news. 

The longest federal government shutdown in history is over. Late Wednesday, six House Democrats joined most Republicans in approving legislation that funds the government through January. That vote came after a handful of Senate Democrats broke ranks with their party last weekend and brokered a deal to end the shutdown. Although the Trump administration was still fighting earlier this week not to fully fund food stamps, the White House has said those benefits would be fully restored within hours of the shutdown’s end. That said, food banks and other safety-net programs have warned the shutdown’s consequences could linger, especially for those who were forced to redirect rent money, dip into savings, and make other sacrifices to feed their families. Notably, despite Democrats’ demands, the deal does not include an extension of the expanded tax credits that help people afford Affordable Care Act plans. That means those enhanced subsidies are still slated to expire at the end of the year. Sandhya, you were on Capitol Hill last night. What was included in the deal? And now that the shutdown’s over, can we expect a vote on extending the tax credits? 

Raman: So part of that deal was that sometime in the middle of next month, the Senate is going to be able to vote on a health bill of Democrats’ choosing to extend the Affordable Care Act enhanced subsidies that are set to expire at the end of the year. There’s been a decent amount of talk already in both chambers about what a health care bill could look like, because it would need to be bipartisan to pass. There’s some multiple camps right now. 

I think in the Senate, Republicans are coalescing around putting money into flexible savings accounts instead of doing an extension of the credits as something that they would want to do instead. There are other Republicans that are still open to extending the credits with some reforms attached. The House, we figured out last night, was a little bit more fragmented. They’re less united in the way the House is around doing something with the flexible spending accounts. So a lot of them are still anti-extending the credits at all. They are working on a health package, but it remains to be seen what they want to do with that, given the short amount of time they have. But I think a lot of them are also looking for the same reforms that the Senate is on the Republican side, if they do sign on to extend them. 

Huetteman: Yeah, short is right. We’re already looking at that Dec. 31 deadline to extend the existing credits. And of course, we’re already in the open enrollment period at this point. People are already getting their plans for next year. Polls show that most Americans blamed Republicans for the shutdown. A tracking poll from my KFF colleagues out last week showed most Americans want Congress to extend the tax credits. Republicans are aware of this heading into the midterms next year, no? 

Raman: I think that’s definitely been a big factor when talking to folks, especially ones that I think have been more interested in extending the credits are set up for our competitive races next year. There has been talk at different times of doing a one-year extension. But that puts us pretty close to the midterms, which might not be in everyone’s best interest depending on how things shake out. So, I think it’s definitely in a lot of folks’ minds, just because it is a lot more popular than it has been in previous years. But there are a lot of the more conservative folks that just have been anti-ACA for so long, that they don’t want to extend something that was … The enhanced subsidies were started by Democrats during covid. They think it’s a covid-era thing that needs to be phased out. 

Huetteman: Yeah, and also notably, you might’ve noticed I said that they only funded the government through January. Does that mean we’re getting ready to do this again in a couple of months? 

Raman: There’s a chance. So part of the deal got done this week is that they did three of the 12 spending bills that they do every year to fund the government. But they usually do them in order of which ones are easiest to get done. So we still have to come to agreements on some of the bigger ones, including Labor, HHS [Health and Human Services]. Education is what funds most of the health activities, and that’s usually a tougher one. So, I think it depends on a few things. Are folks sticking to their word? Do they get that health care vote that they were promised? Do other things shake out that make people at odds with each other over the next bit? But we could possibly be in the same situation if we don’t make inroads on funding the government for a yearlong situation before then. 

Huetteman: Oh goodness. Well, it sounds like we’ll be back again having this conversation soon. Meanwhile, months after the president [Donald Trump] signed into law the One Big Beautiful Bill with big changes to Medicaid, new details are emerging about how the Trump administration is using the Medicaid program to promote its policy goals. My KFF Health News colleague Phil Galewitz recently reported on how the Trump administration has ordered state Medicaid agencies to investigate the immigration status of certain enrollees — providing states with lists of names to re-verify — and effectively roping the health program into the president’s immigration crackdown. 

Also, NPR reports the Trump administration plans to dramatically restrict access to medical care for transgender youth. New proposals that could be released as soon as this month would block federal money from being spent on trans care. Policy experts say that would make it difficult, if not impossible, to access that care, in large part because government funding is a huge source of revenue, and losing it could force hospitals to end the programs entirely. Both of these programs are pretty striking: enlisting Medicaid to perform spot checks of immigration status, and also potentially blocking funding for trans care. Have we seen other presidential administrations use Medicaid like this? And since we’re talking about funding, is there a role for Congress here? 

Luthra: My understanding is that this approach, specifically with gender-affirming care and with immigration, doesn’t really have a precedent. And what I think is really important about these is these are decisions that will be litigated, challenged, argued in court. But, even if and as that happens, there’s a real chilling effect that I think is really important. Already, we know that a lot of immigrants are very afraid to sign up even for benefits they are entitled to, because they’re worried it could count against them. We already know that a lot of immigrants with health needs are skipping their health care because they are so worried about what happens if ICE [Immigration and Customs Enforcement] shows up at a hospital. This only threatens to add to that. On the vantage of gender-affirming care, already we have seen some major hospitals and health providers drop the offering, even in anticipation of this policy coming into effect. So I think what’s really important is to understand that no matter what happens, already, people’s health is really being affected, and people are suffering as a result. 

Raman: I think we’ve seen little sprinkles of some of these things that have happened in the past, but this is elevated at such a level that it’s different. Even in the first Trump administration, there were some things put in place with the public charge to crack down on what benefits immigrants could be entitled to. But I think, as with a lot of the things that we’re seeing, it’s really been amped up. I think one thing that Shefali was saying that made me think of was, we’ve already seen a lot of this chilling effect with a lot of things in abortion and reproductive care, where even if laws or regulations don’t go into effect, they’re being talked about or litigated. It already has that effect of people not wanting to show up or not knowing what’s available to them. So we have a little bit of that to look at as well. 

Huetteman: Yeah, absolutely. All right, well, we’re going to take a quick break. We’ll be right back with more health news. 

We’re back. In an Oval Office announcement last week, President Trump unveiled agreements with the pharmaceutical giants Eli Lilly and Novo Nordisk to offer some Americans lower prices on their weight loss drugs. Under the deals, the Trump administration says, most eligible patients on Medicare and Medicaid, or those who use the planned TrumpRx website, would pay a few hundred dollars a month for some of the most popular GLP-1 drugs. That’s compared to current price tags, which can be $1,000 or more. Anna, these are only some of the most recent deals between the Trump administration and drugmakers. What does this mean for Americans who take these weight loss drugs, and what do the companies get in exchange? 

Edney: Yeah, I think for Americans who take these or are hoping to take these, I think, is probably where it really opens up. Because … Medicare was not covering these. Now that they’ve come to the table and made a deal, it might open it up to some Medicare beneficiaries. I don’t think you’re going to see everyone on Medicare who wants it be able to get it. I think it’ll be a little stricter on what BMI [body mass index] and comorbidities and things that they need to meet, but it will open access to some Americans. Medicaid, I think, it might not be as beneficial for people’s pocketbooks because they’re already paying extremely low out-of-pocket prices, and Medicaid already negotiates very low prices. That might not be the big change that it was hyped up to be. 

But on the Medicare side, certainly, the companies benefit from that, too, because that opens a new patient population to them. And through TrumpRx — that’s the other place where they made this deal for lowered prices on the GLP-1s — a lot of people have employer coverage that they might be trying to already get these drugs through, and then they’re not paying a whole lot out-of-pocket. But there are employer coverage plans that aren’t covering GLP-1s because they’re just so expensive. So it could be a place where some people might go to try to comparison shop and get their GLP-1s that they didn’t have access to before. 

Huetteman: I also noticed, in looking at the Trump administration’s fact sheet on this, that they were heralding that the companies had agreed to some extra American manufacturing. Let’s say concessions. Am I correct about that? Is this connected to tariffs by any chance? 

Edney: Yeah, I think that that’s been going on in conjunction with some of these deals. As you usually hear the companies say, And we’re opening a new factory in Virginia or somewhere. And certainly they’re trying to avoid the tariffs. As with a lot of these things, some of it, in some cases, they have been factories that the companies were already planning to open, and then they just pumped up for this purpose. I think for so many of this — and even for the prices, the lower prices that these companies are negotiating — we just haven’t seen the details that will matter on what the company’s got, and what the American people actually benefit from for all of this, and what these factories will mean or will be making. These are things that might not come online for several years. So you can say you’re building something, but will we see it once Trump is out of office? 

Huetteman: Exactly. And a lot of the framing has been: We’re helping Americans by bringing this work back to America, so that Americans can do the work, so that Americans can benefit from the drug prices. But it seems like there’s at best a lag on that sort of benefit. Right? 

Edney: Definitely. Definitely a lag on being able to bring some of that stuff online. I think with a lot of the Trump administration’s health policies — and I use that word loosely — it is that it is a lot of negotiation and handshakes. And so we don’t really know how solid those efforts will be in the years to come. 

Huetteman: Well, we can definitely keep an eye on that. In other news: Drama, drama, drama at the Food and Drug Administration. With a steady stream of controversial policy reversals, unexplained dismissals, and just plain unflattering stories, concerns are growing that mismanagement at the FDA is undermining the usually cautious agency’s credibility. In some of the latest developments, Stat reported the FDA’s top drug regulator resigned after being accused of using his position to punish a former associate. Stat also reported that dozens of scientists are considering leaving the already diminished FDA office that regulates vaccines, biologics, and the blood supply to get away from a toxic work environment. What are the ramifications of problems at the FDA? Is the internal drama interfering with business there? 

Edney: I think the pharmaceutical industry would say yes, definitely. They’re feeling like their applications for new drugs aren’t getting reviewed in time. They’re worried that they’re not going to be reviewed in time. And this starts with the administration letting go hundreds of workers in those offices, but also, is now … There’s just been such chaos at the top. You had Vinay Prasad, who is the head of vaccines and biologic drugs there, who has been let go and then brought back. And then now we have the head of the drug center, George Tidmarsh, who resigned under investigation for basically using his position to fulfill a vendetta against an old colleague who pushed him out of some companies. And so I think, certainly, there’s a lot of potential for disruption, as people are trying to avoid retaliation, avoid getting in the crosshairs of all of this. 

And recently, the FDA has now put Rick Pazdur, who was the head of their cancer center, in charge of the drug center to try to show some stability to encourage the pharmaceutical industry. Because he is someone who’s really pushed for innovation, pushed for trying to get drugs to the market faster. And he’s been at the FDA for, I think, 26 years. So, they’re trying to show some stability with that. But we’ll have to see how that goes because he’s also been highly criticized in the past by Prasad, and they’ll be working closely together at the head of those two centers. 

Huetteman: Well, finally, in reproductive health news, a federal judge ruled late last month that the FDA violated federal law by restricting access to mifepristone. While the government’s restrictions remain in place for the politically controversial medication, which is used to manage miscarriages as well as abortions, the judge did order the FDA to consider the relevant evidence in order to “provide a reasoned explanation for its restrictions.” And a major anti-abortion group, Susan B. Anthony Pro-Life America, announced plans for it and its super PAC [political action committee] to spend about $80 million in at least four states to support anti-abortion candidates in the midterm elections next year. Shefali, what does this say about how abortion opponents see this moment? What are they looking to gain in the midterms and beyond? 

Luthra: It’s so interesting to me to see how much anti-abortion groups are really — and, in particular, SBA — leaning into this moment. And they really see this as a reversal of last year’s election, where Trump certainly won. But we do know from polling that voters largely opposed abortion restrictions, supported abortion rights. I think some really useful context is to consider that the president, despite being backed by abortion opponents, has not really been the champion many of them would’ve hoped for. He hasn’t actually done very much on abortion, has not taken the very meaningful steps that you might’ve expected in a post-Dobbs landscape [Dobbs v. Jackson Women’s Health Organization] to remarkably restrict it, beyond the normal things any Republican president does. And so I think what we’re seeing here is an effort to reposition the anti-abortion movement beyond this presidential administration. Thinking ahead to what does it look like if there is a post-Trump GOP? 

How do you build out a movement that is a more staunch ally to the anti-abortion movement going forward? One other thing that I think is really noteworthy is: A lot of abortion opponents are looking at polling that says that voters who support abortion rights aren’t prioritizing it in the same way they might have a year ago. And they’re really hoping that things can revert to how they used to be. Or the voters who were these single-issue abortion voters were on their side, were supportive of restrictions, and then might be mobilized by these kinds of really seismic investments in elections. 

Huetteman: Yeah, absolutely. I’m thinking about now how there was such a reaction about a month ago — check me on the timing — when a generic version of the abortion pill was put out. What was the reaction like then, and what does that say about how they feel the Trump administration is reacting to their needs? 

Luthra: A lot of abortion opponents were really livid about this, and approving this generic was pretty standard. It was not that complicated of a process. This drug has been available for so long in other forms. But it underscored that a lot of people who oppose abortion feel like they’re really just waiting. The HHS and the FDA have promised this review of mifepristone that they say could ultimately lead to restrictions. But all it has really been has been a promise this review is ongoing, is coming. There will eventually be results, but there haven’t been any. So to be waiting for some kind of policy that people keep telling you is coming, and then at the same time, to see actually the FDA moving to make abortion medication more available — not less — is really frustrating for a lot of people who hope that this administration would be an ally to them. 

Huetteman: Absolutely. OK. That’s it for this week’s news. Now, we’ll have Julie’s interview with KFF Health News’ Julie Appleby. And then we’ll do our extra credits. 

Julie Rovner: I am pleased to welcome back to the podcast, KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back. 

Julie Appleby: Thanks for having me. 

Rovner: So this month’s patient is actually a doctor, so she knows how the system works. But, as so often happens, she was in a car accident and ended up in an out-of-network hospital. Tell us who she is and what kind of care she needed. 

Appleby: OK. Her name is Lauren Hughes, and she was heading to see patients at a clinic about 20 miles from where she lives in Denver back in February when another driver T-boned her car, totaling it. She was taken by ambulance to the closest hospital, which turned out to be Platte Valley Hospital, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians there recommended immediate surgical repair because they wanted to wash out that wound on her knee. And also, she needed some screws in her ankle to hold it in place. 

Rovner: So then after the surgery and an overnight stay, she goes home, and then the bills start to come. How much did it end up costing? 

Appleby: Well, she was billed $63,976 by the hospital. 

Rovner: And the insurance company denied her claim. What was their argument? 

Appleby: Yeah, this is where it gets complicated, as many of these things often do. Her insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER. But it denied the surgery and the overnight stay charges from the hospital, which did happen to be out-of-network. Four days after her surgery, Anthem notified Hughes in a letter that after consulting clinical guidelines for her type of ankle repair, its reviewer determined that it wasn’t medically necessary for her to be fully admitted for an inpatient hospital stay. So, the note said that if she’d needed additional surgery or had other problems such as vomiting or fever, an inpatient stay might’ve been warranted. But they didn’t have that in this case. And generally, people don’t stay overnight in the hospital after broken ankle surgery. 

Rovner: Of course, she had no car and she … 

Appleby: Right? Her car was totaled. She had no way to get home. She had nobody to pick her up. And it turns out, there’s a couple more little quirks. So the surgery charges were denied because this quirk that under Anthem’s agreement with the hospital, all claims for services before and after a patient are approved or denied together. So, since the hospital stay was generally not required after the ankle surgery, the surgery charges itself were denied as well. Even though Anthem said they always felt that that was medically necessary — that she needed the ankle surgery — it all came down to this overnight hospital stay. 

Rovner: So, isn’t this exactly what the federal surprise billing law was supposed to eliminate — being in an accident, getting taken to an out-of-network hospital for emergency care? How did it not apply here? 

Appleby: Right. Well, that’s where it’s so interesting because initially, that’s what everybody thought: The No Surprises Act would cover it. And the No Surprises Act from 2022, it’s aimed at preventing these so-called surprise bills, which come when you go to an out-of-network hospital or provider. And in those cases, it limits your financial liability for emergency care to the exact same cost sharing as if you had been in an in-network hospital. 

So in this case, it applies to emergency care, and we saw that it did actually cover some of her emergency room charges, and that kind of thing. But generally though, emergency care is defined as treatment needed to stabilize a patient. So once she was stabilized before the surgery, she enters this post-stabilization situation. And if your provider determines that you can travel using nonmedical transport to an in-network facility, you might lose those No Surprises Act protections. Generally, you’re asked to sign some paperwork saying you want to stay at the out-of-network facility, and you want to continue treatment, and you waive your rights in that case. Hughes does not remember getting anything like that. And this case didn’t come down to the No Surprises Act. It was a question of medical necessity. Your insurer has broad power to determine medical necessity. And if they review a situation and determine that it’s not medically necessary, and you’re post-stabilization, that trumps any No Surprises Act protections. 

Rovner: So what eventually happened with this bill? 

Appleby: So what eventually happened was that the hospital resubmitted the charges as outpatient services. And that seemed to be the crux of the matter here. It was that inpatient overnight hospital stay. If she was kept [on] an observation status — which is a lower level of care, hospitals get paid a little bit less — that would’ve seemed to solve the problem. And that’s what happened here. Platte Valley resubmitted the bill, and her insurer paid about $21,000 of that bill. There was another $40,000 that was knocked off by an Anthem discount. And in the end, Hughes only owed a $250 copayment. 

Rovner: Wow. 

Appleby: Yeah. 

Rovner: Of course, you left out the part where we actually called and made it … 

Appleby: Well, there was that, too. And she was very savvy, as you mentioned. She also got her HR department at her employer involved. She wrote letters. She was not going to give up on this. That’s one of the advice that she gave is not to wait — not to delay too long if you get a notice of not medical necessity — but to quickly and aggressively question insurance denials once they’re received. Make sure you understand what’s going on. Try to get it escalated to the insurers and the hospital’s leadership. All of those things. And I think another takeaway for folks is — and this is harder because, look, you’re in the emergency room, you don’t know what’s going on — but it might be worth asking, Hey, am I post-stabilization? Am I being admitted as an inpatient? Am I being held for an observation stay? Is there some kind of difference with that in terms of my insurance coverage? And you could perhaps try to put this to the hospital billing department. But it’s even better if there’s a way you can call your insurer. But that’s not always realistic in these kinds of emergency situations. 

Rovner: Yeah, and just out of curiosity, if somebody totals my car and I end up [in] an ambulance needing surgery, I’m going to assume that the other driver’s insurance is going to pay my medical bills. Why didn’t that happen? 

Appleby: Well, in this case, the way it was explained to me is the other driver had the minimum coverage needed in the state of Colorado. And so it did pay nearly $5,000 toward some of these charges. But that’s about all it paid. 

Rovner: Wow. Well, now, obviously, as you said, Lauren Hughes is a doctor. Savvy about the way the system works, or doesn’t in this case. Even then, it took her months and called us to work this all out. How should somebody with less expertise handle a situation like this? Is there somebody they can turn to help, assuming that they’re not cognizant enough to start asking questions about their admission status while they’re still in the emergency room waiting for surgery? 

Appleby: Right. Again, that is so complicated. If you can, call your insurer and see what they have to say. And again, it may be after hours. It may be not possible. Perhaps see if you can chat with the hospital billing department. But again, some of this is going to be after the fact. And remember, the billing in this situation came down to how the hospital coded the billing. They coded it as an inpatient hospital stay, and that’s after the fact. And there’s not a lot you can do about it. But in the end, it was resubmitted as an outpatient service, and that made all the difference in this case. 

Rovner: Wow. Another complicated one. Or I guess you can just write to us. Julie Appleby, thank you very much. 

Appleby: Thanks for having me. 

Huetteman: All right, now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week that we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Anna, how about you go first this week? 

Edney: Sure. This story is from a few of my colleagues at Bloomberg. “Bayer Weighs Roundup Exit as Cancer Legal Bill Nears $18 Billion.” And I thought this was an interesting story, not just because there is the possibility that the world’s most-used weed killer could be going away because it’s just folding under so many legal challenges related to cancer. But it’s also just a deep dive to look at this herbicide that has affected all of our lives and how it came to be, what’s going on with it now, why it’s not working. And also at this company, Bayer, that in the middle of these legal challenges, bought the company that owned Roundup. So I just think it’s an interesting look at the whole situation and something that we’ve probably all consumed before in certain ways, through just fruits and vegetables and different seeds and things. 

Huetteman: Definitely. Shefali, how about your story? 

Luthra: Sure. So I picked a four-part series by my colleague at The 19th, Orion Rummler. The headline for the piece I picked is “Detransition Is Key to Politicians’ Anti-Trans Agenda. But What Is It Really Like?” I think this is a really smart package of stories because, as Orion notes, people who have “detransitioned” — transitioned and then transitioned back — are a really central part of the modern conservative movement’s efforts to target trans health and, in particular, trans health for young people. Saying, look at these people who transitioned and then came back and regretted it. But there hasn’t been a lot of journalism actually looking at people who navigate this experience beyond those who are these political tokens. So Orion does exactly that. He talked to people who have had the experience of transitioning and then detransitioning in some way. 

He notes that this is a pretty rare experience to have this journey with one’s gender, but that the people he interviewed, he profiled, said that they felt really frustrated with how the conversation has unfolded. In fact, their transitioning was an important part of their journey to discover their gender, and that they are deeply concerned that restrictions on trans health could be harmful to them and their loved ones as well. I think this is really valuable journalism, and I’m so excited that Orion did it, and I hope everyone reads it. 

Huetteman: That’s really interesting. Thank you for sharing that one. Sandhya, what do you have this week? 

Raman: So I pick, “Canada Loses Its Measles-Free Status, With US on Track To Follow,” and it’s by Nadine Yousif for the BBC. So this week, the Pan-American Health Organization, Canada is no longer measles-free. And so that means that the Americas region as a whole has lost its elimination status. I thought this was important because in the U.S., we’re at a 33-year high with measles. And Mexico has also seen a surge in cases. And just an interesting way to look at what’s happening a little broader than just the U.S. lens, as all these places are seeing fewer people vaccinated against measles. 

Huetteman: Thanks for sharing that story, Sandhya. My extra credit this week is a great scoop from my KFF Health News colleague Amanda Seitz. The headline is, “Immigrants With Health Conditions May Be Denied Visas Under New Trump Administration Guidance.” Amanda got her hands on a State Department cable that expands the list of reasons that would make visa applicants ineligible to enter the country, including now age or the likelihood they might rely on government benefits. And it gives visa officers quite a bit of power to make those calls.  

Now immigrants, they’re already screened for communicable diseases and mental health problems. But the new guidance goes further and emphasizes that chronic diseases should be considered. And it calls on those visa officers to assess whether applicants can pay for their own medical care, noting that certain medical conditions can “require hundreds of thousands of dollars’ worth of care.” 

All right, that’s this week’s show. Thanks this week to our editor, Stephanie Stapleton, and our producer-engineers, Taylor Cook and Francis Ying. “What the Health?” is available on WAMU platforms, the NPR app, and wherever you get your podcasts. And, as always, on kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on LinkedIn. Where are you folks these days? Sandhya? 

Raman: I’m on X and on Bluesky @SandhyaWrites. 

Huetteman: Shefali? 

Luthra: I’m on Bluesky @Shefali. 

Huetteman: And Anna? 

Edney: X or Bluesky @AnnaEdney. 

Huetteman: We’ll be back in your feed next week. Until then, be healthy. 

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A shaken Hughes was examined in the emergency room, where she was diagnosed with bruising, a deep cut on her knee, and a broken ankle. Physicians recommended immediate surgical repair, she said.

“They said: ‘You have this fracture and a big gaping wound in your knee. We need to take you to the OR to wash it out and make sure there’s no infection,’” she said. “As a clinician, I thought, ‘Yes.’”

She was taken to the operating room in the early evening, then admitted to the hospital overnight.

A friend took her home the next day.

Then the bills came.

The Medical Procedure

Surgeons cleaned the cut on her right knee, which had hit her car’s dashboard, and realigned a broken bone in her right ankle, stabilizing it with metal screws. Surgery is typically recommended when a broken bone is deemed unlikely to heal properly with only a cast.

The Final Bill

$63,976.35, charged by the hospital — which was not in-network with the insurance plan she got through her job — for the surgery and overnight stay.

The Problem: Should I Stay or Should I Go?

Hughes’ insurer, Anthem, fully covered the nearly $2,400 ambulance ride and some smaller radiology charges from the ER but denied the surgery and overnight stay charges from the out-of-network hospital.

“Sixty-three thousand dollars for a broken ankle and a cut to the knee, with no head injury or internal damage,” Hughes said. “Just to stay there overnight. It’s crazy.”

Insurers have broad power to determine whether care is medically necessary — that is, what is needed for treatment, diagnosis, or relief. And that decision affects whether and how much they will pay for it.

Four days after her surgery, Anthem notified Hughes that after consulting clinical guidelines for her type of ankle repair, its reviewer determined it was not medically necessary for her to be fully admitted for an inpatient hospital stay.

If she had needed additional surgery or had other problems, such as vomiting or a fever, an inpatient stay might have been warranted, according to the letter. “The information we have does not show you have these or other severe problems,” it said.

To Hughes, the notion that she should have left the hospital was “ludicrous.” Her car was in a junkyard, she had no family nearby, and she was taking opioid painkillers for the first time.

When she asked for further details about medical necessity determinations, Hughes was directed deep inside her policy’s benefit booklet, which outlines that, for a hospital stay, documentation must show “safe and adequate care could not be obtained as an outpatient.”

It turns out the surgery charges were denied because of an insurance contract quirk. Under Anthem’s agreement with the hospital, all claims for services before and after a patient is admitted are approved or denied together, said Anthem spokesperson Emily Snooks.

A hospital stay is not generally required after ankle surgery, and the insurer found Hughes did not need the kind of “comprehensive, complex medical care” that would necessitate hospitalization, Snooks wrote in an email to KFF Health News.

“Anthem has consistently agreed that Ms. Hughes’ ankle surgery was medically necessary,” Snooks wrote. “However, because the ankle surgery was bundled with the inpatient admission, the entire claim was denied.”

Facing bills from an out-of-network hospital where she was taken by emergency responders, though, Hughes did not understand why she wasn’t shielded by the No Surprises Act, which took effect in 2022. The federal law requires insurers to cover out-of-network providers as though they are in-network when patients receive emergency care, among other protections.

“If they had determined it was medically necessary, then they would have to apply the No Surprises Act cost,” said Matthew Fiedler, a senior fellow with the Center on Health Policy at Brookings. “But the No Surprises Act is not going to override the normal medical necessity determination.”

There was one more oddity in her case. During one of many calls Hughes made trying to sort out her bill, an Anthem representative told her that things might have been different had the hospital billed for her hospitalization as an overnight “observation” stay.

Generally, that’s when patients are kept at a facility so staff can determine whether they need to be admitted. Rather than being tied to the stay’s duration, the designation mainly reflects the intensity of care. A patient with fewer needs is more likely to be billed for an observation stay.

Insurers pay hospitals less for an observation stay than admission, Fiedler said.

That distinction is a big issue for patients on Medicare. Most often, the government health program will not pay for any care needed in a nursing home if the patient was not first formally admitted to a hospital for at least three days.

“It’s a classic battle between providers and insurers as to what bucket a claim falls in,” Fiedler said.

The Resolution

As a physician and a director of a health policy center at the University of Colorado, Hughes is a savvier-than-usual policyholder. Yet even she was frustrated during the months spent going back and forth with her insurer and the hospital — and worried when it looked like her account would be sent to a collection agency.

In addition to appealing the denied claims, she sought the help of her employer’s human resources department, which contacted Anthem. She also reached out to KFF Health News, which contacted Anthem and the Platte Valley Hospital.

In late September, Hughes received calls from a hospital official, who told her they had “downgraded the level of care” the hospital billed her insurance for and resubmitted the claim to Anthem.

In a written statement to KFF Health News, Platte Valley Hospital spokesperson Sara Quale said that the facility “deeply regrets any anxiety this situation has caused her.” The hospital had “prematurely” and erroneously sent Hughes a bill before working out the balance with Anthem, she wrote.

“After a careful review of Ms. Hughes’ situation,” Quale continued, “we have now stopped all billing to her. Furthermore, we have informed Ms. Hughes that if her insurance company ultimately assigns the remaining balance to her, she will not be billed for it.”

Anthem spokesperson Stephanie DuBois said in an email that Platte Valley resubmitted Hughes’ bill to the insurer on Oct. 3, this time for “outpatient care services.”

An explanation of benefits that was sent to Hughes shows the hospital rebilled for around $61,000 — about $40,000 of which was knocked off the total by an Anthem discount. The insurer paid the hospital nearly $21,000.

In the end, Hughes owed only a $250 copayment.

The Takeaway

There are places where patients receiving emergency care at an out-of-network hospital may fall through the cracks of federal billing protections, in particular during a phase that may be nearly indistinguishable to the patient, known as “post-stabilization.”

Generally, that occurs when the medical provider determines the patient is stable enough to travel to an in-network facility using nonmedical transport, said Jack Hoadley, a research professor emeritus at the McCourt School of Public Policy at Georgetown University.

If the patient prefers to stay put for further treatment, the out-of-network provider must then ask the patient to sign a consent form, agreeing to waive billing protections and continue treatment at out-of-network rates, he said.

“It’s very important that if they give you some kind of letter to sign that you read that letter very carefully, because that letter might give them your permission to get some big bills,” Hoadley said.

If possible, patients should contact their insurer, in addition to asking the hospital’s billing department: Are you being fully admitted, or kept under observation status, and why? Has your care been determined to be medically necessary? Keep in mind that medical necessity determinations play a key role in whether coverage is approved or denied, even after services are provided.

That said, Hughes did not recall being told she was stable enough to leave with nonmedical transportation, nor being asked to sign a consent form.

Her advice is to quickly and aggressively question insurance denials once they are received, including by asking for your case to be escalated to the insurer’s and hospital’s leadership. She said expecting patients to navigate complicated billing questions while in the hospital after a serious injury isn’t realistic.

“I was calling family,” Hughes said, “alerting my work colleagues about what happened, processing the extent of my injuries and what needed to be done clinically, arranging care for my pet, getting labs and imaging done — coming to grips with what just happened.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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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As long predicted, much of the federal government shut down on Oct. 1, after Congress failed to agree on spending bills that keep most programs running. Republicans need at least a handful of Democratic votes to pass spending bills in the Senate. In exchange, Democrats demanded Republicans renew expanded premium subsidies for Affordable Care Act marketplace plans, which were passed during the pandemic — effectively forcing their own shutdown over ACA policies, as Republicans did in 2013. Republicans so far have refused to continue the subsidies or even discuss them — but now say they won’t negotiate unless Democrats agree to reopen the government.

Meanwhile, President Donald Trump announced a deal with the drugmaker Pfizer to lower some drug prices in the U.S., but it’s unclear how much of a difference it will make for consumers.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Shefali Luthra of The 19th, and Lauren Weber of The Washington Post.

Panelists

Among the takeaways from this week’s episode:

• Democrats seized an opportunity to highlight how Republican policies are reshaping the health care system, as health care tends to be a winning campaign issue for Democrats. But as they push to extend enhanced federal subsidies and reverse Medicaid cuts, a big question arises: Will Americans notice?
• Meanwhile, some Republicans suggest they are open to renewing enhanced ACA plan subsidies with certain changes — but do not want to address the issue now, even as open enrollment approaches. And in response to Democrats’ calls to undo Medicaid cuts, the GOP is repeating a misleading talking point about benefits for people living in the U.S. without legal status — when, in fact, the policy change would largely help hospitals.
• And vaccine uncertainty continues, with new recommendations from the remade Advisory Committee on Immunization Practices awaiting sign-off — and holding up some vaccine shipments, particularly for uninsured and underinsured kids. Plus, the Trump administration has struck a deal with Pfizer. Other drug companies are likely to follow with their own deals to spare themselves tariffs. What’s less clear is how patients would benefit from these savings.

Also this week, Rovner interviews KFF Health News’ Cara Anthony, who wrote a recent “Bill of the Month” feature about an out-of-network eye surgery that left one kindergartner’s family with a big bill. If you have an outrageous or inexplicable medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too: 

Julie Rovner: KFF Health News’ “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab,” by Michelle Andrews.  

Shefali Luthra: The Washington Post’s “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting,” by Meg Kelly, Joyce Sohyun Lee, Rael Ombuor, Sarah Blaskey, Andrew Ba Tran, Artur Galocha, Eric Lau, and Katharine Houreld.  

Lauren Weber: Time Magazine’s “Trump Is Breaking Americans’ Trust in Doctors,” by Dr. Craig Spencer.  

Rachel Cohrs Zhang: ProPublica’s “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” by Margaret Coker, The Current.  

Also mentioned in this week’s podcast:

• KFF’s “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire,” by Justin Lo, Larry Levitt, Jared Ortaliza, and Cynthia Cox.
• KFF Health News’ “How Federal Shutdown Hits Health Agencies, Explained to Aspen the Corgi,” by Julie Rovner.
• The Washington Post’s “White House Considers Funding Advantage for Colleges That Align With Trump Policies,” by Laura Meckler and Susan Svrluga.
• Politico’s “Top US Researchers Rush To Relocate to Europe,” by Pieter Haeck.
• Bloomberg News’ “RFK Jr. Mulls Adding Autism Symptoms to Vaccine Injury Program,” by Rachel Cohrs Zhang, Madison Muller, and Gerry Smith.
• MSNBC’s “He Helped Build the Anti-Vaccine Movement. RFK Jr. Just Hired Him,” by Brandy Zadrozny.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Oct. 2, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Shefali Luthra of The 19th. 

Shefali Luthra: Hello. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello, hello. 

Rovner: And Rachel Cohrs Zhang of Bloomberg News. 

Rachel Cohrs Zhang: Hi, everyone. 

Rovner: Later in this episode we’ll play my interview with my colleague Cara Anthony, who reported and wrote the latest KFF Health News “Bill of the Month,” about an out-of-network surgery that looked like it had prior approval from the insurer — but maybe not. But first, this week’s news. 

So today is Oct. 2, and to the surprise of just about nobody who’s been paying attention, much of the government is in a shutdown, thanks to Congress’ failure to pass a spending bill or even a temporary patch for the fiscal year that started Wednesday. And just like in 2013, this shutdown is about the Affordable Care Act. Except in 2013 the Republicans shut down the government because they wanted to delay the start of the ACA. This time Democrats are shutting down the government to try to force Republicans to reup the additional ACA subsidies that Democrats passed during the pandemic but which expire at the end of December. That’s just the beginning of the confusion. 

I’m not even going to ask when or how this ends, because truly nobody knows. But there are lots of things that are very different about this shutdown from previous ones, aside from the fact that Democrats, who are usually the ones fighting to keep the government up and running, are the ones who are forcing the shutdown this time. What has changed the most since March, when Democrats went along with a temporary spending measure that they could have blocked at the time? 

Cohrs Zhang: I think obviously we saw a lot of blowback from the Democratic base in response to [Senate Minority Leader] Chuck Schumer’s decision to go along and just continue funding the government. I think the argument has been that it’s not business as usual and that Democratic leaders shouldn’t be treating it that way. And this is one of the few leverage points Democrats have in Washington right now, just because Republicans control the White House and the House and the Senate. So we have seen much more aggressive actions by the White House to exercise control over government spending and testing the waters as to how far they can go to overrule Congress’ directions for how money’s supposed to be spent in the government, which obviously plays into the government spending fight. 

And we’ve also seen the passage of Republicans’ reconciliation bill in the summer, which always poisons the well a little bit when it comes to bipartisan negotiations. Democrats see an opportunity to highlight Republicans’ spending reductions in Medicaid and all these new policies that they’re passing there. And I think Democrats have always viewed health care as a winning issue for them. I think that’s a lesson that they’ve learned over and over again in midterms and elections, that this is just an issue that generally voters think Democrats do a better job on. So I think they’re seeing this as an opportunity to highlight a potential pocketbook issue for health care and setting up for the midterm elections next year. 

Rovner: It’s interesting that back in March, one of the things that Chuck Schumer said is that he didn’t want to close down the government and give [President Donald] Trump basically that much more power. Well, this time they’re giving Trump that much more power and he seems to be running with it. The head of the OMB [Office of Management and Budget], Russ Vought, has already announced on social media that he’s cutting off funding for Democratic priorities, including a tunnel that’s being built between New York and New Jersey and a lot of the green energy projects that were in the Biden administration infrastructure bill, all of which have had money appropriated for them that the administration is supposed to spend. And now just this morning before we started taping, the president himself said he’s going to meet with Russ Vought to see what else they can do to basically throw sand in the gears of Democratic priorities that are supposed to be carried out. I guess this maybe is where Schumer gets to say, See, I told you so back in March. 

Luthra: Potentially. I think it’s worth noting — right? — that a lot of things, which we’ll talk about later, of course, were cut off, in terms of spending that was already allocated, even without the excuse of a shutdown. So it’s not very productive to engage in counterfactuals and hypotheticals, but it’s totally plausible that even without a shutdown a lot of this funding would’ve been cut off anyway. Which — I don’t know. It’s just we are not living under really normal politics anymore, and we can’t really pretend we can know what would’ve happened. 

Rovner: Yes, “unprecedented” is a word I’ve been using a lot lately. Well, we should review what happens to health programs during a shutdown, and I will post a link to the video that I did with my corgi Aspen to help explain it. What’s running and what’s not in terms of health care when the government is, quote-unquote, “shut down”? Because not everything is shut down? 

Cohrs Zhang: I mean, we do have a lot of the core functions continuing in terms of emergency response at the CDC [Centers for Disease Control and Prevention]. They are cutting back on public communications of public health data that are usually pretty routine. The FDA [Food and Drug Administration] has said they’re no longer accepting new drug applications, but obviously the review of applications that they’ve already received will continue because there are a lot of positions at the FDA specifically, but across the government, that are funded through other streams from fees from industry that don’t necessarily go through the routine process. But we certainly will see less information coming out of agencies. Just the general function of them, policy announcements, policy of movement, everything slows down as things that are in motion kind of grind to a halt as everywhere is kind of strained for resources. 

So I think we’ll see. I know at NIH [the National Instituted of Health] they said that they’re not taking in new patients for clinical trials and the grant reviews may be slowed down. So there’s just a lot of things that will slow down. But I think the core functions — of, like, Is this patient care? Is this emergency response? — for the large part are continuing at this time. 

Rovner: And of course mandatory programs, Medicare and Medicaid, continue because they’re not affected by a shutdown, because the shutdown is only for discretionary programs. Lauren, you were going to add something. 

Weber: I was just going to say I was sitting on an unrelated focus group for five hours on Tuesday night, and like 99% of the people when asked Oh, is anything happening in D.C.? had no idea about the shutdown. Like, none. I mean, just absolutely zero idea. So while all of these points are very important to talk through, I also question whether any of the messaging from both sides is getting through to the average person and whether or not the complexities of this are quite clear. 

Rovner: Well, one of the things that the Democrats are shutting the government down over is the failure of Republicans to renew the expanded subsidies for the Affordable Care Act that were passed in 2021 originally and then extended through the end of this year. People are going to find out about those because there’s 24 million people who are getting ACA coverage, and 90% of them are getting subsidies, and they’re all going to find out in the next couple of weeks how much their premiums are going to go up because of the failure to renew these subsidies. How big is this shock going to be? 

Cohrs Zhang: Depends on who it is, right? So, it’s like some people, especially people who are kind of in the higher income range, around 400% of the federal poverty level, if these tax credits expire, they don’t get any subsidies at all anymore. So we could see hundreds of dollars a month for beneficiaries who fall into this category. But for some beneficiaries there’s a smaller dollars-and-cents change that they’re going to see, because they’ll still get some subsidies but not as many. And I think it’s actually unclear who exactly is going to find out about these rate increases. CMS [the Centers for Medicare & Medicaid Services] has given states some flexibility as to whether they put the actual premium increase in these letters that people are going to be getting over the next month. So I think it’s going to be interesting to see how states strategize in terms of communicating with people about the potential for these increases but not scaring them away from the exchange entirely if Washington does manage to figure this out in the next couple weeks. 

Rovner: Yeah, the Republicans keep saying, Oh, this is a December problem. It’s like, no, this is not a December problem. Open enrollment starts Nov. 1, and if people show up and sign up, or if they’re in a plan that suddenly they can’t afford and they might want to move to a cheaper plan if they can find a cheaper plan to move to, I mean, this is definitely not a December problem. 

Luthra: And going back to your question, Julie, I mean, KFF did a very helpful analysis just looking at how much premiums could go up if the tax credits expire. And the last I checked it was they will more than double, which I noticed when my electricity bill went up this year. I think that’s pretty hard for people to not see when suddenly they’re spending potentially twice as much on their health care. 

Rovner: And I will post a link to that analysis which just came out. It’s an updated analysis with new data that shows that premiums are likely to spike even more. Well, one of the big arguments that Republicans are making about this shutdown, because Democrats not only want a renewal of these subsidies, they also want a reversal of a lot of the Medicaid cuts that were in the big budget bill that passed over the summer, and Republicans say Democrats are asking for federal health funding for illegal immigrants, which is not really true. What is it that Democrats are asking for? 

All right. I’m going to have to answer. I will answer this question myself because I went down the rabbit hole on emergency Medicaid. What the bill this summer did is it basically lowered the reimbursement that hospitals get when they provide emergency coverage to people who are not here with documentation. That is a long-standing program. It dates back to 1986, where hospitals can get reimbursed for treating people in medical emergencies who would be eligible for Medicaid other than the fact that they are not documented, meaning undocumented people are not eligible for Medicaid or for Medicare. Shefali, you were saying there’s a lot of this that is used for labor and delivery, right? 

Luthra: Exactly. And I mean if we even think about who benefits from emergency Medicaid, it’s not really undocumented people. It is hospitals, who are required to provide emergency care. But the example where I hear about this a lot is if you are pregnant and you don’t have documentation, you will go to the hospital because you need to give birth, you need to deliver. And emergency Medicaid is what covers the cost of that, which I just found that to be a really interesting point of tension with Republicans given in particular the vice president’s frequent remarks about how much he cares about healthy births and healthy babies. 

Rovner: And there’s a whole brand-new federal program aimed at improving birth outcomes. At the same time, they’re chastising the Democrats for saying, We would like to pay hospitals for delivering healthy babies — who are going to be American citizens, by the way, even if they’re mothers don’t have documentation, unless the Supreme Court changes that. 

Well as if there wasn’t enough to make your head swim here, I think one of the biggest ironies is that if the Democrats get what they want in terms of getting the Republicans to either roll back some of these Medicaid cuts or extend the additional subsidies, isn’t that going to accrue to the benefit of the Republicans? Because if these cuts happen, it’s presumably the Republicans who are going to get blamed come the midterms next year. 

Weber: That’s the irony of all of it, Julie. I mean, that’s the irony of the shutdown. That’s the irony of the messaging. That’s the irony of the whole thing, is that Republicans polls have shown that if these subsidies do increase, if they do double, I mean to Shefali’s point, I think we all notice when — if something costs you a thousand more dollars a year, I think people are going to sit up and pay attention to that. That will cause an issue. So yes, I mean it is somewhat surprising, but at the same day this is a lot of brinksmanship. And again, I question whether the messaging on either side is really cracking through to the American public about why both sides are arguing about the shutdown. 

Rovner: Yeah, they’re not on social media and cable TV in general watching people trade these fact checks back and forth. 

Weber: Yeah. 

Rovner: Well, meanwhile, back at the now partially shut down Department of Health and Human Services, there is still lots of news. We will start with vaccines. Remember that Advisory Committee on Immunization Practices vote a couple of weeks ago that changed recommendations for a whole bunch of vaccines? Well, the committee’s recommendations are not the end of the process. The committee’s work needs to be officially approved by the head of the CDC or the HHS secretary, neither of which has happened yet. Without that approval, shipping can’t begin, for example, for covid vaccines for the federal Vaccines for Children Program, which provides vaccines to about half of all the children in the U.S., by the way. One thing [Health and Human Services] Secretary [Robert F.] Kennedy [Jr.] has apparently done, according to reporting from MSNBC, is hire as a senior adviser to CDC Mark Blaxill, a high-profile anti-vaccine activist who is neither a physician nor a scientist. Is Kennedy just thumbing his nose now at anyone who believes in vaccines, particularly at Republican senator and doctor Bill Cassidy, without whose vote Kennedy would not now have his job? 

Weber: I think Kennedy has been pretty emboldened by the president even going out further than he has publicly on vaccine issues. And I think we’re seeing his continuing leaning into the vaccine point of it all. Which I mean, this is a man who has been an anti-vaccine activist for many, many years. So it’s not completely surprising that he would hire people in that orbit or institute policies that follow what he’s advocated for for many years. 

Rovner: But I mean, just, I say this every week, he promised at his confirmation hearings that he would not go after the vaccine schedule, and he has definitely not kept that promise. 

Weber: Would you say that most politicians promise things that they do or do not keep, Julia, in your many years of coverage? 

Rovner: I don’t consider Cabinet secretaries who promise things to members of Congress who oversee them to be sort of typical politicians. It’s one thing to run for office and then do something else. It’s quite another thing to say in your confirmation hearing for a job that you won’t do something and then just weeks or months later do it. Shefali wanted to add something. 

Luthra: Oh, I was going to say to that point, Julie, when all of us watched those confirmation hearings, it was really striking to see that what RFK promised was also different from his long record of advocacy. And one watching those could come away deciding to believe what he said in the hearings or decide to believe what he said leading up to those hearings. And if you picked one, you’d be more right than if you picked the other. And I think there’s a real question now, I mean, given the point that you raised, Sen. Cassidy’s role in helping him get confirmed, his public remarks about how much he supports vaccines. There is a role Congress can play here to try and change things. And I don’t think we’ve seen that that will actually happen. 

Weber: So, I’m sorry. I just wanted to throw it back to the confirmation hearing itself. Cassidy asked this question directly. He said something, I’m not quoting it directly, but some version of, You’re a 70-something-year-old man. Does a tiger really change his stripes? — and then voted to confirm him. So as Shefali pointed out, I mean he chose to listen to what he said. But I mean I would say his track record in office has certainly not followed suit on those promises. 

Rovner: Well, while we’re on the subject of vaccines, Rachel, you have a story out this week about Kennedy’s plan to add autism to the list of complications eligible for compensation under the federal Vaccine Injury Compensation Program. What would that mean? 

Cohrs Zhang: We’re unclear exactly what they’re planning to do, but they’re planning to change the list of conditions or symptoms that people can claim are related to vaccines in this kind of arbitration process that the federal government has set up to compensate people who do suffer side effects from vaccines. It does happen, and I think there’s bipartisan agreement that the current system for compensating people, it isn’t really working very well. It’s really backed up, and there’s arguments that it doesn’t pay enough for people who experience these things. However, I think Secretary Kennedy has made clear to his advisers that he wants parents who believe their children have autism because of vaccines to be compensated through this program, which doesn’t currently happen. 

Rovner: No. And would probably bankrupt the program, right? 

Cohrs Zhang: It could. It could. Depending on, there’s just so many children these days that do kind of fall under the definition of autism. They’ve talked about maybe changing a definition of some just general neurological symptoms to maybe allow people with autism to qualify. But I think there’s a clear concern from experts as to how this program works, that it’s already backed up and if it’s flooded with these new claims. There’s actually a statutory limit on how many special masters there are to oversee this process. 

And unless Congress acts, then they can’t increase that number. So there’s a point at which, A, if these claims are getting granted that they just run out of money. They’re funded by a fixed tax on vaccine doses. So, again, unless Congress acts, they have a limited amount of money. And then you’re thinking about just the fixed capacity that they have to process these claims in the first place. And I think there is genuine concern here that without some support from Congress, this could completely overwhelm the program and just kind of be a roundabout way to validate the idea that vaccines cause autism. 

So I think there’s much to watch in terms of what the details are coming out. We’ve just had some high-level comments from an adviser, but stay tuned on that and I think it’ll definitely be something to watch. 

Rovner: Oh, absolutely. In other administration news directly affecting HHS and how it provides research funding to universities, The Washington Post is reporting that the White House is working on a plan that would reward institutions that pledge to, quote, “adhere to the values and policies of the Trump administration.” While others are reporting that Trump is about to close a deal with Harvard that involves the U.S.’ most prestigious university paying $500 million to the federal government and, so we hear, opening up and operating trade schools. And in a related piece of news, Politico EU reports that a program run by the EU’s top research council, essentially the EU’s NIH, has seen a fivefold increase in applications from U.S.-based scientists interested in moving across the pond. I’m not even sure what to make of any of this or what it could mean for the future of biomedical research, but it sounds like potentially big, big changes in how the research operation works here in the U.S.? 

Luthra: It does seem like something that could ripple for years if not generations to come. I mean, research is something that happens in years-long installments. Careers are built over very long periods of time. And, I mean, when I’ve spoken to a lot of young academics, whether that is for work or even in a personal capacity, a lot of them are really navigating so much instability that is just not what they anticipated when they began their years-long Ph.D. programs. And so it’s not at all surprising that we are seeing the EU’s efforts to recruit American scientists really bear fruit. But to your point, it absolutely raises the specter that a lot of cutting-edge research, a lot of really great future biomedical work simply won’t happen here and we won’t reap the immediate benefits in a way that we have historically. I mean, our higher education and research sector has been a real crown jewel, and it’s hard to see if that stays the case. 

Rovner: And it’s been a really important contributor to the economy. I mean, it’s not just the benefits of the research itself. It’s the biomedical research establishment has been something that’s been really important to the United States for a couple of generations now. 

Luthra: When you go to a university town, the university is almost always the largest employer and it plays a really big role in keeping up local economies and state economies. And we don’t have a clear answer for what fills in the gap if the institutions that provide those resources disappear or significantly downsize. 

Rovner: So sort of kind of related to what’s going on in the university community, President Trump is also demanding that U.S. drugmakers lower their prices and move manufacturing back to the USA — which he also demanded in his first term, though he was mostly blocked by the courts in the ways he tried to make that happen. Well, now he’s employing the same strategy that he’s using with other countries with tariffs and with universities, by negotiating individually. He’s now negotiating individually with drug companies and threatening bad things if they don’t do what he wants. And lo and behold, this week he announced a deal with Pfizer. Rachel, what has Pfizer promised to do? And what does it mean for what had been a unified wall of resistance by drug companies to Trump’s demands that they lower prices? 

Cohrs Zhang: Yeah, I agree with your take there that this is a symbolic change for the industry that had warned for so long that if you take, like, put even a toe over the line of imported — tying what Americans pay for medicines to what countries abroad pay, that it was going to be a slippery slope and it was a terrifying concept. So that is a big moment. 

We know at a high level what Pfizer’s committed to, but we don’t have a lot of details yet. There’s little in writing, and the press releases were pretty vague. But at a high level, I think Pfizer has agreed to reduce the prices that they offer state Medicaid programs and make those more in line with what prices abroad are. Again, Medicaid already gets really low prices for drugs, so it really is going to be a drug-by-drug, I think, question of: Is this price even lower? I think in some cases, the experts I’ve spoken with think that it’s possible that Medicaid could save money on some of these drugs, but some of them the price could be higher. And I think there’s a question of exactly what those mean. And drug pricing’s really hard, and they aren’t necessarily public, what each payer is paying for these things. So that’s one big element of this that’s important. 

They’re also agreeing to sell some of their medicines online, straight to consumers, on a website branded TrumpRx. And I think it’s just kind of like a platform, like a shopping platform is how they’ve described it. You can type in the drug name and then the website would direct you to the marketplaces that the drug companies run themselves. 

Rovner: And that just cuts out the middlemen, right? That doesn’t itself save money — I mean, save money for consumers. 

Cohrs Zhang: Right. The price may be discounted, but most people aren’t paying the net price of what their insurer pays for a lot of medicines. They’re paying a copay or a percentage. So again, for some medicines, if you’re uninsured, yeah, it’s a lot better to pay a discounted price. But if you have insurance, it’s unclear how, whether you would save any money by going through this process. And you have to have a prescription anyway for a lot of these medicines. So I think there’s just a lot of unanswered questions about exactly how that would interplay for patients with insurance. And then you also have assurances that Pfizer will launch medicine prices that are kind of aligned with what they charge other countries. Generally companies launch in the U.S. first. So does this create a new floor and leverage for Pfizer? I think that’s going to be a really interesting question. 

And then I think the last commitment that they made was if they raise prices in other countries for medicines that some of this increased revenue that they get from those drug sales abroad would go back to the federal government potentially through the Medicare program. But we don’t have a lot of details. 

Rovner: I saw a story just before we started taping that not only has Pfizer stock gone up since this announcement, but other drug companies’ stocks have gone up since this announcement. Obviously in exchange for this deal, Pfizer has been sort of absolved from having to pay the tariffs that Trump has threatened for three years. And the idea is that other drug companies are likely to make these same deals, which certainly the stock market thinks is not going to cause them to lose money, which suggests that it’s not going to cause big savings for consumers, right? 

Cohrs Zhang: Yes. I think that’s a good question, and it is important that analyst notes have expressed that Pfizer’s U.S. revenue, only like 5% of it is for Medicaid. So it’s a very small amount of what they make on drugs. But I think there is this looming regulatory option where Trump could kind of force drugmakers to comply with price reductions in other programs if they don’t make deals. So I don’t think this story is over. And they’ve foreshadowed that more deals are coming, and they may not have exactly the same terms as Pfizer. So I think we’re very much staying tuned here. 

Rovner: Well, we will cover them as they happen. OK, that is this week’s news. Now we’ll play my “Bill of the Month” interview with Cara Anthony, and then we’ll come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ Cara Anthony, who reported and wrote the latest KFF Health News “Bill of the Month.” Cara, welcome back. 

Cara Anthony: Hey, thanks for having me. 

Rovner: So this month’s patient — or her family, more accurately — did everything right before an elective surgery. At least they thought they did. Tell us who the patient was and what kind of care she needed. 

Anthony: Yeah, this month we introduced our readers to a little girl named Chloë Jones. She was in kindergarten at the time. She needed an elective surgery. She had a condition known as ptosis. In layman’s terms, that just means that she had a droopy eyelid. Her parents didn’t want this to interfere with her vision in the future, and so they elected to have this surgery. 

Rovner: And they lived where? 

Anthony: Just outside of St. Louis, pretty close to me, actually. But here’s the thing: They had a hard time finding a provider who was in network, and the story kind of goes on from there. 

Rovner: Yeah. So I guess pediatric ophthalmologists are not a dime a dozen. And they did find somebody. And knowing that it was out of network, they asked their insurer for permission, right? 

Anthony: Yeah. They asked for something called a gap exception and actually worked with their pediatrician, worked with Chloë’s primary care doctor, who wrote a letter on their behalf to say: Hey, she needs to have this surgery. Would you honor it as an in-network treatment? Because the closest person that could do this surgery was in Wisconsin, which wasn’t reasonable for them. This is a family with a lot of little kids. So they did. They dotted all of the i’s, crossed all the t’s — or so they thought, because they ended up with a huge bill. 

Rovner: Yeah. So then she has the surgery, everything is great, and then the bill comes. How big was the bill? 

Anthony: Thirteen thousand dollars, Julie, which was a huge surprise to the family. They didn’t have the means to pay that. So immediately, Chloë’s mom, Keyanna Jones, starts to ask questions, making phone calls, trying to figure out, Hey, what’s going on? They only paid just under $2,000, and there was no way they could pay a $13,000 bill. 

Rovner: So they had this letter from the insurance company that said that they would cover this. What happened? 

Anthony: Yeah, and this is why we had to ask ourselves in this case: What does covered actually mean? And in this case, the insurers said that they would cover it though without offering network discounts, the surgery itself. Now, some of her other exams that she needed, they did honor those as in network and that was fine. But the surgery itself was covered, but they weren’t willing to cover it as in network and offer those discounts, which would’ve made it much more reasonable, which is why we ended up with the $13,000 bill. 

But the tricky part here is that they received letters that looked basically identical. So the letters that said that they would get those in-network discounts were just for the pre-surgery and some post-surgery exams. Those look the same as the letter that said that they were covered for the surgery. But in that letter, the insurer explained that, Hey, we are not going to offer you network discounts. So the family was really confused here, and they had to ask for some serious help. 

Rovner: And what finally happened with the bill? 

Anthony: Well, Keyanna has a brother who was a former state senator. So she got so frustrated with the situation, she reaches out to her brother, who’s former state Sen. Caleb Rowden, here in Missouri, and he says, Hey, reach out to the senator who represents you, Sen. Travis Fitzwater, and they got the ball rolling. She also reached out to the Missouri attorney general, wrote a letter. Representative Fitzwater also contacted the hospital and the insurer, and they worked it out. So it’s really important for people to know that they can contact their local lawmakers, and that’s what they do — they advocate for their constituents. And in this case, the family paid absolutely nothing. 

Rovner: So eventually the bill was basically completely taken care of? 

Anthony: It was taken care of completely. They didn’t even have to pay the copay. That’s how much this was kind of messed up. And UnitedHealthcare and both the hospital here in St. Louis just said: You know what? We’re done. So kind of wild. 

Rovner: So what’s the takeaway here, besides that you can go for help? I mean, that’s obviously a big piece of it. But what’s the takeaway in the asking permission and getting what we think of as these prior authorizations, these preapproval letters for things like elective surgery? 

Anthony: Yeah. I think the main thing is that even if the letters look the same, you have to read every line, make sure that you have clarity there. But it’s also, here’s another reflection of how complicated our health care system is. And in this case, the family had a happy ending. But I don’t know, had she not contacted her brother, who’s a state senator, and not everybody has that kind of advantage. But everyone can contact their local lawmaker for help. But in this case, I would just say read the fine print, and if you think you understand it, read it again because there might be something in there that you’ll catch, and hopefully you can avoid a huge bill. But I’m glad this family was taken care of. 

Rovner: Oh, good advice. Cara Anthony, thank you so much. 

Anthony: Hey, thanks for having me, Julie. 

Rovner: OK, we are back. It’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Shefali, you chose first this week. Why don’t you go first? 

Luthra: Sure. My story is from The Washington Post. I normally try and give every byline, but there are a lot. Many journalists really worked very hard on this piece. The headline is “Trump’s USAID Pause Stranded Lifesaving Drugs. Children Died Waiting.” And it’s a very impressive, in-depth investigation. It takes us to Congo, where we meet a young girl who has malaria, and she dies because she can’t get the medication she needs even though it is less than 10 miles away. And the medication never comes to her, because of the freeze on USAID [U.S. Agency for International Development] funding, and this is the taking of U.S. aid inside the State Department. 

The story does a remarkable job following the grants and orders that were stopped in the United States when we have the USAID freeze take effect. And then it takes us to the people who suffered and whose lives were lost, including many children, because they couldn’t get medication that was actually not even that far away but simply couldn’t travel the last few miles to get there. It puts all of these against Secretary of State Marco Rubio’s promise that no one has died because of the USAID funding freeze and shows that that probably isn’t true. I mean, not probably, that isn’t true, because these people here in this story did in fact die because they couldn’t get medications that we purchased and sent there and then simply could not get the final step there. I think it’s a really great look at just how devastating this policy choice has been and will continue to be around the world. 

Rovner: Yeah, it was quite an impressive project. Lauren. 

Weber: I picked an op-ed in Time by Dr. Craig Spencer titled “Trump Is Breaking Americans’ Trust in Doctors.” It’s an op-ed after Trump and RFK Jr. talked about Tylenol and Trump went on to talk about vaccines and what that means for the rest of the country. And I will just say personally, I’ve been struck by how many of my friends from the Midwest, mom friends, regular friends, have reached out like: Hey, you are a reporter for The Washington Post that covers health. What is this? And I do think the Tylenol press conference really broke through in a way that a lot of other things have not. 

And Craig makes a bunch of different points about how it essentially pits doctors against the president. And what does that do for decaying trust in medical authorities? What does it do for trust in authorities, period? And I think that’s a question we’re going to continue to see bear out over the next couple of years. 

Rovner: Yeah, I think the byword of 2025 is “losing trust.” Rachel. 

Cohrs Zhang: My extra credit this week is in ProPublica. The headline is “Georgia’s Medicaid Work Requirement Program Spent Twice as Much on Administrative Costs as on Health Care, GAO Says,” and that’s by Margaret Coker with The Current. And I just thought this story did a great job of just kind of being grounded in the local reporting of: What have we seen? I think there’s tremendous interest in how some of these Medicaid policies that Republicans have committed to will play out across the country. We know state Medicaid officials are already scrambling. Insurance companies, hospitals are trying to figure out: How are we going to implement work requirements at the beginning of 2027? And I think this is a really interesting test project of what that could mean. And I think the administrative burden should not be underestimated, and I think this is just a great way to quantify the infrastructure you need to run a program like this. And I think if you’re spending more on the infrastructure to track people than on the actual health care, then I think that just raises questions about the program as a whole and how efficiently it’s running. So. 

Rovner: I would say a lot of eyes on Georgia because they’ve got the only one that’s actually up and running at the moment that people can study. 

My extra credit this week is from KFF Health News by Michelle Andrews, and it’s called “Big Loopholes in Hospital Charity Care Programs Mean Patients Still Get Stuck With the Tab.” And it’s about how stupid and bifurcated our health system now is that you can go to a hospital, get approved for charity care, and then still get billed into bankruptcy by doctors who work at the hospital but not for the hospital. It’s kind of a perfect case study into just how dysfunctional things have gotten, and with the impending Medicaid cuts and the ACA premium increases, lots more people are going to become uninsured and likely fall into this same trap. It’s really good story. 

All right, that is this week’s show. Thanks this week to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. If you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can find me on X, @jrovner, or on Bluesky, @julierovner. Where are you folks hanging these days? Rachel. 

Cohrs Zhang: I’m still on X, @rachelcohrs. 

Rovner: Shefali? 

Luthra: I’m Bluesky, @shefali. 

Rovner: Lauren. 

Weber: I’m on X and Bluesky, @LaurenWeberHP. 

Rovner: Excellent. We will be back in your feed next week. Until then, be healthy. 

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“I could hear the bones moving around in my elbow,” said Buttgereit, who was 60 when she slipped on a patch of ice in December outside her apartment in Bozeman, Montana.

Emergency room scans showed she had fractured her left arm near the joint. Doctors told her she needed surgery to repair it.

At the time, Buttgereit didn’t have health insurance — she had struggled to afford coverage after her husband’s death. The local health system, Bozeman Health, estimated Buttgereit would have to pay $50,560 out-of-pocket for the outpatient surgery to have her elbow pieced back together.

The estimate noted: “You could be charged more if complications or special circumstances occur.”

Four days after her fall, Buttgereit went in for surgery, which took about three hours. During a follow-up visit, she said, her doctor told her the procedure ended up being more complicated than expected.

Then the bill came.

The Medical Procedure

Buttgereit broke her humerus, the upper-arm bone that meets two other bones and forms the elbow. The way the bone splintered is known as a distal humerus fracture. It’s rare as far as breaks go, accounting for only about 2% of all fractures among adults. But older people, as well as kids in high-contact sports, are more prone to the big falls that lead to such fractures. The injury is painful and can make it impossible to move the elbow.

Some of these types of fractures heal with time in a splint, but most often surgery is the only fix. The patient is put under anesthesia while a surgeon repositions fragmented bones with plates and screws.

The Final Bill

$97,998. That includes at least $44,300 for the operating room and anesthesia administration, plus more than $50,000 for medical supplies and implants, such as screws and plates. After the hospital applied a self-pay discount, Buttgereit was on the hook for $78,398.40.

The Problem: Surprise Complications, Surprising Charges 

The hospital said the price for Buttgereit’s surgery increased because doctors encountered complications midprocedure.

In particular, the fall had shattered Buttgereit’s bone into more pieces than her surgeon anticipated, according to operating notes. That meant it took more time, skill, and supplies to reconstruct her elbow. And, since she was uninsured, Buttgereit alone faced the burden to pay the higher costs.

“I’ll make payments the rest of my life to pay it all off,” she said.

Buttgereit’s husband died suddenly in 2023. About a year later, she left her job with the company that had employed them both. The memories of him in that space were too difficult, she said. That also meant leaving behind her health coverage. She moved to Bozeman to be closer to one of her daughters and found a health plan at healthcare.gov that the federal government subsidized because of her limited income.

But she also faced a higher cost of living in Bozeman than her Social Security benefits could cover, and she needed part-time work. While that new income helped pay her bills, Buttgereit said, she no longer qualified for the same level of subsidized coverage and couldn’t afford her plan. So she dropped her health insurance.

About two months later, she fell.

After getting the surgery bill, Buttgereit began calling and emailing the hospital’s customer service team, asking how the price had risen from the $50,560 estimate to nearly $98,000. The hospital had automatically applied the self-pay discount of $19,600 to Buttgereit’s bill — 20% of the total. But that still left her with a tab of more than $78,000.

After more time to think pain-free, she said, she also wanted to know why the initial estimate was much steeper than those she found online for similar procedures.

Specifically, Buttgereit asked how to dispute her bill. When she felt she wasn’t making progress contesting the charges with the hospital, she asked about her options under the No Surprises Act, a federal consumer protection law.

According to emails reviewed by KFF Health News, a Bozeman Health billing employee incorrectly told Buttgereit the law applies only to ER services. The employee later said Buttgereit had the right to dispute the bill but gave her an incorrect deadline.

Hospital staffers recommended Buttgereit set up a payment plan and apply to the health system’s financial aid program.

Erin Schaible, a spokesperson with Bozeman Health, told KFF Health News that online estimates don’t reflect the specific details of a patient’s care. In addition to the shattered bones noted in Buttgereit’s surgery notes, Schaible said the physician identified nerve damage midsurgery that required additional work to fix.

“This situation highlights the importance of clear and compassionate communication,” Schaible said. “In response, our team leaders are revising internal protocols for escalating patient concerns and are reeducating staff on best practices for communicating cost estimate changes.”

The Resolution

Buttgereit refused to apply for financial aid, opting instead to challenge what she sees as inflated pricing. Using Healthcare Bluebook, an online price comparison tool that draws on insurance claims data, Buttgereit found similar procedures ranged from $8,000 to $40,000.  

She said she believes that there are also errors on her bill and that the complications didn’t justify the price.

“I felt like going through financial assistance means that I’m OK with the price of the bill,” she said. “I want to get the bill reduced on the front end and then, if I need financial assistance, go through it.”

A billing employee emailed Buttgereit in May to offer an additional $7,000 discount if she set up a payment plan. If she later qualified for financial assistance, “we will adjust the amount accordingly,” the email said.

In June, the employee told Buttgereit her account would be put on hold before a collection process was initiated, “so that you have time to decide what to do.”

Buttgereit agreed to a payment plan of $100 a month, though she continued to contest the total charges.

At that rate, it would take about 60 years to pay off the debt — or longer, if the health system were to charge interest.

Buttgereit made one more bid for help: She emailed the White House.

This month, in the same week she got a detailed letter from the hospital standing by its charges, Buttgereit said she received a call from an official with the Centers for Medicare & Medicaid Services, saying she could dispute the bill to federal health officials.

The Takeaway

The best time to push back against a price is before surgery, upon receiving a hospital’s best guess on costs, known as a “good faith estimate.” Otherwise, undergoing surgery is considered tacit acceptance of that price as a baseline.

Patricia Kelmar, director of health care campaigns at the national consumer advocacy group U.S. PIRG, follows ways in which people get tangled financially in the health industry. She said patients should compare cost estimates by searching their hospital’s online pricing tool (as well as those of nearby hospitals) to see whether the estimates align. But not every procedure makes those lists, especially those for uncommon injuries, nor is every hospital’s list easy to access and navigate.

Post-surgery, patients have few resources to fight big bills, but a little-known rule in the No Surprises Act could help, Kelmar said.

The law, which took effect in 2022, is best known for protecting patients from surprise bills for out-of-network, emergency care. But it also created a formal dispute process for uninsured patients, or those paying completely out-of-pocket for nonemergency procedures, if their final tab is $400 or more than the initial estimate.

“This is a valid, important part of making sure that patients who are cash-pay have a watchdog,” Kelmar said.

People can start the patient-provider dispute process online, through the CMS website, by providing medical records and paying a $25 fee. Patients must initiate the process within 120 days of receiving the bill, and the bill may not be sent to a collection agency while under review.

An independent reviewer evaluates whether the final price is drastically different from what a health insurance company would have paid and whether the complication was predictable. If the review finds that the health provider erred on either front, federal health officials could require them to reduce the bill to match the original estimate or the median price insurers pay.

Buttgereit said she initially opted against pursuing that formal dispute process because, after such a review, the floor would be the hospital’s initial estimate, and she still had questions about how it would work. But after hearing from CMS, Buttgereit said it’s the path she plans to take.  

“You’ve got to fight for yourself,” she said. “I don’t know where this is going to end up, but I feel a little bit more hopeful.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!

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).