Health and Fitness Tips

Journalists Explain Colorectal Cancer Risk and Federal Pullback on Georgia Disability Oversight

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed on CBS News 24/7’s The Daily Report on Feb. 16 how the recent deaths of two actors sparked searches for colorectal cancer information.

Click here to watch Gounder on The Daily Report.

KFF Health News Southern correspondent Sam Whitehead discussed on WUGA’s The Georgia Health Report on Feb. 13 how the Justice Department is pulling back its oversight of Georgia’s system for people with disabilities.

Click here to hear Whitehead on The Georgia Health Report.
Read Whitehead’s “Georgians With Disabilities Are Still Being Institutionalized, Despite Federal Oversight.”

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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MAHA Moms Turn Against Trump: ‘Women Feel Like They Were Lied To’

President Trump’s executive order aimed at spurring production of a pesticide has infuriated leaders of Health Secretary Robert F. Kennedy Jr.’s MAHA movement.

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A Cancer Detection Test Fails in Major Study

A closely watched clinical trial in Britain that screened blood for early detection of cancer did not show a reduction in later stages of the disease.

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Should Drug Companies Be Advertising to Consumers?

Tamar Abrams had a lousy couple of years in 2022 and ’23. Both her parents died; a relationship ended; she retired from communications consulting. She moved from Arlington, Virginia, to Warren, Rhode Island, where she knew all of two people.

“I was kind of a mess,” recalled Abrams, 69. Trying to cope, “I was eating myself into oblivion.” As her weight hit 270 pounds and her blood pressure, cholesterol, and blood glucose levels climbed, “I knew I was in trouble health-wise.”

What came to mind? “Oh, oh, oh, Ozempic!” — the tuneful ditty from television commercials that promoted the GLP-1 medication for diabetes. The ads also pointed out that patients who took it lost weight.

Abrams remembered the commercials as “joyful” and sometimes found herself humming the jingle. They depicted Ozempic-takers cooking omelets, repairing bikes, playing pickleball — “doing everyday activities, but with verve,” she said. “These people were enjoying the hell out of life.”

So, just as such ads often urge, even though she had never been diagnosed with diabetes, she asked her doctor if Ozempic was right for her.

Small wonder Abrams recalled those ads. Novo Nordisk, which manufactures Ozempic, spent an estimated $180 million in direct-to-consumer advertising in 2022 and $189 million in 2023, according to MediaRadar, which monitors advertising.

By last year, the sum — including radio and TV commercials, billboards, and print and digital ads — had reached an estimated $201 million, and total spending on direct-to-consumer advertising of prescription drugs topped $9 billion, by MediaRadar’s calculations.

Novo Nordisk declined to address those numbers.

Should it be legal to market drugs directly to potential patients? This controversy, which has simmered for decades, has begun receiving renewed attention from both the Trump administration and legislators.

The question has particular relevance for older adults, who contend with more medical problems than younger people and are more apt to take prescription drugs. “Part of aging is developing health conditions and becoming a target of drug advertising,” said Steven Woloshin, who studies health communication and decision-making at the Dartmouth Institute.

The debate over direct-to-consumer ads dates to 1997, when the FDA loosened restrictions and allowed prescription drug ads on television as long as they included a rapid-fire summary of major risks and provided a source for further information.

“That really opened the door,” said Abby Alpert, a health economist at the Wharton School of the University of Pennsylvania.

The introduction of Medicare Part D, in 2006, brought “a huge expansion in prescription drug coverage and, as a result, a big increase in pharmaceutical advertising,” Alpert added. A study she co-wrote in 2023 found that pharmaceutical ads were much more prevalent in areas with a high proportion of residents 65 and older.

Industry and academic research have shown that ads influence prescription rates. Patients are more apt to make appointments and request drugs, either by brand name or by category, and doctors often comply. Multiple follow-up visits may ensue.

But does that benefit consumers? Most developed countries take a hard pass. Only New Zealand and, despite the decadelong opposition of the American Medical Association, the United States allow direct-to-consumer prescription drug advertising.

Public health advocates argue that such ads encourage the use and overuse of expensive new medications, even when existing, cheaper drugs work as effectively. (Drug companies don’t bother advertising once patents expire and generic drugs become available.)

In a 2023 study in JAMA Network Open, for instance, researchers analyzed the “therapeutic value” of the drugs most advertised on television, based on the assessments of independent European and Canadian organizations that negotiate prices for approved drugs.

Nearly three-quarters of the top-advertised medications didn’t perform markedly better than older ones, the analysis found.

“Often, really good drugs sell themselves,” said Aaron Kesselheim, senior author of the study and director of the Program on Regulation, Therapeutics, and Law at Harvard University.

“Drugs without added therapeutic value need to be pushed, and that’s what direct-to-consumer advertising does,” he said.

Opponents of a ban on such advertising say it benefits consumers. “It provides information and education to patients, makes them aware of available treatments and leads them to seek care,” Alpert said. That is “especially important for underdiagnosed conditions,” like depression.

Moreover, she wrote in a recent JAMA Health Forum commentary, direct-to-consumer ads lead to increased use not only of brand-name drugs but also of non-advertised substitutes, including generics.

The Trump administration entered this debate last September, with a presidential memorandum calling for a return to the pre-1997 policy severely restricting direct-to-consumer drug advertising.

That position has repeatedly been urged by Health and Human Services Secretary Robert F. Kennedy Jr., who has charged that “pharmaceutical ads hooked this country on prescription drugs.”

At the same time, the FDA said it was issuing 100 cease-and-desist orders about deceptive drug ads and sending “thousands” of warnings to pharmaceutical companies to remove misleading ads. Marty Makary, the FDA commissioner, blasted drug ads in an essay in The New York Times.

“There’s a lot of chatter,” Woloshin said of those actions. “I don’t know that we’ll see anything concrete.”

This month, however, the FDA notified Novo Nordisk that the agency had found its TV spot for a new oral version of Wegovy false and misleading. Novo Nordisk said in an email that it was “in the process of responding to the FDA” to address the concerns.

Meanwhile, Democratic and independent senators who rarely align with the Trump administration also have introduced legislation to ban or limit direct-to-consumer pharmaceutical ads.

Last February, independent Sen. Angus King of Maine and two other sponsors introduced a bill prohibiting direct-to-consumer ads for the first three years after a drug gains FDA approval.

King said in an email that the act would better inform consumers “by making sure newly approved drugs aren’t allowed to immediately flood the market with ads before we fully understand their impact on the general public.”

Then, in June, he and independent Sen. Bernie Sanders of Vermont proposed legislation to ban such ads entirely. That might prove difficult, Woloshin said, given the Supreme Court’s Citizens United ruling protecting corporate speech.

Moreover, direct-to-consumer ads represent only part of the industry’s promotional efforts. Pharmaceutical firms actually spend more money advertising to doctors than to consumers.

Although television still accounts for most consumer spending, because it’s expensive, Kesselheim pointed to “the mostly unregulated expansion of direct-to-consumer ads onto the web” as a particular concern. Drug sales themselves are bypassing doctors’ practices by moving online.

Woloshin said that “disease awareness campaigns” — for everything from shingles to restless legs — don’t mention any particular drug but are “often marketing dressed up as education.”

He advocates more effective educational campaigns, he said, “to help consumers become more savvy and skeptical and able to recognize reliable versus unreliable information.”

For example, Woloshin and Lisa Schwartz, a late colleague, designed and tested a simple “drug facts box,” similar to the nutritional labeling on packaged foods, that summarizes and quantifies the benefits and harms of medications.

For now, consumers have to try to educate themselves about the drugs they see ballyhooed on TV.

Abrams read a lot about Ozempic. Her doctor agreed that trying it made sense.

Abrams was referred to an endocrinologist, who decided that her blood glucose was high enough to warrant treatment. Three years later and 90 pounds lighter, she feels able to scramble after her 2-year-old grandson, enjoys Zumba classes, and no longer needs blood pressure or cholesterol drugs.

So Abrams is unsure, she said, how to feel about a possible ban on direct-to-consumer drug ads.

“If I hadn’t asked my new doctor about it, would she have suggested Ozempic?” Abrams wondered. “Or would I still weigh 270 pounds?”

The New Old Age is produced through a partnership with The New York Times.

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Investigators Blame NASA and Boeing for Starliner Failures

Technical and oversight problems left two astronauts aboard the International Space Station for months longer than had been expected.

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The Host

Mary Agnes Carey KFF Health News @maryagnescarey Read Mary Agnes' stories.

The midterm elections are months away, yet changes at the Department of Health and Human Services suggest the Trump administration is focusing on how to win on health care, which remains a top concern for voters. Facing growing concern about the administration’s actions on vaccines in particular, the Food and Drug Administration this week reversed course and said it would review a new mRNA-based flu vaccine after all.

And some top HHS officials are changing seats as the Senate prepares for the long-delayed confirmation hearing of President Donald Trump’s nominee for surgeon general, Casey Means.

This week’s panelists are Mary Agnes Carey of KFF Health News, Tami Luhby of CNN, Shefali Luthra of The 19th, and Lauren Weber of The Washington Post.

Panelists

Tami Luhby CNN @Luhby Read Tami's stories. Shefali Luthra The 19th @shefali.bsky.social Read Shefali's stories. Lauren Weber The Washington Post @LaurenWeberHP Read Lauren's stories.

Among the takeaways from this week’s episode:

After a week of bad press, the FDA announced it would review Moderna’s application for a new flu vaccine. Yet the agency’s original refusal fits a pattern of agency decision-making based on individual officials’ views rather than set guidelines — and reinforces a precedent that’s problematic for drug development.
Those caught up in the latest HHS leadership shake-up include Jim O’Neill, who, as acting director of the Centers for Disease Control and Prevention, signed off on changes to the childhood vaccine schedule. His removal from that role comes as the White House is showing more interest in controlling health care messaging ahead of the midterms — and as polling shows Americans are increasingly concerned about federal vaccine policy.
Senators will hear from Means next week as they consider her nomination as surgeon general. Means, a key figure in the “Make America Healthy Again” movement, is expected to be asked about her medical credentials and past, problematic claims about medicine.
And while early numbers show that Affordable Care Act marketplace enrollment has not dipped as much as feared, Americans are still absorbing the rising cost of health care this year. The collapse of congressional efforts to reach a deal on renewing enhanced premium subsidies could be an issue for voters come November.

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

Mary Agnes Carey: Politico’s “Why Congress Failed To Reach an Obamacare Deal,” by Robert King and Simon J. Levien.

Lauren Weber: NiemanLab’s “The Atlantic’s Elizabeth Bruenig on Her ‘Hypothetical,’ Heavily Reported Measles Essay,” by Laura Hazard Owen.

Tami Luhby: The City’s “NewYork-Presbyterian Nurses Reject Contract by Overwhelming Margin,” by Claudia Irizarry Aponte and Ben Fractenberg.

Shefali Luthra: NPR’s “Minneapolis Doctors Warn of Lasting Medical Effects, Even After ICE Agents Leave,” by Jasmine Garsd.

Also mentioned in this week’s episode:

Politico’s “FDA’s Reversal on Moderna Flu Shot Bid Followed White House Pressure,” by Lauren Gardner and Tim Röhn.
The Washington Post’s “How RFK Jr. Upended the Public Health System,” by Rachel Roubein, Lena H. Sun, and Lauren Weber.
CNN’s “Trump Promised RFK Jr. Would ‘Restore Faith in American Health Care.’ A Year in, Trust Has Plummeted,” by Meg Tirrell.
The Washington Post’s “She Left the Medical Mainstream and Rose To Be RFK Jr.’s Surgeon General Pick,” by Lauren Weber and Rachel Roubein.
KFF’s “KFF Health Tracking Poll: Health Care Costs, Expiring ACA Tax Credits, and the 2026 Midterms,” by Shannon Schumacher, Audrey Kearney, Mardet Mulugeta, Isabelle Valdes, Ashley Kirzinger, and Liz Hamel.
CNN’s “Trump Wants To Focus on Health Care in the Midterms, Creating Headaches for the GOP,” by Adam Cancryn.
Health Affairs’ “HHS Proposes Sweeping Changes for 2027 Marketplace Plans (Part 1),” by Katie Keith.
Health Affairs’ “HHS Proposes Sweeping Changes for 2027 Marketplace Plans (Part 2),” by Katie Keith and Matthew Fiedler.
Health Affairs’ “HHS Proposes Sweeping Changes for 2027 Marketplace Plans (Part 3),” by Katie Keith.

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Francis Ying Audio producer Emmarie Huetteman Editor

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An Arm and a Leg: Personal Finance Guru Faces Down an Insurance Denial

Less than 36 hours before his wife was scheduled to undergo major surgery, New York Times personal finance columnist Ron Lieber got an unwelcome letter from his family’s insurance plan: It was denying prior authorization for the procedure.

With no time to lodge an appeal, Lieber and his wife decided to proceed and bet on her doctors’ ability to reverse the decision post-surgery. They succeeded, but the experience troubled Lieber. Why had no one warned them sooner? He set out to find answers to help people avoid scrambling to deal with a last-minute denial.

In this episode of An Arm and a Leg, Lieber shares with host Dan Weissmann takeaways from his New York Times series about how doctors and other health care clinicians can do a better job of keeping patients informed.

Dan Weissmann @danweissmann @danweissmann.bsky.social Host and producer of "An Arm and a Leg." Previously, Dan was a staff reporter for Marketplace and Chicago's WBEZ. His work also appears on "All Things Considered," the BBC, "99% Invisible," and "Reveal," from the Center for Investigative Reporting.

Credits

Emily Pisacreta Producer Claire Davenport Producer Adam Raymonda Audio wizard Ellen Weiss Editor Click to open the Transcript Transcript: NYT’s Ron Lieber: ‘These people are not going to win.’

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

Dan: Hey there. Let’s meet somebody.

Ron Lieber: I’m Ron Lieber. I write the “Your Money” column for the New York Times. I write all sorts of books, and I live in Brooklyn, New York.

Dan: Ron’s specialty is beating the system: How to not pay more than you really need to. His most recent book — about paying for college — we’ve practically worn out our copy around my house.

Now, it’s possible Ron’s not the most prominent journalist in his household. A major Hollywood movie a few years ago had Zoe Kazan starring as Ron’s wife, Jodi Kantor.

Zoe Kazan as Jodi Kantor: Hi. We’re from the New York Times. I believe you used to work for Harvey Weinstein.

Dan: She was one of the reporters who exposed the movie producer Harvey Weinstein’s history of sexual assault, and helped kick start the Me Too movement. I mean, that’s hard to beat.

In 2024, Jodi was diagnosed with breast cancer, and she got scheduled for surgery at Memorial Sloan Kettering on a Monday morning in December.

Ron Lieber: And she was doing all the things you’re supposed to do to get ready for surgery. She did the meditation for a week and, you know, she wound down everything at work she went away for a couple days with friends.

Dan: So on Saturday, two days before surgery, Jodi is on that trip with friends. Ron spends the day with their 9-year-old, just the two of them.

Ron Lieber: And we get home and there’s a pile of mail and I put the 9-year-old to bed and I start going through the mail and there is a fat envelope from United Healthcare.

Dan: Ron says he suspects right away that it’s bad news about the surgery.

Ron Lieber: And sure enough it’s, you know, kind of pages of gobbledygook, but it’s clear from the cover page, that they’re issuing a partial denial, in effect, and we have, flunked partially, our prior authorization test.

Dan: Prior authorization. It rings a bell. He does a quick search to get his bearings– and quickly realizes: This is a HUGE phenomenon. It hasn’t hit him personally before, but it hits millions of people every year.

Ron Lieber: So at this point, a whole bunch of stuff goes through my head.

Dan: First, professional embarrassment. Ron’s a personal finance columnist at the New York Times. And he’s thinking: how could he have missed something that causes so much personal financial distress to so many people?

Ron Lieber: I had that same feeling that I did in 2008.

Dan: When the financial crisis hit and he hadn’t seen it coming.

Ron Lieber: Back in 2008. It was, you know, Ron, why did you not become an expert on mortgage securitization before now?

Dan: This time, it’s prior authorization. Ron manages to forgive himself pretty quickly on that score– and move on to more pressing concerns.

Ron Lieber: The first thing I gotta figure out is: What am I gonna say to Jodi?

Dan: Is he gonna crash her pre-op mellow she’s worked so hard for?

And second: How worried should they be?

Ron Lieber: Should we show up on Monday? What’s the worst thing that can happen? And so I’m starting to do mental math, like what’s the rack rate for this procedure anyway, and I’m thinking, eh, probably 150- $200,000. Right?

Dan: Yeah, like real money. This is the point when a lot of people would decide to reschedule surgery. But Ron digs into the paperwork, and he can see this denial is a mistake. United isn’t even denying the reconstructive part of Jodi’s surgery — the part a plastic surgeon does. They’re denying the mastectomy itself.

That’s gotta be wrong. And Ron decides that is not going to stick.

Ron Lieber: These people are not going to win. I am going to win, because I’m Ron Lieber.

Dan: He’s a professional at beating the system.

Ron Lieber: I’m gonna stand up for my wife.

Dan: And he’s not in this alone.

Ron Lieber: I work for a big company. We have excellent HR people.

Dan: And he figures the hospital will hold up their end in this fight.

Ron Lieber: I imagine that there are 10, 15, 20 people at Memorial Sloan Kettering who do nothing but deal with nonsense, all day long. So one way or another, we’re gonna win.

Dan: One thing he says knows he WON’T do in this fight: Let on to anybody at the hospital or the insurance company that they should give him special treatment because he, you know, works for the New York Times.

Ron Lieber: We have the strictest ethics code, probably on the planet, right? We get fired for throwing our weight around. The moment you open your mouth at 1-800 United Healthcare and say, I work for the New York Times, stop messing around with me, you lose your job. There’s no second chances.

Dan: He DOES plan on taking notes. Because eventually, this could be a good story.

And I’ll just tell you right now. It was. Ron eventually put his family’s story in the New York Times, looking to help other people avoid — at the least — getting a scary notice that there’s some problem with their insurance with no time to do anything about it.

Hundreds of readers wrote back with their own stories, with suggestions, with complaints.

And Ron responded by coming back to the story with a tool he hoped people — actually people’s doctors — could use to prevent these kind of scary situations, at least some of them.

I freaking love it.

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

Jodi comes home from her trip with friends on Sunday. Surgery is scheduled for the next morning, first thing. Ron tells her the news. She hits the roof.

Ron Lieber: She’s not angry, she’s just sad and she’s stressed all the things that should not happen, right, when you’re going into major surgery.

Dan: Meanwhile, Ron does what he can to get the insurance thing resolved. Which, on a Sunday, isn’t much.

Ron Lieber: There’s this stupid appeal form that you can send to a supposed emergency fax line. So, you know, I download E-fax for the first time in 19 years, um, and send the fax off into the ether. Nothing happens.

Dan: Next morning, they show up for surgery, and once Jodi’s under anesthesia, Ron figures he’s got 6 hours to kill, maybe eight.

So he starts roaming the hospital campus, looking for someone who could explain what was up, and what to do.

Ron Lieber: So I was just showing up at desks saying, Hey, check out this love letter I got from UnitedHealthcare.

Dan: And the people at those desks are like, Oh wow– we got one of these TODAY?

Because Ron and Jodi’s story was playing out against the backdrop of a much bigger story, one that had started just a few days before.

Jessica Tisch: In Midtown Manhattan, early this morning, 50-year-old Brian Thompson, the CEO of UnitedHealthcare was shot and killed in what appears at this early stage of our investigation to be a brazen, targeted attack.

News announcer: Protestors have targeted United Healthcare, which reportedly denies one of every three claims.

News reporter: CBS news also confirms law enforcement found shell casings at the crime scene with the words deny, defend, and depose written on them.

Dan: Those words – “deny, defend, depose”– they suggested to lots of people that issues like prior authorization played a role in the killer’s motivation.

And: Police were chasing the suspected shooter– later identified as Luigi Mangione– that very morning. So when Ron shows up at the billing office with his UnitedHealthcare denial…

Ron Lieber: People are like, oh, is he still on the loose? They just, just couldn’t believe that like this thing, you know, that Luigi was clearly upset about, right, was presenting itself in real time while he was still being chased.

Dan: They also quickly reassured Ron about his immediate situation.

Ron Lieber: The nice woman in the billing office, you know, clicks a bunch of keys on her keyboard and she pulls it up and she said, oh yeah. She said, this isn’t gonna be a problem. She said, it may take a while. But don’t worry about it.

Dan: And she said something else that gets Ron’s wheels spinning.

Ron Lieber: She said, we got notice of this, you know, seven or eight days ago. If we had thought that there was gonna be a problem, we would’ve called you right away and told you not to come.

Dan: Ron was thinking: I sure wish you’d have given us a heads-up — and this kind of reassurance — before now.

Ron Lieber: I’m mad because we didn’t find out about it until 36 hours ahead of time when it was too late to do anything ’cause it was Saturday night and the surgery was Monday morning. So why didn’t you just tell me?

Dan: And he’s thinking: Ok, what’s my next move?

Ron Lieber: There are three voices played simultaneously in my head at a minimum. Number one is I’ve got a personal situation on my hand that I gotta solve, you know, as cheaply as possible. Number two, this is a story and I ought to be taking really careful notes, not just for my own purposes, but to make sure that I’ve documented things correctly and so that I can, you know, make the best case to the reader and, and the best case to the entities involved when it comes time to ask them some questions. And then number three. Try to avoid as best as I can, compromising the story in any way. Right? So like, don’t lose your temper, don’t lose your patience. Try not to even utter the words the New York Times…

Dan: How do you not blow your cover?

Ron Lieber: Exactly. Right.

Dan: And there’s another thought: UnitedHealthcare is like the day’s top story. It’s coming out that this issue — pre-authorization — seems to be one of the alleged killer’s big issues.

Ron Lieber: So then I have a conversation with my editors while Jodi is still under anesthesia saying, I think I wanna write about this right now. Right? So this is like an hour before they catch Luigi. We’re right on the news here and I think this is the thing that he was upset about and we should just go with it. And my editor correctly said “no.” In order this for this to be, um, a useful story for the reader and to make sure we are 182% in compliance, you know, with our ethical responsibilities, we gotta let this thing play out to its conclusion on its own.

Dan: Ron went back to focusing on what really mattered to him right then. Which was not getting a scoop.

Ron Lieber: I was not the main character here. My wife was the main character, right? She was sick. We were trying to fix her. It was a big deal. and I was sort of relieved, you know, at two in the afternoon when my editor was basically like, hit the pause button on this thing.

Dan: And there was more relief coming right up.

Ron Lieber: Jodi does great. The surgery’s successful. The surgeons did an amazing job.They were happy. Recovery was perfect. And we feel real good and so I’m sort of watching the mail.

Dan: Waiting for a super-high bill from the hospital. Or some word from United. Weeks go by. Nothing.

Ron does something that I wouldn’t expect — or necessarily advise — any normal person to do, any civilian: He keeps waiting.

Partly ‘cause he’s super-confident that this will work out, and as a reporter, he’s gathering data: What would the system do, just left to its own devices?

Finally, on March 1st — more than two and a half months after Jodi’s surgery — Ron calls United. He says, ‘Hey, you said in early December that you were denying us, and I faxed you an appeal. I was just wondering: any news?’

Ron Lieber: And they took a look and they said, oh yeah. Um, the appeal on this one just went today to the physician, uh, who’s going to review the appeal. And I said, you guys waited like two and a half months to do that. And they said, yep. Um, uh, and I thought, well, okay.

Dan: Ron gets off the phone. Waits another few weeks before he finally calls again and hears from a United rep: Yep, this seems to be resolved.

Eventually, Ron gets a bill. It’s reasonable. He pays it. And switches to reporter mode.

So Ron the Reporter gets to ask the same questions Ron the Civilian has been asking all along.

Couldn’t someone have given him and Jodi a heads-up earlier?

Ron: Why did you not just tell us immediately, not through the United States Mail, you know, which some people don’t even open and some people don’t get. Why did you not send up some kind of flare? Send us a text. Call us on her phone, send an email, um, do all three at once. Like fly a freaking, you know, banner over Prospect Park saying, ‘Ron and Jodi call UnitedHealthcare right now. You have a problem.’

Dan: There’s a whole HUGE set of questions to ask about prior authorization itself — like, why on EARTH would you deny a mastectomy for breast cancer??

But for this story, Ron’s keeping a narrow focus.

Ron Lieber: The conversation I wanna have with UnitedHealthcare is not, you’re terrible. The system is terrible. Prior authorization is terrible. All I wanted to know was, given that we have to live within this system for now, why didn’t you call us?

Dan: The first words of that question– GIVEN THAT WE HAVE TO LIVE WITHIN THIS SYSTEM FOR NOW — rang out so loud for me. Because, God help us, we do.

And it is such a reasonable question: Isn’t giving people a heads-up the LEAST you could do? So, Ron asked. On the record.

Ron Lieber: And here’s what they said. Um, they said, yeah, you know, we know more needs to be done here about prior auth, you know, blabbity, blah, blah. And then they said this: ‘We continue to make our own changes to help members navigate through these types of situations, including by offering the opt-in paperless communications.’

Dan: Opt-in. Like — oh, well. You COULDA opted in. Ron was like: Grr. You trying to say it’s my fault, because I didn’t opt in? He says he kept arguing to the United spokesperson — who he says was a total gentleman — you really should just go ahead and give people notice. He says it didn’t take.

Ron Lieber: So I thought to myself, okay, UnitedHealthcare doesn’t seem that excited to change their processes 180 degrees and do what I’m telling them to do.

Dan: And by the way, Ron says he has one idea about why they wouldn’t.

Ron Lieber: If they sent out the kind of notices that I am suggesting, they would need twice as many phone reps and it would cost them a ton of money. And they actually do not want people calling about this. But then I had another idea about how to work around them.

Dan: And that is coming right up.

This episode of An Arm and a Leg is a co-production between Public Road Productions and KFF Health News. KFF Health News is a nonprofit newsroom covering health issues in America. Their journalists win all kinds of awards, every year. We are honored to work with them.

So Ron has another idea about how — if we have to live in a system where insurance companies issue stupefying, horrifying denials of care to millions of people — we don’t have to get the news at the last possible minute.

And it’s this: Maybe our PROVIDERS could help us out here. I mean, they want to treat us. They want to get paid. We’re a natural team.

So there was an obvious question to ask the folks at Memorial Sloan Kettering: the question he’d held back from pressing on the day of Jodi’s surgery.

That’s when the lady from the billing department told him they’d known about United’s denial for seven or eight days. Why didn’t you give us a heads up?

Ron Lieber: And, um, basically their response went like this, well, we just don’t wanna bother patients with this. We only wanna bother them with, uh, what they described as clinically necessary information. But here’s my response to that, right? Pre-surgery, mental health ought to be part of the institution’s concern, right? You want people walking in there with their heads clear, without too much worry, without too much fear.

Dan: And again: Ron didn’t find himself persuading Memorial Sloan Kettering to change their policy.

So when he wrote all this up in a column — in August, more than eight months after Jodi’s surgery — he basically had a couple pieces of advice for readers.

One: Yeah, if your insurance requires you to OPT-IN to get a heads-up, then… OK, opt in.

And two: If you need some kind of treatment, ask your doctor’s office some questions: Is prior authorization gonna come into play here? Can you start requesting it ASAP, so we can avoid some last-minute scramble? And if you hit any roadblocks, can someone give me a heads-up right away? And if *I* find out about a problem, who in your office should I call?

That column got people’s attention. More than 500 people left comments. Ron says even for the New York Times, that’s a lot. A lot of them were supportive. A lot were from people who’d had much worse experiences than Jodi and Ron.

Ron Lieber: There were multiple notes from people who said, I was sent home the morning of surgery because they cannot work it out. And there was one person who had already had the anesthesia stuck in her arm and they yanked the needle out and had to send her away to come back and try another day.

Dan: Oh my God.

Ron Lieber: And then there was like a small handful of readers that were basically like, you’re an idiot, right? How did you not investigate the possibility of an insurance denial ahead of time?

Dan: He thought about giving that advice in a follow-up column: Never turn your back for a minute. Make multiple calls.

But he decided to take a different approach.

Ron Lieber: And I thought, okay, well how could this have been avoided, um, in our situation? Oh, they could have just given us a very plain spoken piece of paper, you know, upon diagnosis or when we scheduled the surgery.

Dan: Something to give them a heads-up that this kind of thing could happen. In his newsletter, he asked readers for suggestions about what that piece of paper should say.

He says he got lots of responses — including from some angry physicians.

Ron Lieber: Who said to me, who are you to tell me how to run my medical practice? And then, and this was the loudest one. This is not my fault. Why are you putting this on me? And there were just as many doctors who wrote in who said, hey, in case I miss the story, can you send this to me when it comes out?

Dan: And he got lots of good suggestions. So he published a column with a template for a note doctors could use.

Ron Lieber: It said: ‘Hey, um, here’s what prior authorization is, and here’s how it works. Um, sometimes people run into problems, um, where the insurance company says that they’re not gonna pay for stuff. We don’t want you to worry about this. You can call us here or email us here if you run into these issues, and we will try to take care of it. If you have any questions about this form, please call our billing specialist. We understand that you don’t want to take up valuable exam time talking about this with the doctor. Frankly, our doctors don’t either, but we wanna make sure that you know about this ahead of time.’

Dan: Again, lots of responses. Useful responses.

Ron Lieber: I got incredibly good critical feedback. And I realized that the note could get a lot better.

Dan: For instance, Ron’s initial memo included some grouching about insurance companies, from a doctor’s point of view. For instance:

“Often, a doctor will have to do what’s known as a peer review with someone from the insurance company. We find this burdensome, since the “peer” on the line with us may not have the same level of expertise as we do. That prolongs the call, adds to our overall operating expenses and keeps us from spending more time with you, the patient.”

And although lots of doctors say exactly those things in lots of forums, they don’t do it on hospital letterhead.

Ron Lieber: There were some doctors who said, uh, There’s no way I could ever get this by our lawyers. Um, you know, nice try, uh, wish I wish I could, but ain’t gonna happen over here. To which I said, send it to your lawyer and have them call me and we can have a conversation about what would pass muster.

Dan: Other readers told Ron the language just needed to be simpler. They’d his note through software that analyzes a piece of text for reading difficulty.

Ron Lieber: And then wrote me notes and said, this is written at a 12th grade level. And like, my patients don’t speak English at a first language, or they’re never gonna read this, and you need to write it at a fifth grade level. And so I, so I thought, okay, yeah, that’s, that’s pretty good advice.

Dan: Ron digested all the feedback on the memo he’d published.

Ron Lieber: And then I published another one, which was better, right? It was shorter, the language was plainer. I took out the the commentary.

Dan: We’ll have a link to that second version wherever you’re listening to this. If you’re a health care worker — or know some health care workers who might find it useful — please check it out, pass it around.

Of all the comments on Ron’s stories, one that stuck with me was from a reader who made a wish that was actually like a lament– on behalf of anybody who needed major medical care. Anyone in that situation, they wrote, Quote: “should be enrolled in a certificate course for how to navigate the healthcare system.

Ron Lieber: So this is the thing, Dan, right? This is why I have a job and I’m pretty sure this is why you have a job too. And I would love to be put out of business, right? But the way in which I would be put out of business. Is if there were mandatory certificate programs in 25 different categories of personal finance existence, right. And so that’s how I would be put outta business. But because nobody’s ever gonna require such a certificate in, in any of the areas of personal finance that we are forced, um, to wade through as human beings, I have a job and I’m just trying to do a better job of it.

Dan: ?I hear that. There is so much I appreciate about having my job, but I wish it weren’t so necessary. Lots of people end up in much worse circumstances than Ron Lieber and Jodi Kantor.

In a book called “Coverage Denied,” coming out this spring, University of Pittsburgh professor Miranda Yaver cites estimates ranging from 850 million to 3 billion denials a year.

She also cites data showing that appeals work more often than most of us think — about half the time.

But appealing is hard work. The less privilege you have — like, say if you don’t have a flexible schedule to call and fax and everything else — the harder it is.

She calls the result “Rationing by inconvenience.”

And we can all use all the help we can get making life less annoying and inconvenient. Which is why I’m gonna leave you with Ron Lieber’s answer to my last big question for him.

Because hearing one part of his advice on how not to get blindsided by an insurance denial led to another question — one that seemed like a good one to ask an expert at beating the system.

I said: Hey, you recommend opting in to emails and texts from your insurance company so they might give you a quicker heads-up.

Let’s say I do. How the heck am I supposed to find that in my inbox — which keeps getting harder to sort through every day with things I don’t want and don’t need to look at?

I asked him: How do you, Ron Lieber, manage the inbound? How do you identify what actually needs your attention?

And he had a good answer:

Ron Lieber: ?Yeah. So I have three email inboxes. I have, you know, work email, I have personal email that is only personal correspondence and the most vital other stuff, you know, kids’ school, uh, college tuition payments. And then I have an old Yahoo email for everything else. And so, you know, I read the last 12 to 24 hours of the Yahoo email, you know, once a day or so. Uh, and then, you know, once a month, I’ll open the inbox and I won’t close it until I’ve unsubscribed to 10 things. And, and so that keeps it more or less manageable.

Dan: This is such good advice. I haven’t had a chance to implement it since I talked with Ron — hey, I was on deadline for this episode! — but honest: I’m going to.

Here’s one other thing I’m going to do in the next few weeks: Have surgery myself. A hernia repair, it’s gonna be fine, I’m in great hands. But it’s happening a few days before our next episode is scheduled to come out.

So, as it happens, I’ve got a great story from somebody ELSE to share with you then. We’ll have another new episode of our own for you when I’m back.

And meanwhile, we’ll keep the First Aid Kit newsletter coming. If you aren’t subscribed, it’s really good!

My colleagues Emily and Claire have been serving up need-to-know information: Like, when you get your annual checkup… what’s actually covered? A lot of the time, it’s less than you’d think.

Which sucks, but is SO important to know. If you’re not signed up, check it out at arm and a leg show dot com, slash, newsletter.

I’ll catch you soon. Till then, take care of yourself.

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.

Claire Davenport is our engagement producer.

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

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

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

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

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

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

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

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

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

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

To hear all KFF Health News podcasts, click here.

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

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How Microbes Got Their Crawl

In the oceans and on land, scientists are discovering rare, transitional organisms that bridge the gap between Earth’s simplest cells and today’s complex ones.

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F.D.A. Reverses Decision and Agrees to Review Moderna’s Flu Vaccine

Moderna said it had held further discussions with regulators and announced that the agency would accept the company’s application for approval of its flu vaccine that uses mRNA technology.

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Red and Blue States Alike Want To Limit AI in Insurance. Trump Wants To Limit the States.

It’s the rare policy question that unites Republican Gov. Ron DeSantis of Florida and the Democratic-led Maryland government against President Donald Trump and Gov. Gavin Newsom of California: How should health insurers use AI?

Regulating artificial intelligence, especially its use by health insurers, is becoming a politically divisive topic, and it’s scrambling traditional partisan lines.

Boosters, led by Trump, are not only pushing its integration into government, as in Medicare’s experiment using AI in prior authorization, but also trying to stop others from building curbs and guardrails. A December executive order seeks to preempt most state efforts to govern AI, describing “a race with adversaries for supremacy” in a new “technological revolution.”

“To win, United States AI companies must be free to innovate without cumbersome regulation,” Trump’s order said. “But excessive State regulation thwarts this imperative.”

Across the nation, states are in revolt. At least four — Arizona, Maryland, Nebraska, and Texas — enacted legislation last year reining in the use of AI in health insurance. Two others, Illinois and California, enacted bills the year before.

Legislators in Rhode Island plan to try again this year after a bill requiring regulators to collect data on technology use failed to clear both chambers last year. A bill in North Carolina requiring insurers not to use AI as the sole basis of a coverage decision attracted significant interest from Republican legislators last year.

DeSantis, a former GOP presidential candidate, has rolled out an “AI Bill of Rights,” whose provisions include restrictions on its use in processing insurance claims and a requirement allowing a state regulatory body to inspect algorithms.

“We have a responsibility to ensure that new technologies develop in ways that are moral and ethical, in ways that reinforce our American values, not in ways that erode them,” DeSantis said during his State of the State address in January.

Ripe for Regulation

Polling shows Americans are skeptical of AI. A December poll from Fox News found 63% of voters describe themselves as “very” or “extremely” concerned about artificial intelligence, including majorities across the political spectrum. Nearly two-thirds of Democrats and just over 3 in 5 Republicans said they had qualms about AI.

Health insurers’ tactics to hold down costs also trouble the public; a January poll from KFF found widespread discontent over issues like prior authorization. (KFF is a health information nonprofit that includes KFF Health News.) Reporting from ProPublica and other news outlets in recent years has highlighted the use of algorithms to rapidly deny insurance claims or prior authorization requests, apparently with little review by a doctor.

Last month, the House Ways and Means Committee hauled in executives from Cigna, UnitedHealth Group, and other major health insurers to address concerns about affordability. When pressed, the executives either denied or avoided talking about using the most advanced technology to reject authorization requests or toss out claims.

AI is “never used for a denial,” Cigna CEO David Cordani told lawmakers. Like others in the health insurance industry, the company is being sued for its methods of denying claims, as spotlighted by ProPublica. Cigna spokesperson Justine Sessions said the company’s claims-denial process “is not powered by AI.”

Indeed, companies are at pains to frame AI as a loyal servant. Optum, part of health giant UnitedHealth Group, announced Feb. 4 that it was rolling out tech-powered prior authorization, with plenty of mentions of speedier approvals.

“We’re transforming the prior authorization process to address the friction it causes,” John Kontor, a senior vice president at Optum, said in a press release.

Still, Alex Bores, a computer scientist and New York Assembly member prominent in the state’s legislative debate over AI, which culminated in a comprehensive bill governing the technology, said AI is a natural field to regulate.

“So many people already find the answers that they’re getting from their insurance companies to be inscrutable,” said Bores, a Democrat who is running for Congress. “Adding in a layer that cannot by its nature explain itself doesn’t seem like it’ll be helpful there.”

At least some people in medicine — doctors, for example — are cheering legislators and regulators on. The American Medical Association “supports state regulations seeking greater accountability and transparency from commercial health insurers that use AI and machine learning tools to review prior authorization requests,” said John Whyte, the organization’s CEO.

Whyte said insurers already use AI and “doctors still face delayed patient care, opaque insurer decisions, inconsistent authorization rules, and crushing administrative work.”

Insurers Push Back

With legislation approved or pending in at least nine states, it’s unclear how much of an effect the state laws will have, said University of Minnesota law professor Daniel Schwarcz. States can’t regulate “self-insured” plans, which are used by many employers; only the federal government has that power.

But there are deeper issues, Schwarcz said: Most of the state legislation he’s seen would require a human to sign off on any decision proposed by AI but doesn’t specify what that means.

The laws don’t offer a clear framework for understanding how much review is enough, and over time humans tend to become a little lazy and simply sign off on any suggestions by a computer, he said.

Still, insurers view the spate of bills as a problem. “Broadly speaking, regulatory burden is real,” said Dan Jones, senior vice president for federal affairs at the Alliance of Community Health Plans, a trade group for some nonprofit health insurers. If insurers spend more time working through a patchwork of state and federal laws, he continued, that means “less time that can be spent and invested into what we’re intended to be doing, which is focusing on making sure that patients are getting the right access to care.”

Linda Ujifusa, a Democratic state senator in Rhode Island, said insurers came out last year against the bill she sponsored to restrict AI use in coverage denials. It passed in one chamber, though not the other.

“There’s tremendous opposition” to anything that regulates tactics such as prior authorization, she said, and “tremendous opposition” to identifying intermediaries such as private insurers or pharmacy benefit managers “as a problem.”

In a letter criticizing the bill, AHIP, an insurer trade group, advocated for “balanced policies that promote innovation while protecting patients.”

“Health plans recognize that AI has the potential to drive better health care outcomes — enhancing patient experience, closing gaps in care, accelerating innovation, and reducing administrative burden and costs to improve the focus on patient care,” Chris Bond, an AHIP spokesperson, told KFF Health News. And, he continued, they need a “consistent, national approach anchored in a comprehensive federal AI policy framework.”

Seeking Balance

In California, Newsom has signed some laws regulating AI, including one requiring health insurers to ensure their algorithms are fairly and equitably applied. But the Democratic governor has vetoed others with a broader approach, such as a bill including more mandates about how the technology must work and requirements to disclose its use to regulators, clinicians, and patients upon request.

Chris Micheli, a Sacramento-based lobbyist, said the governor likely wants to ensure the state budget — consistently powered by outsize stock market gains, especially from tech companies — stays flush. That necessitates balance.

Newsom is trying to “ensure that financial spigot continues, and at the same time ensure that there are some protections for California consumers,” he said. He added insurers believe they’re subject to a welter of regulations already.

The Trump administration seems persuaded. The president’s recent executive order proposed to sue and restrict certain federal funding for any state that enacts what it characterized as “excessive” state regulation — with some exceptions, including for policies that protect children.

That order is possibly unconstitutional, said Carmel Shachar, a health policy scholar at Harvard Law School. The source of preemption authority is generally Congress, she said, and federal lawmakers twice took up, but ultimately declined to pass, a provision barring states from regulating AI.

“Based on our previous understanding of federalism and the balance of powers between Congress and the executive, a challenge here would be very likely to succeed,” Shachar said.

Some lawmakers view Trump’s order skeptically at best, noting the administration has been removing guardrails, and preventing others from erecting them, to an extreme degree.

“There isn’t really a question of, should it be federal or should it be state right now?” Bores said. “The question is, should it be state or not at all?”

Do you have an experience navigating prior authorization to get medical treatment that you’d like to share with us for our reporting? Share it with us here.

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Nuevas reglas de trabajo de Medicaid podrían impactar más fuerte en adultos de mediana edad

La visión cada vez más deteriorada de Lori Kelley le ha dificultado encontrar un trabajo estable.

La mujer de 59 años, que vive en Harrisburg, Carolina del Norte, cerró el año pasado su escuela de artes circenses sin fines de lucro porque ya no veía lo suficientemente bien como para estar al día con todo el papeleo administrativo. Luego trabajó un tiempo haciendo masas en una pizzería. Ahora clasifica materiales reciclables, como latas y botellas, en un lugar de conciertos local. Es su principal fuente de ingresos, pero el trabajo no es durante todo el año.

“Este lugar me conoce, y este lugar me quiere”, dijo Kelley sobre su empleador. “Aquí no tengo que explicar por qué no puedo leer”.

Kelley vive en una casa rodante y sobrevive con menos de $10.000 al año. Dice que eso es posible, en parte, gracias a su cobertura de salud de Medicaid, que le cubre medicamentos para la artritis y la ansiedad, y le permite ir al doctor para controlar su hipertensión.

Pero le preocupa perder esa cobertura el año que viene, cuando entren en vigencia nuevas reglas que exigirán a millones de personas como ella trabajar, hacer voluntariado, ir a la escuela o realizar otras actividades que califiquen durante al menos 80 horas al mes.

“Ahora mismo tengo miedo”, dijo.

Antes de que se promulgaran los cambios para acceder a esta cobertura, legisladores republicanos sugirieron que hombres jóvenes y desempleados estaban abusando del programa gubernamental de salud que ofrece cobertura médica a millones de personas con bajos ingresos o con alguna discapacidad.

Medicaid no está pensado para “hombres de 29 años sentados en el sofá jugando videojuegos”, dijo Mike Johnson, presidente de la Cámara de Representantes, a CNN.

Pero en realidad, los adultos de entre 50 y 64 años, especialmente las mujeres, son quienes probablemente resulten más afectados por las nuevas reglas, según explicó Jennifer Tolbert, subdirectora del Programa sobre Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro de información sobre salud de la cual KFF Health News forma parte.

Para Kelley y otras personas, los requisitos laborales crearán obstáculos para mantener su cobertura, explicó Tolbert. Muchos podrían perder Medicaid, poniendo en riesgo su salud física y financiera.

A partir de enero de 2027, unos 20 millones de estadounidenses de bajos ingresos en 42 estados y el Distrito de Columbia tendrán que cumplir con los requisitos de actividad para obtener o conservar esta cobertura.

Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming no ampliaron sus programas de Medicaid para cubrir a más adultos de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), por lo que no tendrán que implementar las reglas de trabajo.

La no partidista Oficina de Presupuesto del Congreso, prevé que las reglas de trabajo resulten en al menos 5 millones de personas menos bajo Medicaid en la próxima década.

Según críticos, estas reglas son el principal factor de pérdida de cobertura dentro de la ley presupuestaria republicana, la cual recorta cerca de $1.000 millones para compensar reducciones de impuestos que benefician principalmente a personas con mayores ingresos y para aumentar la seguridad fronteriza.

“Estamos hablando de ahorrar dinero a costa de vidas humanas”, dijo Jane Tavares, investigadora en gerontología de la Universidad de Massachusetts en Boston. “El requisito de trabajo es solo una herramienta para lograr eso”.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos, dijo que exigir a los “adultos sin discapacidades” que trabajen garantiza la “sostenibilidad a largo plazo” de Medicaid, mientras protege a las personas más vulnerables.

Las personas con discapacidades, quienes cuidan a familiares, personas embarazadas o en posparto, veteranos con discapacidades totales y otras personas que enfrentan dificultades médicas o personales están exentas de la regla de trabajo, indicó Nixon a KFF Health News.

La expansión de Medicaid ha sido un salvavidas para adultos de mediana edad que, de otro modo, no tendrían seguro médico, según investigadores de la Universidad Georgetown. Medicaid cubre a 1 de cada 5 estadounidenses de entre 50 y 64 años, dándoles acceso a atención médica hasta que califican para Medicare a los 65 años.

Entre las mujeres beneficiarias de Medicaid, las que tienen entre 50 y 64 años enfrentan más desafíos para conservar su cobertura que las más jóvenes, y suelen tener una mayor necesidad de servicios de salud, explicó Tolbert.

Estas mujeres de mediana edad tienen menos probabilidades de trabajar el número requerido de horas porque muchas son cuidadoras familiares o tienen problemas de salud que limitan su capacidad para trabajar, agregó.

Tavares y otros investigadores hallaron que solo el 8% de la población total de Medicaid que se considera “apta para trabajar” no trabaja. Este grupo está compuesto en su mayoría por mujeres muy pobres que han salido de la fuerza laboral para convertirse en cuidadoras. Entre ellas, 1 de cada 4 tiene 50 años o más.

“No son adultos jóvenes saludables simplemente perdiendo el tiempo”, escribieron los investigadores.

Además, dificultar el acceso a la cobertura de Medicaid “podría en realidad dificultar que estas personas trabajen”, ya que sus problemas de salud no recibirían tratamiento, advirtió Tolbert. De todas formas, si este grupo pierde la cobertura, sus condiciones crónicas igual necesitarán atención, señaló.

Muchos adultos empiezan a tener problemas de salud antes de ser elegibles para Medicare.

Si las personas mayores no tienen recursos para tratar sus problemas de salud antes de los 65 años, llegarán más enfermas a Medicare, lo que podría generar mayores costos para ese programa, apuntaron expertos en políticas de salud.

Muchas personas de entre 50 y principios de los 60 años ya no trabajan porque son cuidadoras de tiempo completo de hijos o familiares mayores, explicaron defensores, quienes se refieren a este grupo como “la generación sándwich”.

La ley presupuestaria republicana permite que algunos cuidadores queden exentos de las reglas de trabajo de Medicaid, pero las excepciones son “muy limitadas”, dijo Nicole Jorwic, directora de programas del grupo Caring Across Generations.

Le preocupa que personas que deberían calificar para una exención queden fuera por errores o complicaciones.

“Vamos a ver a más cuidadores familiares enfermándose, dejando de atender su propia salud y a más familias enfrentando crisis”, dijo Jorwic.

Paula Wallace, de 63 años, residente de Chidester, Arkansas, dijo que trabajó la mayor parte de su vida adulta y ahora dedica sus días a cuidar a su esposo, quien tiene cirrosis avanzada.

Después de años sin seguro, recientemente obtuvo cobertura gracias a la expansión de Medicaid en su estado, lo que significa que tendrá que cumplir con los nuevos requisitos laborales para conservarla. Pero le cuesta imaginar cómo podrá hacerlo.

“Como soy su única cuidadora, no puedo salir a trabajar fuera de casa”, dijo.

Su esposo recibe beneficios del Seguro por Incapacidad del Seguro Social, explicó, y la ley dice que ella debería quedar exenta de los requisitos de trabajo como cuidadora de tiempo completo de una persona con discapacidad.

Pero las autoridades federales aún no han emitido instrucciones específicas sobre cómo definir esa exención. Y la experiencia de Arkansas y Georgia —los únicos estados que han implementado programas de trabajo en Medicaid— muestra que muchas personas beneficiarias tienen dificultades para navegar sistemas de beneficios complejos.

“Estoy muy preocupada”, dijo Wallace.

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Listen: Why Do I Need Prior Authorization?

Listen in as “Life Kit” host Marielle Segarra and health reporter Sarah Boden untangle the red tape that can make the prior authorization process frustrating.

When the doctor says you need a prescription or treatment, sometimes you need approval from your health insurance first. That’s called prior authorization. Without that sign-off, insurance won’t pay.

What triggers the need for prior authorization is not fully clear. It’s another “black box” part of the health care system.

You might think insurance companies mostly target expensive treatments or care approaches when a disagreement over effectiveness prompts a prior authorization review. Often that’s not the case. Some doctors complain they spend a lot of time filling out paperwork to try to secure approval for medicine or treatments that are routine.

In the meantime, patients can be left in pain, while their medical conditions worsen.

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story.

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Daniel Radcliffe on Returning to Broadway in ‘Every Brilliant Thing’

The Tony winner returns to the stage in “Every Brilliant Thing,” an interactive monologue with a message of hope “that might be vital for somebody to hear.”

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Vaccine Makers Curtail Research and Cut Jobs

Federal policies under Robert F. Kennedy Jr. that are hostile to vaccines have “sent a chill through the entire industry,” one scientist said.

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Should Drug Companies Be Advertising to Consumers?

Aging means “becoming a target” of the industry, one expert said. After decades of debate, politicians of all stripes are proposing bans.

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Journalists Unpack Impact of ICE Arrests on Families and Caffeine’s Effect on Dementia Risk

KFF Health News senior contributing editor Elisabeth Rosenthal discussed the cost of cancer care in the wake of James Van Der Beek’s death on ABC News’ ABC News Live on Feb. 12.

Click here to watch Rosenthal on ABC News Live.

KFF Health News Southern California correspondent Claudia Boyd-Barrett discussed how families of detainees by the U.S. Immigration and Customs Enforcement agency are struggling to find those who have been hospitalized on KQED’s The California Report on Feb. 10.

Click here to hear Boyd-Barrett on The California Report.
Read Boyd-Barrett’s “‘I Can’t Tell You’: Attorneys, Relatives Struggle To Find Hospitalized ICE Detainees.”

Céline Gounder, KFF Health News’ editor-at-large for public health, discussed a new study linking daily coffee or caffeinated tea intake to lower dementia risk on CBS News’ CBS Mornings on Feb. 10.

Click here to watch Gounder on CBS Mornings.

KFF Health News senior correspondent Aneri Pattani discussed differing opinions within the addiction medicine community on WNO’s Louisiana Considered on Feb 6.

Click here to hear Pattani on Louisiana Considered.
Read Pattani’s “Inside the Battle for the Future of Addiction Medicine.”

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Trump Team’s Planned ACA Rule Offers Its Answer to Rising Premium Costs: Catastrophic Coverage

The Trump administration has unveiled a sweeping set of regulatory proposals that would substantially change health plan offerings on the Affordable Care Act marketplace next year, aiming, it says, to provide more choice and lower premiums. But it also proposes sharply raising some annual out-of-pocket costs — to more than $27,600 for one type of coverage — and could cause up to 2 million people to drop insurance.

The changes come as affordability is a key concern for many Americans, some of whom are struggling to pay their ACA premiums since enhanced subsidies expired at the end of last year. Initial enrollment numbers for this year fell by more than 1 million.

Health care coverage and affordability have become politically potent issues in the run-up to November’s midterm elections.

The proposed changes are part of a 577-page rule that addresses a broad swath of standards, including benefit packages, out-of-pocket costs, and health care provider networks. Insurers refer to these standards when setting premium rates for the coming year.

After a comment period, the rule will be finalized this spring.

It “puts patients, taxpayers, and states first by lowering costs and reinforcing accountability for taxpayer dollars,” said Centers for Medicare & Medicaid Services Administrator Mehmet Oz in a Feb. 9 press release.

One way it would do so focuses heavily on a type of coverage — catastrophic plans — that last year attracted only about 20,000 policyholders, according to the proposal, although other estimates put it closer to 54,000.

“To me, this proposal reads like the administration has found their next big thing in the catastrophic plans,” said Katie Keith, director of the Health Policy and the Law Initiative at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center.

Such plans have very high annual out-of-pocket costs for the policyholder but often lower premiums than other ACA coverage options. Formerly restricted to those under age 30 or facing certain hardships, the Trump administration allowed older people who lost subsidy eligibility to enroll in them for this year. It is not yet known how many people chose to do so.

The payment rule cements this move by making eligible anyone whose income is below the poverty line ($15,650 for this year) and those earning more than 2.5 times that amount who lost access to an ACA subsidy that lowered their out-of-pocket costs. It also notes that a person meeting these standards would be eligible in any state — an important point because this coverage is currently available in only 36 states and the District of Columbia.

In addition, the proposal would require out-of-pocket maximums on such plans to hit $15,600 a year for an individual and $27,600 for a family, Keith wrote this week in Health Affairs. (The current out-of-pocket max for catastrophic plans is $10,600 for an individual plan and $21,200 for family coverage.) Not counting preventive care and three covered primary care doctor visits, that spending target must be met before a policy’s other coverage kicks in.

In the rule, the administration wrote that the proposed changes would help differentiate catastrophic from “bronze” plans, the next level up, and, possibly, spur more enrollment in the former. Currently, the proposal said, there may not be a significant difference if premiums are similar. Raising the out-of-pocket maximum for catastrophic plans to those levels would create that difference, the proposal said.

“When there is such a clear difference, the healthier consumers that are generally eligible and best suited to enroll in catastrophic plans are more motivated to select a catastrophic plan in lieu of a bronze plan,” the proposal noted.

However, ACA subsidies cannot be used toward catastrophic premiums, which could limit shoppers’ interest.

Enrollment in bronze plans, which currently have an average annual deductible of $7,500, has doubled since 2018 to about 5.4 million last year. This year, that number will likely be higher. Some states’ sign-up data indicates a shift toward bronze as consumers left higher-premium “silver,” “gold,” or “platinum” plans following the expiration of more generous subsidies at the end of last year.

The proposal also would allow insurers to offer bronze plans with cost-sharing rates that exceed what the ACA law currently allows, but only if that insurer also sells other bronze plans with lower cost-sharing levels.

In what it calls a “novel” approach, the proposal would allow insurers to offer multiyear catastrophic plans, in which people could stay enrolled for up to 10 years, and their out-of-pocket maximums would vary over that time. Costs might be higher, for example, in the early years, then fall the longer the policy is in place. The proposal specifically asks for comments on how such a plan could be structured and what effect multiyear plans might have on the overall market.

“As we understand it thus far, insurers could offer the policy for one year or for consecutive years, up to 10 years,” said Zach Sherman, managing director for coverage policy and program design at HMA, also known as Health Management Associates, a health policy consulting firm that does work for states and insurance plans. “But the details on how that would work, we are still unpacking.”

Matthew Fiedler, senior fellow with the Center on Health Policy at the Brookings Institution, said the proposed rule included a lot of provisions that could “expose enrollees to much higher out-of-pocket costs.”

In addition to the planned changes to bronze and catastrophic plans, he points to another provision that would allow plans to be sold on the ACA exchange that have no set health care provider networks. In other words, the insurer has not contracted with specific doctors and hospitals to accept their coverage. Instead, such plans would pay medical providers a set amount toward medical services, possibly a flat fee or a percentage of what Medicare pays, for example. The rule says insurers would need to ensure “access to a range of providers” willing to accept such amounts as payment in full. Policyholders might be on the hook for unexpected expenses, however, if a clinician or facility doesn’t agree and charges the patient the difference.

Because the rule is so sweeping — with many other parts — it is expected to draw hundreds, if not thousands, of comments between now and early March.

Pennsylvania insurance broker Joshua Brooker said one change he would like to see is requiring insurers that sell the very high out-of-pocket catastrophic plans to offer other catastrophic plans with lower annual maximums.

Overall, though, a wider range of options might appeal to people on both ends of the income scale, he said.

Some wealthier enrollees, especially those who no longer qualify for any ACA premium subsidies, would prefer a lower premium like those expected in catastrophic plans, and could just pay the bills up to that max, he said.

“They’re more worried about the half-million-dollar heart attack,” Brooker said. It’s tougher for people below the poverty level, who don’t qualify for ACA subsidies and, in 10 states, often don’t qualify for Medicaid. So they’re likely to go uninsured. At least a catastrophic plan, he said, might let them get some preventive care coverage and cap their exposure if they end up in a hospital. From there, they might qualify for charity care at the hospital to cover out-of-pocket costs.

Overall, “putting more options on the market doesn’t hurt, as long as it is disclosed properly and the consumer understands it,” he said.

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Louisville Found PFAS in Drinking Water. The Trump Administration Wouldn’t Require Any Action.

Every day, the Ohio River sends billions of gallons of water flowing past Louisville’s pumping station, where the Kentucky city’s utility sucks it up to turn it into tap water.

To ensure it tastes good and is safe to drink, a small team of scientists and technicians is constantly testing the water for pH, odors, heavy metals, and microbes.

But unlike many smaller municipal utilities in the U.S., Louisville Water regularly checks for PFAS — per- and polyfluoroalkyl substances.

That’s a class of chemicals used by manufacturers for decades to make things like nonstick pans, cosmetics, raincoats, food wrappers, and firefighting foam.

Research studies have linked PFAS to health risks like cancer, reduced immune system functioning, high cholesterol, and developmental delays in children.

They’re also known as “forever chemicals” because their strong chemical structures make them degrade incredibly slowly in the environment.

Today, they litter soil and water sources around the world and can be found in the blood of almost everyone in the U.S.

One type of PFAS that the Louisville water technicians are tracking is HFPO-DA, also known by a trade name, GenX.

Just over a year ago, workers noticed an unexpected increase in the level of GenX detected in a sample of the raw, untreated water drawn from the Ohio River for filtering and processing.

The GenX levels Louisville found in December 2024 were 15 times the reading from the previous month: 52 parts per trillion versus 3.4 ppt.

“A part per trillion is like one second in 32,800 years. Put your head around that, right?” said Peter Goodmann, the city utility’s director of water quality and research.

He offered another way to think of it: One part per trillion would be a single drop of water in 20 Olympic swimming pools.

Goodmann told KFF Health News and NPR he wasn’t worried about local customers’ safety, because the increased levels were still pretty low.

Risks posed by low PFAS concentrations are measured over a lifetime of exposure, he said. And recent data from Louisville shows the PFAS levels in city drinking water fell back within planned federal safety limits.

Plus, water is just one way people can be exposed to PFAS, Goodmann added. “Because you get a lot more of these pollutants from packaging, from prefixed food, cake mixes, weird things, you know, popcorn boxes,” he said.

Louisville Water’s data showed that the elevated levels of GenX in the water sample drawn in December 2024 fell once the water underwent typical treatment and filtering.

Federal Regulation Fight

The federal government has long regulated the levels of certain contaminants in drinking water, such as arsenic, E. coli, and lead.

But the Environmental Protection Agency didn’t issue regulations regarding PFAS until 2024, during the final year of the Biden administration. The new limits applied to six types of PFAS in drinking water. Starting in 2029, utilities that exceeded the limits would have been required to treat the water to reduce the contamination.

But after Donald Trump’s reelection, new EPA administrator Lee Zeldin announced the agency will keep the rules for only two types of PFAS, called PFOA and PFOS, but drop the restrictions on the other four types, including GenX.

In addition, the EPA announced it will give water utilities two additional years, until 2031, to comply with the remaining rules, attributing the change in part to the financial burden on rural water plants.

Many utilities, large and small, may need to invest in infrastructure to remove PFAS.

A federal study estimated about 45% of U.S. tap water contains at least one type of PFAS.

When it announced the final PFAS limits, the Biden administration anticipated that up to 10% of the estimated 66,000 U.S. public drinking water systems affected by these regulations might have PFAS levels high enough to require them to take action to reduce the contamination.

Finding the Source

Goodmann’s team traced the increased levels of PFAS up the Ohio River, past Cincinnati, and through Appalachian forests, all the way to a West Virginia factory about 400 miles upstream.

There, the Chemours Co. uses GenX to make fluoropolymers, a plastic critical to the semiconductors that power phones.

Its Washington Works facility near Parkersburg, West Virginia, has a history of PFAS pollution.

A lawyer, Robert Bilott, fought the plant’s previous owner, DuPont, in court, ultimately revealing the company knew that a type of PFAS it was using, PFOA, was toxic but didn’t disclose that information.

DuPont went on to settle various lawsuits that claimed it contaminated local environments with forever chemicals. The company has repeatedly denied wrongdoing.

Chemours was spun off from DuPont in 2015.

The Louisville Water team’s calculations eventually showed that the December 2024 spike in GenX levels corresponded to publicly available data from Chemours about its chemical discharges into the Ohio River.

In Chemours’ responses to a lawsuit filed by a West Virginia environmental group, the company denied its discharges were connected to Louisville’s GenX spike. (Louisville is not a party in the lawsuit.)

The company also contended that sampling data showed levels of GenX in the river and in downstream utilities’ treated drinking water are “indisputably safe.”

PFAS Removal Will Challenge Water Utilities

Under current federal environmental regulations, Chemours can release some chemicals into the Ohio River. But it has exceeded the legal limits repeatedly over several years, according to court filings and the EPA.

That’s why the West Virginia Rivers Coalition filed its lawsuit in 2024.

The EPA took enforcement action in 2023, when it said it found Chemours’ West Virginia factory had repeatedly exceeded permit limits for two types of forever chemicals, GenX and PFOA.

But the West Virginia Rivers Coalition said in a court filing that the EPA’s consent order for Chemours “is not being diligently prosecuted.”

Chemours declined to answer questions from KFF Health News and NPR, citing ongoing litigation, except to point out that Louisville’s “finished drinking water is safe for consumption,” with PFAS levels below the EPA’s regulatory limits, as stated on Louisville Water’s website and in the annual water quality report from Cincinnati, which also draws from the Ohio River.

As research into the health effects of PFAS exposure continues, environmental advocates say it’s imperative for companies to meet the limitations set by government permits.

“Environmental regulatory permitting is a license to pollute,” said Nick Hart, the water policy director for the Kentucky Waterways Alliance.

“You’re permitting someone to put something into the atmosphere, into water, into soil that would not be there otherwise. And so when we talk about the safe levels,” he said, “stop using the word ‘safe,’ right? This is the maximum allowable limit.”

It is possible to remove PFAS from drinking water. For example, Louisville’s utility is spending about $23 million to redesign its powdered activated carbon system, which is one method used to take out PFAS.

But PFAS removal can get expensive, especially for small, rural towns, Hart said. Preventing contaminants such as PFAS from getting into a community’s drinking water supply is easier and less costly compared with removing it on the back end, he added.

In Chemours’ responses to the lawsuit, the company acknowledged that its violating its current permit but noted it’s working with government regulators on an eventual fix.

The federal judge in the case, Joseph Goodwin, decided that wasn’t fast enough.

In August, he ordered Chemours to immediately stop overpolluting. The company quickly filed an appeal.

The West Virginia Rivers Coalition declined to speak with KFF Health News and NPR but did point to its August news release on the judge’s ruling.

“This is a victory for public health and the Ohio River,” Autumn Crowe, the organization’s deputy director, said in the statement. “The Court recognized what communities have known for years: Chemours has been polluting our water and ignoring its legal obligations.”

In a court filing for the case, Goodmann said that elevated levels of GenX could make it more challenging for water utilities such as Louisville’s to comply with federal rules for safe drinking water.

In regard to Chemours specifically, Goodmann told KFF Health News and NPR that when government regulators issue the company’s next permit, he wants them to take into account the water treatment plants downstream.

“So what we do is manage risk, and we start that at the river,” he said. “It sounds weird, but source water protection — keeping the stuff out of the river — is a big deal.”

This article is from a partnership that includes Louisville Public Media, NPR, and KFF Health News.

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