Julie Appleby, KFF Health News

'It's insane': Family of Texas 4-year-old hit with $1.4K bill for measles shot

In the early days of the West Texas measles outbreak, Thang Nguyen eyed the rising number of cases and worried. His 4-year-old son was at risk because he had received only the first of the vaccine’s two doses.

So, in mid-March, he took his family to a primary care clinic at the University of Texas Medical Branch in Galveston.

By the end of the visit, his son, Anh Hoang, had received one shot protecting against four illnesses — measles, mumps, rubella, and chickenpox. He also received a second shot against tetanus, diphtheria, and whooping cough, as well as a flu shot. His twin daughters, who had already had their measles vaccinations, got other immunizations.

Nguyen, who is a UTMB postdoctoral fellow in public health and infectious disease, said he asked clinic staff whether his family’s insurance would cover the checkups and immunizations. He said he was assured that it would.

Then the bills came.

The Medical Procedure

The first measles vaccine was licensed in 1963 and became part of the combination measles, mumps, and rubella, or MMR, vaccine in 1971. Today the vaccine against chickenpox, or varicella, is sometimes combined into what is known as the MMRV vaccine.

A first dose of the measles vaccine is usually given between 12 and 15 months, with a second between ages 4 and 6. Experts may recommend vaccinating children at younger ages during an outbreak — like the ongoing U.S. measles outbreak, which has led to more than 1,200 cases, 750 of them in Texas. According to the Centers for Disease Control and Prevention, 95% of the cases have occurred in unvaccinated people or those whose vaccine status is unknown.

Recommendations affecting administration and insurance coverage are made by the Advisory Committee on Immunization Practices. In mid-June, Health and Human Services Secretary Robert F. Kennedy Jr. replaced the committee, adding vaccine skeptics. The new panel, which met last week, is expected to scrutinize past recommendations, including for the MMR vaccine.

The Final Bill

UTMB billed $2,532 for the boy’s office visit and three shots. The MMRV shot alone was billed at $1,422, plus $161 for administering it.

The Billing Problem: Coverage Gaps and Provider ‘Errors’

There are guardrails in the U.S. health system intended to prevent recommended vaccines from being prohibitively expensive. They did not help the Nguyen family.

Their health plan, purchased from insurance broker TaiAn for Nguyen’s wife and children and administered by the International Medical Group, does not cover immunizations. And, initially, the family was not offered assistance under the Vaccines for Children Program, a federally funded effort, created after a measles outbreak more than 30 years ago, that provides free immunizations for uninsured and underinsured children.

So the family was exposed to the sticker shock of U.S. medical care without insurance, with providers setting prices. In this case, UTMB’s price for the child’s MMRV shot was about $1,400, more than five times what the CDC says it costs in the private sector.

Nguyen was surprised when their insurer did not pay anything, leaving bills for his three children’s checkups that, combined, were close to $5,000.

He said the family’s income, from his job in UTMB’s labs, is less than $57,000 a year. Nguyen’s job provides him health insurance, but he balked at the $615 a month it would cost to cover his family, too, and instead purchased the one-year policy from TaiAn, which totaled $1,841. The policy covers certain types of office visits, emergency room care, hospitalization, and chemotherapy, but not immunizations or checkups.

Nguyen and his wife, who are from Vietnam, are living in the country on temporary visas while he completes his studies. In Vietnam, Nguyen said, the total cost of the preventive care his family received at the clinic would probably be no more than $300.

He was concerned about the high prices set by the clinic for the vaccines, particularly during a measles outbreak.

“It’s insane,” he said.

Carly Kessler, a spokesperson for International Medical Group, confirmed in an email to KFF Health News that the family’s plan does not cover preventive care, including immunizations.

After UTMB was contacted by KFF Health News, its vice president of clinical contracting strategies, Kent Pickering, looked into the matter. “This situation should not have happened” but did so because of “a series of errors,” he said in an interview.

Most insurance offered in the U.S. must cover, without copays, a variety of preventive care services — including the measles vaccine — under rules in the Affordable Care Act. But some plans are exempt from those rules, including short-term plans or travel insurance. International students on temporary visas do not have to buy an ACA-compliant plan during their first five years in the country.

But what about the cost of the vaccines?

Hospitals and other providers may set their own prices for services, creating price lists called chargemasters. Insurers negotiate discounts for services they agree to cover. People with no insurance coverage are generally on the hook for the full amount.

“One of the most frustrating parts of our health care system is that people who don’t have health insurance coverage have to pay far more than even a health insurance company would pay,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.

While prices can vary, the CDC’s Vaccines for Children Program price list shows the MMRV vaccine — also known by the brand name ProQuad — costs about $278 in the private sector. Consumer prices for ProQuad at Galveston-area pharmacies range from about $285 to $326, according to the prescription cost-tracking website GoodRx.

UTMB’s Pickering told KFF Health News that, initially, the Nguyen family’s insurance was entered incorrectly by the clinic staff, so they did not pick up that his plan didn’t cover vaccines. If they had, UTMB likely would have checked whether the Texas Vaccines for Children Program would cover the cost of the shots, charging only the program’s small administration fee.

A second error was uncovered when Pickering looked into the bill. He said UTMB’s chargemaster had been updated a few months earlier and the vaccine prices for those who do not receive shots through the children’s vaccine program were listed at incorrectly high amounts, resulting in the price Nguyen’s son was charged.

Pickering said the prices had been corrected, though he declined to cite exact figures.

The Resolution

In addition to contacting the insurer, Nguyen reached out to the financial offices at UTMB, asking for a reduction or waiver of the fees.

In mid-May, UTMB sent Nguyen a revised bill for his son’s office visit. It applied a 50% self-pay discount, which its website says is offered to those who are uninsured. His revised total was $1,266, $711 of which was for the MMRV vaccination.

“I expected them to waive the vaccination cost for my children or at least reduce it more, especially for MMRV vaccine,” said Nguyen, noting that his family would still be strapped trying to pay their bills.

After Pickering spoke with KFF Health News, a customer service representative reached out to Nguyen, waiving the cost of the vaccines. His new bill was $202.75 for his son’s office visit, as well as similarly smaller amounts for his daughters’ medical care.

The Takeaway

More Bill of the Monmth

Profit over patients? Medicare insurers accused of bribing brokers

A blockbuster lawsuit from the federal Department of Justice alleges that insurers Aetna, Elevance Health (formerly Anthem), and Humana paid “hundreds of millions of dollars in kickbacks” to large insurance brokerages eHealth, GoHealth, and SelectQuote. The payments, made from 2016 to at least 2021, were incentives to steer patients into the insurer’s Medicare Advantage plans, the lawsuit alleges, while discouraging enrollment of potentially more costly disabled beneficiaries.

All the insurers and brokers named in the case have denied the allegations and say they will fight them in court.

Policy experts say the lawsuit, filed May 1, will add fuel to long-running concerns about whether Medicare enrollees are being encouraged to select the coverage that is best for them — or the one that makes the most money for the broker.

In other Medicare news, The Wall Street Journal last week, citing unnamed sources, reported that a separate insurer, UnitedHealth Group, was being investigated by the Justice Department regarding unspecified potential Medicare violations. UnitedHealth pushed back, calling the article “deeply irresponsible” and saying it had not been notified by the DOJ as to any such investigation.

Regardless of how this attention shakes out, Medicare Advantage, the private sector alternative to original Medicare, is likely to continue to draw scrutiny because it covers more than half of those enrolled. But the plans, which often include benefits not covered by the traditional government program, cost taxpayers more per enrollee and have drawn criticism for requiring patients to get prior authorization for certain services, something rarely required in original Medicare.

The DOJ lawsuit alleges insurers made large payments they called “marketing” or “sponsorship” fees to get around rules that set caps on broker commissions. The payments, according to the lawsuit, added incentives — often more than $200 per enrollee — for brokers to direct Medicare beneficiaries toward their coverage “regardless of the quality or suitability of the insurers’ plans.”

The case joins the DOJ in a previously filed whistleblower lawsuit brought by a then-employee of eHealth, Andrew Shea. The whistleblower’s attorney, Gregg Shapiro, said his client is grateful the DOJ chose to intervene: “People with Medicare must know that when an insurance agent recommends a plan, that recommendation is based solely on the client’s individual needs and preferences,” Shapiro said in an emailed statement.

While encouraged that the Trump administration filed the case under investigations initiated by the Biden administration, policy experts say Congress and insurers need to do more.

“What we see in this lawsuit highlights the terrible incentives that desperately need Congress to reform,” said Brian Connell, a vice president at the Leukemia & Lymphoma Society, an advocacy group.

'Junk insurance': Patient shocked by $7k colonoscopy bill despite coverage

Tim Winard knew he needed to buy health insurance when he left his management job in manufacturing to launch his own business.

It was the first time he had shopped around for coverage, searching for a plan that would cover him and his wife, who was also between jobs at the time.

“We were so nervous about not being on a company-provided plan,” Winard said.

After speaking with an insurance agent, he decided against enrolling in an Affordable Care Act plan because he was concerned about the potential cost. Instead, he chose a short-term policy, good for six months.

Six months later, Winard was still working on starting his business, so he signed up for another short-term policy with a different insurer that cost about $500 a month.

When he needed a colonoscopy, Winard, 57, called his insurance company. He said a representative told him to go to any facility he wanted for the procedure.

Early last year, he had the colonoscopy at a hospital in Elmhurst, Illinois, not far from his home in Addison.

The procedure went well, and Winard went home right afterward.

Then the bill came.

The Medical Procedure

Periodic colon cancer screening is recommended for people at average risk starting at age 45 and continuing until age 75, according to the U.S. Preventive Services Task Force. In addition to those for preventive purposes, doctors may order colonoscopies to diagnose existing concerns, as was the case for Winard.

There are several ways to screen, including noninvasive stool tests. A colonoscopy allows clinicians to examine and remove any polyps, which are then tested to see whether they are precancerous or malignant.

The Final Bill

$10,723.19, including $1,436 for the anesthesia and $1,039 for the recovery room. After an insurance discount, his plan paid $817.47. Winard was left owing $7,226.71.

The Billing Problem: A Short-Term Plan, With Coverage Caps and Gaps

Short-term, limited-duration insurance policies do not have to follow rules established under the ACA because they are intended to be only temporary coverage.

As Winard experienced, benefits within the plans can vary, with some setting specific dollar caps on certain types of medical care — sometimes far below what it costs. What’s covered can be hard to parse, and the insurer generally gets the last word on interpreting its rules.

While some short-term policies look like comprehensive major medical policies, all come with significant caveats. Most have limits that people accustomed to work-based or comprehensive ACA plans may find surprising.

All short-term insurance carriers, for example, screen applicants for health conditions and can reject them because of health problems or exclude those conditions. Many do not include drug coverage or maternity care.

The fact that short-term plans can cover fewer services, conditions, and patients is why they are generally less expensive than an unsubsidized ACA plan.

“The general trade-off is lower premiums versus what the plans actually cover,” said Cynthia Cox, vice president and director of the program on the ACA at KFF, a health information nonprofit that includes KFF Health News. “But the reason short-term plans are priced lower than a more comprehensive ACA plan is that they can deny people with preexisting conditions and don’t have to cover a lot of essential health benefits.”

Stunned that he owed more than $7,000 for his colonoscopy, Winard contacted his insurance company, Companion Life Insurance of Columbia, South Carolina.

An insurance representative told him in an email that it classified the procedure and all its costs, including the anesthesia, under his policy’s “outpatient surgery facility” benefit.

That benefit, the email said, capped insurance payment “within that facility” to a maximum of $1,000 per day.

That definition surprised Winard, who said he read his policy to mean that there was a cap on what could be charged for the facility itself — not for all the care he received there.

“I interpreted it to be a facility like a recovery room or surgery room,” he said. “They defined it to include any services at an outpatient facility.”

His plan says it covers colon cancer screening at 80% after patients meet their deductible. It also covers 80% of the cost of drugs provided in an outpatient setting.

Winard, who had met his deductible, said he expected he would pay only 20% toward the cost of his colonoscopy. But he also wondered why the screening, performed at Endeavor Health Elmhurst Hospital, was categorized by the insurer as a procedure at an “outpatient” facility.

According to the email Winard received from his insurer, his policy’s $1,000-a-day limit applies to “treatment or services in a state-approved freestanding ambulatory surgery center that is not part of a hospital, or a hospital outpatient surgery facility.”

Elmhurst Health spokesperson Allie Burke said that the hospital has an attached building where same-day outpatient procedures like colonoscopies are performed.

Short-term plans have been sold for decades. But in recent years, they’ve become a political football.

Out of concern that people would choose them over more comprehensive ACA insurance, President Barack Obama’s administration limited short-term plans’ terms to three months. Those rules were lifted in President Donald Trump’s first term, allowing the plans to again be sold as 364-day policies.

President Joe Biden, calling such plans “junk insurance,” restricted the policies to four months — a change that took effect one month after Winard’s procedure. Trump is expected to reverse Biden’s reversal and again make them available for longer durations.

The Resolution

In December, Winard hired an advocate, Linda Michelson, to help him parse his bill. They wrote to the hospital, offering to pay $4,000 if it would settle the entire bill — an amount Michelson said is about four times what Medicare would pay for a colonoscopy. Winard said the hospital declined the offer.

Spencer Walrath, another Elmhurst spokesperson, wrote in an email to KFF Health News that the hospital’s prices “reflect the value of the services we deliver.”

Companion Life did not respond to requests for comment. Scott Wood, who identified himself as a program manager and co-founder of Pivot Health, which markets Companion Life and other insurance plans, said in an interview that there was room for interpretation in the billing and that he had asked Companion Life to take another look.

Shortly after Wood’s comment to KFF Health News, Winard said he was contacted by his insurer. A representative told him that, upon reconsideration, the bill had been adjusted — although he was given no specific explanation as to why.

His new bill showed he owed only $770.

The Takeaway

Short-term plans can be appealing for some people because of the relatively low cost of their premiums, but consumers should read all the plan documents carefully before enrolling. Understand that the plans often won’t cover a full range of benefits, and check to see which services are covered and which are excluded. Check whether a policy includes per-day or per-policy-period dollar caps on coverage or other payout limits.

The federal government offers subsidies based on household income for ACA plans, which can make them comparable in cost to cheaper, short-term plans — but with a wider range of benefits.

In hindsight, Winard said he had not understood the difference between ACA policies and short-term plans.

His advice? Don’t rely solely on marketing materials, and always get a cost estimate, preferably in writing, before a nonemergency procedure like a colonoscopy.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

'I will always be honest': Republican shamed over 'false' promise on Medicaid

“On Feb. 25, I voted yes on a budget resolution that protects Social Security, Medicare, and Medicaid while cutting some spending elsewhere.”

Rep. Nick LaLota (R-NY), in a YouTube video posted March 4, 2025

On Feb. 25, Rep. Nick LaLota (R-NY) voted in favor of a House budget resolution that calls for sharp cuts in spending across a vast array of government areas. Medicaid is among the programs that could be at risk — catapulting it to the center of the political debate.

President Donald Trump has insisted he won’t harm Medicaid, Medicare, and Social Security benefits, saying his administration is looking to root out fraud. But Democrats have pushed back, saying the sheer size of the proposed cuts will result in harm to the Medicaid program, its enrollees, and medical providers.

A KFF tracking poll has found widespread public support for Medicaid, which suggests efforts to cut the program could face political headwinds. KFF is a health information nonprofit that includes KFF Health News.

LaLota, who represents part of Long Island, posted a video for his constituents explaining his position: “I voted yes on a budget resolution that protects Social Security, Medicare, and Medicaid while cutting some spending elsewhere.”

Because much of his video focused on Medicaid, we did too. We found that his statement in this regard was layered with mischaracterizations and inaccuracies. Yet, in his video, LaLota advises his constituents to get their information straight from him, saying, “I’ll always be honest with you.”

We asked LaLota’s office for the information he used to back up his statement. The budget resolution makes no cuts to those programs, he wrote in a statement emailed by his communications aide Mary O’Hara. “Rather, it opens the door to protect Medicaid with common-sense solutions which ensure its availability for those Americans who qualify, including the removal of illegals from the rolls, work requirements for able-bodied adults, and the elimination of waste, fraud, and abuse.”

Let’s parse what the resolution does say and do, and the changes it could trigger for Medicaid.

Explaining the Basics

Budget resolutions are not law, but rather blueprints that guide lawmakers on budget-related legislation. The House-passed resolution — approved with 217 Republicans voting for it and 214 Democrats and one Republican against — is just one part of the budget process. The Senate also has a say, so changes are possible.

As written, the resolution seeks broad spending reductions across a range of areas overseen by various committees. It specifically asks the House Committee on Energy and Commerce to submit proposals “to reduce the deficit by not less than $880,000,000,000 [$880 billion] for the period of fiscal years 2025 through 2034.”

It does not say it would protect Medicaid. The word Medicaid is nowhere in the document. It does not prescribe any specific action on the program, such as instituting work requirements for recipients. Lawmakers separately draft legislation to make program adjustments to achieve the spending cut targets.

A little background: Medicaid is a state-federal program that provides medical coverage to lower-income residents, as well as payments to nursing homes for caring for seniors and disabled residents. Medicaid and the closely related Children’s Health Insurance Program cover more than 79 million people.

Medicare is the federal program that provides health insurance for some disabled people and most people over age 65. More than 68 million people are enrolled.

The resolution directs the committee to draft legislative language that would cut spending from areas under its jurisdiction, which include Medicaid and about half of Medicare.

Social Security is mainly overseen in the House by the Committee on Ways and Means. The panel also shares jurisdiction over Medicare with Energy and Commerce.

Policy experts and the Congressional Budget Office have said that, after removing Medicare from consideration, there’s not enough under the committee’s jurisdiction to cut $880 billion without substantially reducing Medicaid spending. (Medicare is generally considered a third rail because its beneficiaries are a powerful voting bloc.)

Indeed, of the $8.8 trillion in projected spending under the committee’s purview for the 10-year period, Medicaid accounts for $8.2 trillion, or 93%.

“Even if the committee eliminated all of non-Medicare and non-Medicaid spending, they would still have to cut Medicaid by well over $700 billion,” said Alice Burns, an associate director of KFF’s Program on Medicaid and the Uninsured.

Adding work requirements — most Medicaid recipients already have jobs — would not yield that level of savings and could increase state costs. Other cuts suggested by Republicans, including capping federal spending per enrollee, reducing federal matching dollars, and eliminating the use of provider taxes, which states use to pay for their share of Medicaid spending, could force states to cut spending or find new revenue sources.

“Cuts to Medicaid could mean eliminating coverage for children, parents, working adults or those who might need long term care; limiting benefits; or cutting payment rates for health plans or providers. These choices could come at a time when state revenue growth is slowing, and most states face requirements to pass balanced budgets,” according to an analysis by Robin Rudowitz, vice president of the KFF Program on Medicaid and the Uninsured.

The downstream effects if the House-passed budget resolution were enacted would be wide-ranging and significantly alter the safety net program, said Edwin Park, a research professor at the Center for Children and Families at Georgetown University.

He noted growing opposition to such large-scale Medicaid cuts from “beneficiaries and parents of children with disabilities, families with parents in nursing homes, and from health care providers.”

“Medicaid cuts are highly unpopular even among Trump voters,” he said.

Opposition to Medicaid cuts helped kill the 2017 attempt to repeal the Affordable Care Act during the first Trump administration, noted Joseph Antos, a senior fellow emeritus at the American Enterprise Institute.

Antos thinks the current spending cut target is unrealistic and will likely not survive the effort to merge the House budget blueprint with what the Senate wishes to do.

“Ultimately, the problem is you can’t take that much out of Medicaid,” Antos said.

LaLota’s focus on immigrants lacking legal status as a way to reduce federal spending on Medicaid is also misleading.

A number of states, including New York, offer coverage to children or adults regardless of immigration status, but they can use only state money to pay for such programs.

“States cannot use federal funding to cover undocumented immigrants,” Burns said. So removing them “won’t do anything for the deficit reduction targets.”

Our Ruling

LaLota said, “On Feb. 25, I voted yes on a budget resolution that protects Social Security, Medicare, and Medicaid while cutting some spending elsewhere.”

His statement is inaccurate and mischaracterizes laws and the language included in the budget resolution, creating a false impression of what his vote supported.

The 32-word sentence that directs the Energy and Commerce Committee to trim $880 billion over 10 years from programs it authorizes does not include any protections, guardrails, or specific directions for the panel to follow.

We rate this claim False.

Sources:

Rep. Nick LaLota, constituent video, March 4, 2025.

Clerk, United States House of Representatives, “Roll Call 50 | Bill Number H. Con. Res. 14,” Feb. 25, 2025.

Newsweek, “Donald Trump Issues Social Security, Medicaid Update,” March 10, 2025.

Rep. Hakeem Jeffries, press release, March 16, 2025.

KFF, February tracking poll, March 7, 2025.

Medicaid.gov, “October 2024 Medicaid & CHIP Enrollment Data Highlights,” accessed March 17, 2025.

Congressional Budget Office, letter to Reps. Brendan Boyle and Frank Pallone, March 5, 2025.

KFF Quick Takes, “As Governors Meet in D.C., Possible Federal Medicaid Cuts Loom as Big State Funding Issue,” Feb. 20, 2025.

KFF, “Key Facts on Health Coverage of Immigrants, Jan. 15, 2025.

Telephone interview with Joseph Antos, senior fellow emeritus, American Enterprise Institute, March 17, 2025.

Telephone interview with Edwin Park, research professor at the Center for Children and Families, Georgetown University, March 17, 2025.

Telephone interview with Alice Burns, associate director, Program on Medicaid and the Uninsured, KFF, March 17, 2025.

Subscribe to KFF Health News' free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

Most insurance covers IUDs — hers cost more than $14K

During her annual OB-GYN visit, Callie Anderson asked about getting off the birth control pill.

“We decided the best option for me was an IUD,” she said, referring to an intrauterine device, a long-acting, reversible type of birth control.

Anderson, 25, of Scranton, Pennsylvania, asked her doctor how much it might cost. At the time, she was working in a U.S. senator’s local office and was covered under her father’s insurance through a plan offered to retired state police.

“She told me that IUDs are almost universally covered under insurance but she would send out the prior authorization anyway,” Anderson said.

She said she heard nothing more and assumed that meant it was covered.

After waiting months for an appointment, Anderson had the insertion procedure last March. She paid $25, her copay for an office visit, and everything went well.

“I was probably in the room itself for less than 10 minutes, including taking clothes on and off,” she said.

Then the bill came.

The Medical Procedure

According to Planned Parenthood, IUDs and implantable birth control represented nearly 25% of its contraceptive services provided from October 2021 to September 2022, per the latest data available.

There are two types of IUDs: copper, which Planned Parenthood says can protect against pregnancy for up to 12 years, and hormonal, which can last from three to eight years depending on the brand. Hormonal IUDs can prevent ovulation, and both types affect the movement of sperm, designed to stop them from reaching an egg.

A physician or other practitioner uses a tube to insert the IUD, passing it through the cervix and releasing it into the uterus.

Doctors often recommend over-the-counter drugs for insertion pain, a concern that prompts some patients to avoid IUDs. Last year, federal health officials recommended doctors discuss pain management with patients beforehand, including options such as lidocaine shots and topical anesthetics.

The Final Bill

$14,658: $117 for a pregnancy test, $9,862 for a Skyla IUD, $4,057 for “clinic service,” plus $622 for the doctor’s services.

The Billing Problem: A ‘Grandfathered’ Plan

Anderson got a rare glimpse of what can happen when insurance doesn’t cover contraception.

The Affordable Care Act requires health plans to offer preventive care, including a variety of contraceptives, without cost to the patient.

But Anderson’s plan doesn’t have to comply with the ACA. That’s because it’s considered a “grandfathered” plan, meaning it existed before March 23, 2010, when President Barack Obama signed the ACA into law, and has not changed substantially since then.

It’s unclear how many Americans have such coverage. In its 2020 Employer Health Benefits survey, KFF estimated that about 14% of covered workers were still on “grandfathered” plans.

Anderson said she didn’t know that the plan was grandfathered — and that it did not cover IUDs — until she contacted her insurer after it denied payment. Her doctor with Geisinger, a nonprofit health system in Pennsylvania, was in-network.

“My understanding was Geisinger would reach out to insurance and if there was an issue, they would tell me,” she said.

Mike McCullen, a Geisinger spokesperson, said in an email to KFF Health News that with most insurance plans, “prior authorization is not required for placing birth control devices, however, some insurers may require prior authorization for the procedure.”

He did not specify whether it is the health system’s policy to seek such authorizations for IUDs, nor did he comment on the amount charged.

The Pennsylvania State Troopers Association, which offers some retirees the plan that covered Anderson, did not respond to requests for comment. Highmark Blue Cross Blue Shield, the insurer, referred questions to the state.

Dan Egan, communications director for the state’s Office of Administration, confirmed in an email that the insurance plan is a grandfathered plan “for former Pennsylvania State Troopers Association members who retired prior to January 13, 2018.”

A benefit handbook for the plan identifies it as grandfathered and lists a variety of excluded services. Among them are “contraceptive devices, implants, injections and all related services.”

The $14,658 bill, an amount that typically would be negotiated down by an insurer, was solely Anderson’s responsibility.

“Fourteen thousand dollars is astronomical. I’ve never heard of anything that high” for an IUD, said Danika Severino Wynn, vice president for care and access at the Planned Parenthood Federation of America.

Costs for IUDs vary, depending on the type, where the patient lives, insurance status, the availability of financial assistance, and additional medical factors, Severino Wynn said.

She said most insurers cover the devices, but coverage can vary, too. For instance, some cover only certain types or brands of contraceptives. Generally, an IUD insertion costs $500 to $1,500, she added.

Many providers, including Planned Parenthood, have sliding-scale rates based on income or can set up payment plans for cash-paying or underinsured patients, she said.

According to FAIR Health, a cost estimation tool that uses claims data, an uninsured patient in the Scranton area could expect to be charged $1,183 for an IUD insertion done at an ambulatory surgery center or $4,319 in a hospital outpatient clinic.

The Resolution

Anderson texted and called her insurer and Geisinger multiple times, spending hours on the phone. “I am appalled that no one at Geisinger checked my insurance,” she wrote in one message with staff at her doctor’s office.

She said she felt rebuffed when she asked billing representatives about financial assistance, even after noting the bill was more than 20% of her annual income.

“I wasn’t in therapy at the time, but at the end of this I ended up going to therapy because I was stressed out,” she said. The billing office, she said, “told me that if I didn’t pay in 90 days, it would go to collections, and that was scary to me.”

Eventually, she was put in touch with Geisinger’s financial assistance office, which offered her a self-pay discount knocking $4,211 off the bill. But she still owed more than she could afford, Anderson said.

The final offer? She said a representative told her by phone that if she made one lump payment, Geisinger would give her half off the remaining charges.

She agreed, paying $5,236 in total.

The Takeaway

It’s always best to read your benefit booklet or call your insurer before you undergo a nonemergency medical procedure, to check whether there are any exclusions to coverage. In addition, call and speak with a representative. Ask what you might owe out-of-pocket for the procedure.

While it can be hard to know whether your plan is grandfathered under the ACA, it’s worth checking. Ask your insurance plan, your employer, or the retiree benefits office that offers your coverage. Ask where the plan deviates from ACA rules.

With birth control, “sometimes you have to get really specific and say, ‘I’m looking for this type of IUD,’” Severino Wynn said. “It’s incredibly hard to be an advocate for yourself.”

Most insurance plans offer online calculators or other ways to learn ahead of time what patients will owe.

Be persistent in seeking discounts. Provider charges are almost always higher than what insurers would pay, because they are expected to negotiate lower rates.

This article first appeared on KFF Health News and is republished here under a Creative Commons license

Fact-checker busts Vance as he rewrites history about Trump and Obamacare

Donald Trump could have destroyed the Affordable Care Act, but “he chose to build upon [it].”

Sen. JD Vance (R-Ohio) on “Meet the Press,” Sept. 15

Sen. JD Vance (R-Ohio) on Sept. 15 told viewers of NBC’s “Meet the Press” that former President Donald Trump built up the Affordable Care Act, even though Trump could have chosen to do the opposite.

“Donald Trump had two choices,” Vance, Trump’s running mate, said. “He could have destroyed the program, or he could actually build upon it and make it better so that Americans didn’t lose a lot of health care. He chose to build upon a plan, even though it came from his Democratic predecessor.”

The remarks follow statements the former president made during his Sept. 10 debate with Vice President Kamala Harris in Philadelphia. Trump said of the ACA, “I saved it.”

The Affordable Care Act, aka Obamacare, has grown more popular as Americans have increasingly used it to gain health coverage. More than 20 million people enrolled this year in plans sold through the marketplaces it created. That makes the law a tricky political issue for Republicans, who have largely retreated from their attempts over the past decade to repeal it.

Both Vance’s and Trump’s statements are false. We contacted Vance’s campaign; it provided no additional information. But here’s a review of policies related to Obamacare that Trump pursued as president.

So What Did Trump Do With the ACA?

Most of the Trump administration’s ACA-related actions involved cutting the program, including reducing by millions of dollars funding for marketing and enrollment assistance and backing the many failed efforts in Congress and the courts to overturn the law. In June 2020, for example, the administration asked the Supreme Court to overturn the law in a case brought by more than a dozen GOP states. The high court eventually rejected the case.

“The fact the ACA survived the Trump administration is a testament to the strength of the underlying statutory framework, and that the public rallied around it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

Most ACA provisions took effect in 2014, during Barack Obama’s presidential administration.

Average premium costs, already rising when Trump took office, jumped for some plans in 2018, before beginning a modest decline for the rest of his term, according to statistics from KFF, a health information nonprofit that includes KFF Health News.

Some of those increases were tied to a 2017 Trump administration decision to stop making payments to insurers, which was intended to reduce deductibles and copayments for people with low to moderate incomes. By law, though, insurers still had to offer the plans.

Two months earlier, the Congressional Budget Office warned that stopping the payments could cause some insurers to leave the ACA marketplace — and that premiums would rise by 20% in the first year.

Most states, however, let insurers make up for the lost payments by increasing monthly premiums. That had the unintended effect of boosting federal subsidies for people who buy Obamacare plans, because the subsidies are tied to the cost of premiums.

“By accident, that gave people cheaper access to better coverage in the exchange plans,” said Joe Antos, a senior fellow emeritus with the American Enterprise Institute.

Some Republicans think Trump deserves credit for this inadvertent improvement.

But Larry Levitt, KFF’s executive vice president for health policy, said that wasn’t the Trump administration’s intention.

“The one time when Trump improved the ACA, it was an unintended consequence of an attempt to weaken it,” he said.

Meanwhile, the Trump administration expanded access to some kinds of less expensive health coverage that aren’t compliant with ACA rules, including short-term plans that generally have more restrictions on care and can leave consumers with surprise medical bills. Democrats call the plans “junk insurance.”

Brian Blase, president of the Paragon Health Institute, a conservative health research group, said broader access to cheaper, less comprehensive plans helped more people get coverage. The plans’ critics say that if they had attracted too many healthy people from ACA-compliant insurance, increases could have spiked for people who remained.

Trump also supported congressional repeal-and-replace efforts, all of which failed — including on the memorable night when Sen. John McCain (R-Ariz.) helped kill the effort with a thumbs-down vote. The Trump administration never issued its own replacement plan, despite the former president’s many promises that he would.

Trump, during the debate with Harris, said that he has “concepts of a plan” to replace Obamacare and that “you’ll be hearing about it in the not-too-distant future.”

On “Meet the Press,” host Kristen Welker asked Vance when Trump’s plan would be ready. He didn’t answer directly but said it would involve “deregulating the insurance market.”

Critics say that’s code for letting insurers do business as they did pre-ACA, when sick people could be denied coverage or charged exorbitant premiums based on preexisting conditions.

Our Ruling

Vance’s assertion that Trump as president took steps to build upon the ACA and protect the health coverage of 20 million Americans is simply not supported by the record.

Trump administration policies, for example, didn’t buttress the ACA but often undermined enrollment outreach efforts or were advanced to sabotage the insurance marketplace. Also, Trump vocally supported congressional efforts to overturn the law and legal challenges to it.

By the numbers, Affordable Care Act enrollment declined by more than 2 million people during Trump’s presidency, and the number of uninsured Americans rose by 2.3 million, including 726,000 children, from 2016 to 2019, according to the U.S. Census Bureau. That includes nearly three years of Trump’s presidency.

We rate Vance’s statement False.

SOURCES:

“Meet the Press” interview with Sen. JD Vance, Sept. 15, 2024.

Brookings Institution, “Six Ways Trump Has Sabotaged the Affordable Care Act,” Oct. 9, 2020.

Vox, “Trump Is Slashing Obamacare’s Advertising Budget by 90%,” Aug. 31, 2017.

Center on Budget and Policy Priorities, “Trump Administration Has Cut Navigator Funding by Over 80 Percent Since 2016,” Sept. 13, 2018.

The New York Times, ‘Trump Administration Asks Supreme Court To Strike Down Affordable Care Act,” June 26, 2020.

Constitutional Accountability Center, Texas v. United States, accessed Sept. 16, 2024.

Harvard T.H. Chan School of Public Health, “Quantifying Health Coverage Losses Under Trump,” Nov. 3, 2020.

Center on Budget and Policy Priorities, “Uninsured Rate Rose Again In 2019, Further Eroding Earlier Progress,” Sept. 15, 2020.

U.S. Census Bureau, Health Insurance Historical Tables, revised Aug. 22, 2024.

KFF, Marketplace Average Benchmark Premiums, accessed Sept. 16, 2024.

Brookings Institution, “The Case for Replacing ‘Silver Loading,’” May 20, 2021.

KFF Health News, “Trump Administration Loosens Restrictions on Short-Term Health Plans,” Aug. 1, 2018.

The New York Times, “Biden Administration Finalizes Rule Curbing Use of Short-Term Health Plans,” March 28, 2024.

Telephone interview, Sabrina Corlette, co-director of the Center on Health Reforms at Georgetown University, Sept. 16, 2024.

Telephone interview, Joe Antos, senior fellow emeritus, American Enterprise Institute, Sept. 16, 2024.

Email correspondence, Brian Blase, president of the Paragon Health Institute, Sept. 16, 2024.

Email correspondence, Larry Levitt, KFF executive vice president for health policy, Sept. 18, 2024.

Congressional Budget Office, “The Effects of Terminating Payments for Cost-Sharing Reductions,” Aug. 15, 2017.

USA Today, “Trump To End Cost-Sharing Subsidies to Insurance Companies,” Oct. 12, 2017.

New York magazine, “Vance: Trump’s Health-Care Plan Is To Let Insurers Charge More for Preexisting Conditions,” Sept. 17, 2024.

Republicans unveil new lines of attack against Obamacare

The Affordable Care Act is back under attack. Not as in the repeal-and-replace debates of yore, but in a fresher take from Republican lawmakers who say key parts of the ACA cost taxpayers too much and provide incentive for fraud.

Several House Republican leaders have called on two watchdog agencies to investigate, while Sen. Chuck Grassley (R-Iowa) fired off more than half a dozen questions in a recent letter to the Centers for Medicare & Medicaid Services.

At issue are the ACA’s enhanced subsidies, put in place during the covid-19 pandemic as part of economic recovery legislation. Grassley said in a recent news release that the subsidies “left Obamacare, a program already riddled with problems, wide open to new waste, fraud and abuse.”

While potential fraud in government programs has always been a rallying cry for conservatives, the recent criticisms are a renewed line of attack on the ACA because repealing it is unlikely, given that more than 21 million people enrolled in marketplace plans for this year.

“I see what’s happening right now as laying the groundwork for the big fight next year,” said Debbie Curtis, a vice president at consulting firm McDermott+.

The enhanced subsidies are set to expire in late 2025. Without them, millions of Americans would likely see their premiums go up.

But the debate will also likely draw in other issues, including Trump-era tax cuts, which also must be addressed next year. Also potentially in play are other aspects of the ACA, including a special year-round enrollment period and zero-premium plans for low-income consumers.

Much of what eventually happens will depend on the makeup of the Senate and House, as well as control of the White House, after the November elections.

“The fate of the enhanced tax credits is dependent on the Democrats holding some majority in Congress and/or winning the presidency and is also tied inextricably to the Trump tax cut expiration,” said Dean Rosen, a partner at Mehlman Consulting and a former senior Republican congressional staffer. That’s because both sides have incentive to extend all or part of the tax cuts, but each will want some kind of compromise on other issues as well.

The growing outcry by Republicans about the subsidies goes hand in hand with a controversial recent report from a conservative think tank that estimates millions of people — or their brokers — may be misstating their incomes and getting the most generous ACA subsidies.

The Paragon Health Institute report estimates that the number of people who enrolled in ACA coverage for this year who projected they would earn between 100% of the federal poverty level and 150% — amounts that qualify them for zero-premium plans and smaller deductibles — likely exceeds the number of people with that level of income, particularly in nine states.

It recommends several changes to the ACA, including letting the enhanced subsidies expire, increasing repayment amounts for people who fail to project their incomes correctly, and ending the Biden-backed initiative that allows very low-income people to enroll in ACA coverage year-round rather than having to wait for the once-a-year general open enrollment period.

The Paragon report was cited by both Grassley and the House GOP lawmakers in their letters to government overseers. It also notes what they consider a related concern: ongoing problems of unscrupulous, commission-seeking agents enrolling people in ACA coverage or switching their plans without their permission, often into highly subsidized plans. KFF Health News uncovered the enrollment and switching schemes in the spring.

Some critics, though, question how the Paragon analysis was done.

For instance, Paragon’s findings rely on two unrelated data sets from different years. Combining them makes many people who are eligible for subsidies appear to be ineligible, said Gideon Lukens, a senior fellow and director of research at the Center on Budget and Policy Priorities. “The analytic approach is not careful or sophisticated enough to provide accurate or even meaningful results.”

Paragon President Brian Blase, a former senior Trump administration official and a co-author of the report, said it used publicly available data that others could use to confirm its results.

Paragon’s recommendations also drew mixed reactions.

Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University, said they “would make coverage less affordable, disproportionately affecting low-income people, and that’s the opposite of the goals of the ACA.”

Another ACA expert, Joseph Antos of the conservative American Enterprise Institute, agrees with one of the recommended fixes: changing the structure of the subsidies to limit zero-premium plans.

“Giving health insurance away is the problem,” said Antos, who said it is probably contributing to the unauthorized switching by some rogue brokers, who know if they sign someone up for a free plan without their permission, they’re unlikely to get caught for a while because the person won’t get monthly bills.

Another potential solution to people misstating their income is that “the seven or eight states that still haven’t expanded Medicaid should do that,” Antos said. The expansion would open Medicaid eligibility to more people who earn less than the poverty level, reducing the incentive to overestimate their income to qualify for ACA subsidies.

Among other things, the subsidies are larger now for low-income enrollees. For example, families at the poverty level or just above it ($30,000 to $45,000 for a family of four) can currently qualify for coverage with no monthly premium, whereas before they would have had to pay 2% to 4% of their annual income toward such a plan.

President Joe Biden has pushed to make the subsidies permanent and has often touted the record enrollment in ACA plans under his watch. Across all income groups, nearly 20 million people out of 21 million ACA enrollees this year got at least some subsidy, according to a KFF report.

Subsidies, also called premium tax credits, are generally paid directly to health insurers, and applicants must estimate their income for the coming year to qualify.

Those who incorrectly project their incomes — possibly because they work irregular retail hours, are self-employed and give a best guess of business, or get an unexpected raise or a new job — must pay back all or part of the subsidy, on a sliding scale linked to income.

The cost of the enhanced subsidies has been sharply criticized by some GOP leaders after the Congressional Budget Office recently estimated that making them permanent would add $335 billion to the federal budget deficit over 10 years.

Democrats have pointed to another recent CBO report estimating extending the Trump-era tax cuts would add $4.6 trillion to the deficit over 10 years.

The enhanced subsidies “cost a lot less than that and it’s actually helping people,” Curtis said.

Ultimately, “every health care debate comes down to money,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News. “There is a trade-off here. Millions of people have gotten coverage and more affordable premiums due to these enhanced subsidies, but extending them would cost the government a lot of money.”

Despite the attention paid by some GOP lawmakers to the fraud concerns, many political observers say they don’t think they will play a direct role during the election campaigns of either party.

“For Republicans, they’ll stay away from health care period. It is not a winning campaign issue for them,” Curtis said. “With Harris’ campaign, we will see a continued drive for affordable coverage being key, particularly drug costs. In neither party will you hear much about the importance of extending the enhanced subsidies. It’s too complicated.”

GOP unveils fresh attacks on Obamacare amid ongoing healthcare debate

Several House Republican leaders have called on two watchdog agencies to investigate, while Sen. Charles Grassley (R-Iowa) fired off more than half a dozen questions in a recent letter to the Centers for Medicare & Medicaid Services.

“I see what’s happening right now as laying the groundwork for the big fight next year,” said Debbie Curtis, a vice president at consulting firm McDermott+.

The enhanced subsidies are set to expire in late 2025. Without them, millions of Americans would likely see their premiums go up.

Much of what eventually happens will depend on the makeup of the Senate and House, as well as control of the White House, after the November elections.

Some critics, though, question how the Paragon analysis was done.

Paragon President Brian Blase, a former senior Trump administration official and a co-author of the report, said it used publicly available data that others could use to confirm its results.

Paragon’s recommendations also drew mixed reactions.

Another ACA expert, Joseph Antos of the conservative American Enterprise Institute, agrees with one of the recommended fixes: changing the structure of the subsidies to limit zero-premium plans.

Subsidies, also called premium tax credits, are generally paid directly to health insurers, and applicants must estimate their income for the coming year to qualify.

Democrats have pointed to another recent CBO report estimating extending the Trump-era tax cuts would add $4.6 trillion to the deficit over 10 years.

The enhanced subsidies “cost a lot less than that and it’s actually helping people,” Curtis said.

Despite the attention paid by some GOP lawmakers to the fraud concerns, many political observers say they don’t think they will play a direct role during the election campaigns of either party.

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