An Arm and a Leg host Dan Weissmann traces Engelberg’s story back more than 50 years, from a scrappy childhood on the Atlantic City boardwalk to watching President Ronald Reagan sign his bill into law at the . Today, Engelberg advocates for policy changes he believes will enable more generic drugs to reach the market faster.Ìý

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

Dan:ÌýHey there–

We are kicking off a new series here — We’re calling it An Arm and a Leg 101.

We’ve spent years of reporting on two huge questions: Why does health care cost so freaking much? And what can we maybe do about it?

We’ve been chasing answers one story, one question at a time.

Now, we’re pulling together some of what we’ve learned. Digging a little deeper, going a little broader.

Starting with why so many drugs cost so much.

One of the first questions I ever asked — one of our first stories — was: How can insulin be so expensive? Wasn’t it discovered in the early 20th century? Shouldn’t it be a generic drug by now?

You know, cheap?Ìý

And part of the answer I got was: Insulin has been transformed since the early 20th century. A lot.

A medical researcher named Jing Luo told me: Today’s insulins are a long way from what we had a hundred years ago.

Jing Luo:ÌýThey’ve been really modified at a molecular level. It’s cool stuff. It’s super cool stuff. And you know, there are multiple Nobel prizes in physiology and medicine that have made this happen.

Dan:ÌýAnd all that super-cool stuff, those amazing discoveries, got patented.

Meaning: The patent-holders– the pharma companies — got a monopoly on those amazing discoveries.

The pharma companies claimed patents — and monopolies– on aÌýbunch of other thingsÌýtoo. Not all of them amazing.

But each new patent can mean another delay for a generic version coming to market.

Jing Luo:ÌýCompanies can stack dozens of patents on top of each other to try to thwart generic competition because they can say, look, we’ve got three patents on the active ingredient. We’ve got patents on the medical uses of the active ingredient. We’ve got patents on the non-active excipient associated with this ingredient. We’ve got multiple patents on the devices, and so you who are trying to enter this space will sue you for patent infringement on all of them.

Dan:ÌýA patent guarantees you at least a 20-year monopoly. Drugs can generally get an extra five.Ìý

And these extra patents — secondary patents –can keep you protected LONGER. If you don’t file them at the same time as the original:Ìý

To talk about a drug that’s in the news right now. The original patent on the active ingredient in Wegovy and Ozempic actually expired this year.. The extra five years extends it to the early 2030s.Ìý

But dozens of extra patents — secondary patents, filed later — meanÌýthat here in the U.S.,Ìýwe might not see cheaper generic versions until 2042. Or later.

And as Jing Luo told me: This strategy isn’t a secret. It’s an industry cornerstone.Ìý

Jing Luo:ÌýWhen you listen to these like CEOs of pharma companies being interviewed at CNBC, you know, they’d be like, well, what about generic competition for this product? And they’ll just keep saying, no, no, no. We’ve got this really robust patent portfolio. We can withstand any challenge. We’re gonna tie this up in courts forever and don’t worry about it.We’re gonna continue this gravy boat for a long, long time. That’s the way they reinsure investors.

Dan:ÌýA robust patent portfolio. ?Or what researchers and advocates call a patent thicket.

They say quality matters less than quantity.Ìý

The numbers are wild.Ìý

, the 10 best-selling drugs for 2021 — drugs for cancer, HIV, arthritis — were protected by a combined total of seven hundred and forty-two patents. With hundreds more “pending.”

When these add-on patents get challenged in court, they actually get tossed out more often than primary patents..

But lawsuits cost money. A robust patent portfolio — a patent thicket — means generic companies would need to be ready to file a LOT of them.

So, we wanted to know: How did all this happen? How did these games get started?

It turns out, there is one guy who can tell you the story from the beginning, for better and for worse. Who helped shape it. Made millions of dollars from it. Saw its flaws. And has spent most of the last 30 years trying to fix them. Hie’s a lawyer named Al Engelberg, and he’s 86 years old.

Alfred Engelberg:ÌýI tell people all the time, I live in a world, a pharma world where half the people think I’m dead and the other half wish I was.ÌýÌý

Dan:ÌýAl Engelberg’s story is the storyÌý of generic drugs in America. And it’s a wild ride.Ìý

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

?Al Engelberg’s parents fled Nazi Germany in the late 1930s.

He was born here, less than a year after they arrived. They had nothing.

AndÌý here’s where they made their new life.Ìý

Retro news reel:ÌýWe are flying over a well-known eastern city. That is remarkable because manufacturing is almost non-existent. A city whose principle business is the entertainment of millions. Atlantic city, often called the vacation capital of the nation

Dan:ÌýAl likes to say he learned most of what he knows about practicing law on the Atlantic City boardwalk, by the time he was 16.Ìý

Alfred Engelberg:ÌýWe grew up very, very fast there. I started working when I was about nine or 10 and, and there were lots of opportunities on the boardwalk.Ìý

Dan:ÌýHis first “job” was crawling around under the boardwalk, looking for loose change.

Alfred Engelberg:ÌýBut I went on to work at hotdog stands and at an illegal bingo game for the local mob.

Dan:ÌýAnd in every job, Atlantic City drove home its major lesson: Cheating — hustling — is something you’ve gotta expect.Ìý

At this illegal bingo parlor, Al’s job was walking between tables, doling out bingo cards for a dime apiece. The bosses hired college kids to walk behind kids like Al, to keep him honest.

Alfred Engelberg:ÌýI mean, these guys are running an illegal game, but they still need to count, and they still inherently don’t trust anybody.Ìý

Dan:ÌýWhich was correct. Al says the college kids had their own hustle: They’d have him set aside a dollar or two before turning in his dimes — split that dollar with him fifty-fifty — and tell the bosses Al’s count was fine.

Alfred Engelberg:ÌýAnd everybody knowing that the counts were wildly inaccurate anyway ‘cause the little old ladies were, were stealing cards. Everybody in the room had their own thing going, you know, from the customers on.

Dan:ÌýAfter Al made it out of Atlantic City, his unique on-the-job education continued. He studied chemical engineering at Drexel, then took a job as a patent examiner while going to law school at night.

And at that job, he learned: The patent system was ripe for hustling.

Partly because most of his colleagues weren’t necessarily giving the job their all.Ìý

Like him, most patent examiners were working their way through law school. And they were sneaking time to study on the job.

Alfred Engelberg:ÌýWe used to be able to cut our notes down so they fit in these file drawers with the patents. And we would be reading your notes and if your boss came by, you would just drop a patent on top of the notes.

Dan:ÌýYou could say it was Atlantic City all over again. Everybody in the job is sneaking something for themselves — in this case, time.

And Al Engelberg could see that, even if his colleagues gave it their all, they were too green to do their job well.Ìý

A patent examiner’s job — deciding whether a proposed invention deserves a monopoly (which at that time was 17 years) — means deciding whether the idea for that invention would be obvious to “a person of ordinary skill in that field.”

Alfred Engelberg:ÌýAnd most of the examiners had never worked in that field and had absolutely no idea. And this is the big leagues. You’re granting somebody a monopoly for 17 years, and it seemed ridiculous on its face.

Dan:ÌýAl cut his own path at the patent office. He’d worked his way through engineering school, in manufacturing plants, he saw what people of ordinary skill in that field solve problems every day. So he specialized in examining patents he actually knew something about.

That got him promoted, then it got him recruited by a corporate lawyer.. After the company paid his way through the rest of law school, he jumped to the Justice Department.Ìý

He was ambitious– he wanted experience junior lawyers don’t usually get — like trying cases of his own.

After a few years doing just that, he took a job with a small law firm in New York City in 1968.

Alfred Engelberg:ÌýI came to New York to private practice at the age of 30 and I was ready to go. I mean, I was ready to, to tear the world apart and I did.

Dan:ÌýPatents were still a specialty. Then, in 1973, he gets a call that leads to his first generic drug case.

Generic drugs were not a hot market at the time.

Alfred Engelberg:Ìý?The generic drug industry in 1970s was essentially, a half a dozen, privately owned family businesses, mostly in the metropolitan New York area. And most of the drugs that they were selling were drugs that were approved before 1962.Ìý

Dan:ÌýYeah. 1962 is when the FDA made it harder to get a new drug approved — you had to go through long clinical trials to show that your drug was safe and effective.Ìý

Even if your drug was a generic version of an existing drug. Those little companies didn’t have the capital to run those trials, so they were stuck selling those old drugs.

Not much of a business. Maybe 20 percent of prescriptions were for generic drugs.

So when Al Engelberg got a call for his first generic drug case, that was the context. And the case itself did not sound promising. For one thing:

Alfred Engelberg:ÌýThe call wasn’t even from the client. It was from a bank. The client was bankrupt.Ìý

Dan:ÌýThe client was bankrupt.ÌýThis bankrupt client, Premo Pharmaceuticals, was getting sued for patent infringement. The bank was willing to put up ten thousand dollars for a defense. Nowhere near enough to actually try a case. Oh, and…

Alfred Engelberg:ÌýFrom what they told me, the information they gave me, we didn’t have a very good defense.

Dan:ÌýBut Al Engelberg saw an opening. He could see that his opponents have weaknesses too.

Alfred Engelberg:ÌýThe patent owners were in a very strange position. If they won, they got nothing because we were already bankrupt. Two, they were gonna have to spend the legal fees to win.

Dan:ÌýWin against a young lawyer named Al Engelberg who already had a rep as a tough opponent. So they could lose.

Alfred Engelberg:ÌýAnd if they lost, they would lose millions and millions of dollars in business because there wouldn’t be a patent. And they’d have competition from generic drugs.

Dan:ÌýAnd meanwhile, Al Engelberg is also sizing up the judge.ÌýHe knows the guy doesn’t love patents.

So Al shows up to the first conference and he bluffs.Ìý

Alfred Engelberg:ÌýI said to the judge, oh, your Honor, you know, it’s another one of those patents. They’re all invalid. And I said, we don’t need very much discovery. We’re, we’ll be ready to go to trial in a few months. Just set a trial date.

Dan:ÌýThe other side walks out beside themselves.

And within a couple of weeks they call Al to say: Hey, how about this? You guys just acknowledge our patent is OK, and we’ll give you the money we would’ve spent litigating. Call it 400,000 bucks?

Alfred Engelberg:ÌýI called the client and said, how’s $400,000? He said, are you kidding?

Dan:ÌýThey didn’t just get out of trouble — they got out of bankruptcy, with $400,000 in their pockets. Because Al Engelberg knew how to size up a situation.ÌýÌýÌý

Alfred Engelberg:ÌýYou don’t learn that in law school.ÌýThat’s not what they teach.

Dan:ÌýWord getsÌý around about that case, and pretty soon everybody in the generic drug world is calling him.

It’s a small world, but by the end of the 1970s, there may be room for it to start getting bigger.Ìý

People are starting to notice: Drugs are expensive. Maybe there should be more cheap generics.Ìý

Some generic drug companies form an association and start lobbying: Make it easier to get generic drugs to market without having to go through all those trials.

The brand-name drugmakers push back: They say it takes so long to run the trials and get their drugs approved, they don’t get enough time to make money before those patents expire.

In 1983, Democratic Representative Henry Waxman steps in to broker a compromise, with Republican Senator Orrin Hatch.

And Mr. Engelberg goes to Washington. To run strategy for the generic drugmakers.Ìý

Alfred Engelberg:ÌýIn a lot of ways , that’s where my Atlantic City training really helped me at the end of the day

Dan:ÌýThere were a lot of people, with a lot of interests. A lot of angles. ?He starts commuting from New York to Washington DC a couple times a week — for months and months, more than a year.

And Al Engelberg says: This time, it wasn’t just about winning a case.

Alfred Engelberg:ÌýI was in the back of a cab the way I remember, with the senior partner of the law firm.ÌýAnd he says to me, why are you breaking your ass going to Washington two or three times? Why don’t you send an associate? You know, it’s just like, it’s just another case. And I said. I said, are you kidding? I said, you know, how many lawyers ever get to do what I’m doing right now?ÌýTo be at the table influencing what may be a major law that’s gonna have major consequences is, is like something I never thought my whole life I’d be doing.

Dan:ÌýA kid from Atlantic City was exactly the right person to try to balance all the angles, negotiate a compromise. It took more than a year. It almost didn’t happen. But then it did. Congress passed the bill, and President Ronald Reagan got in front of cameras to sign it.

Ronald Reagan:ÌýLet me turn my attention to the real reason we’re here this afternoon, signing into law the Drug Price Competition and Patent Term Restoration Act of 1984.Ìý

Dan:Ìýbetter known as Hatch-Waxman.

Hatch Waxman had three basic components:

One: Brand drugmakers got a few extra years on their patents.

Two: Generic drugmakers got a pathway to get FDA approval.

And three –The new law laid out rules for a generic drugmaker when they wanted to CHALLENGE an existing patent.Ìý

Negotiating that third part was the part where Al Engelberg’s education on the Atlantic City boardwalk, and the U.S. patent office, and the generic drug industry came together: The result would make him millions and millions of dollars — and blow a giant hole into the grand bargain he had worked so hard to bring about.

That’s coming right up.

This episode of An arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom covering health issues in America. The folks at Ñî¹óåú´«Ã½Ò•îl Health News are amazing journalists — their work wins all kinds of awards, every year. We are honored to work with them.

So. The brand-name drug makers and the generic drug makers struck a deal. That deal was good for them. Both sides got something big out of it. The public was supposed to get something out of it too.

And, to be fair, we did: Remember, back then, maybe one out of five prescriptions was for a generic drug. Now it’s nine out of ten.

But we pay more than ever for drugs. Mostly for branded, patent-protected drugs. And the biggest, most-important, most profitable drugs get locked behind patent thickets.

How did that happen?Ìý

Well, to understand that, it helps to know what Al Engelberg got out of the whole bargain.

Al had been there at the bargaining table, on behalf of the generics.Ìý

One day, during those negotiations, he was in the office with Henry Waxman’s lead counsel, a guy named Bill Corr, when Corr got a call from someone on the other side.

Corr starts pointing at the phone, pointing to Al — indicating: This guy is talking about you.

When Corr gets off the phone he says: That guy’s not sure about this deal where bad patents could be challenged. He’s suspicious about where you might take this. Like, are you just gonna set up a bounty-hunting operation, to get patents declared invalid?

And Corr said, Al, would you do that?Ìý

Alfred Engelberg:ÌýAnd I said, you know, Bill, until this moment, I’ve never given it any thought, but it’s a hell of a good idea. Maybe I’ll look at it.Ìý

Dan:ÌýAnd he did. Starting almost as soon as Hatch-Waxman became law.

Alfred Engelberg:ÌýAndÌýwe sat in the rose garden, September 23rd, 1984, watched Reagan sign the bill. And in December of that year, I sat down at my kitchen table with a yellow pad and I laid out a strategy.

Dan:ÌýIf you were gonna set up a bounty-hunting operation, how would you do it?

Al Engelberg knew a lot of patents were garbage. Knew it from his time in the patent office, knew it from practicing law. And he knewÌýhow much money a successful patent challenge could be worth.

The way Hatch-Waxman worked: If a generic drug company challenged a patent and won, they would get six months before any OTHER generic drugmakers could get a crack at the market.

So their only competition would be the brand. If a pill cost two cents to make, and the brand was selling for a dollar a pill — that’s 98 cents of profit for every pill.

You’re the only competitor? You could charge 75 cents a pill and get 73 cents of profit. On a hit drug, you could make millions and millions — just in those six months.Ìý

Al’s idea was this: Partner up with a generic drugmaker. Go find cases– drugs with weak patents. Win ’em.Ìý

And split those millions in potential profits fifty-fifty.Ìý

Al pitched a generic drugmaker — they were ready to go — and brought the deal to his law firm. .

Alfred Engelberg:ÌýAs it turned out, my partners weren’t interested in having me do this. They tried to talk me out of it.

Dan:ÌýBut they couldn’t. So he left. Went out on his own.ÌýAll on his own.

Alfred Engelberg:ÌýI never hired a single soul, not even a secretary. And I couldn’t type. I still can’t type.

Dan:ÌýBut he hunted and pecked his way through brief after brief. He bought an early portable computer — it weighed thirty pounds — and lugged it around in the back of his car. For ten years.

Alfred Engelberg:ÌýIt was stupid. I almost killed myself. But, it worked out okay.

Dan:ÌýYeah. Turns out Al was really good at finding the problems with drug patents.

In one of his first cases, Al Engelberg personally made more than 70 million dollars. Others settled: A few million here, a few million there– it adds up.

And then…

Alfred Engelberg:ÌýIt got to be the mid nineties, and I was working on a case called Buspar.Ìý

Dan:ÌýThe Buspar case ended up a big winner for Al Engelberg and his generic drug partners.Ìý

But itÌýhad consequences that wentÌýway beyond a single case.ÌýAnd led to big losses for the public..ÌýHere’s how it went.ÌýÌý

Alfred Engelberg:ÌýBuspar was an anti-anxiety drug. And by all accounts not a very good one.

Dan:ÌýBut Bristol Meyers Squibb invested in big advertising and marketing campaigns.

Speaker 5:ÌýI feel anxious. I can’t concentrate.Ìý

Speaker 6:ÌýI’m so irritable. If you. You suffer from excessive worry. It can feel like a mountain of anxiety.Ìý

Speaker 5:ÌýI’ll never get it all done. I’m overwhelmed.Ìý

Speaker 6:ÌýBut a prescription medication called buspar can help.

Dan:ÌýAnd all that marketing did its job. By the mid-1990s, Buspar was making more than 200 million dollars a year for Bristol.

Alfred Engelberg:ÌýThe only problem for them was that the drug was not new.Ìý

Dan:ÌýThe active ingredient was well-known in medical literature as a tranquilizer. Nobody had bothered to market it.

So Bristol Myers Squibb filed a patent on it, claiming it had discovered a new use for this well-known tranquilizer: Treating anxiety.

Al Engelberg says when he read the patent application, he could barely believe it: What do tranquilizers do if not… treat anxiety?

It’s like saying: There’s this stuff called sugar. We’re gonna take out a patent on using it as a sweetener.

This looked like a case for a guy from Atlantic City.Ìý

Alfred Engelberg:ÌýI did something that lawyers don’t. That’s just the way I was built.Ìý

I filed a motion with the court and basically said, we don’t need any evidence.

You just have to read the patent. If you believe it’s true, the patent’s invalid. Just, you know, all you need is a dictionary basically.

Dan:ÌýAl says Bristol was eager to settle.Ìý

Alfred Engelberg:ÌýWe get into a settlement discussion and we keep saying, no, no, no, no.

Dan:ÌýAl’s partners had done the math: They figured they stood to make a hundred million dollars or more once they won. So when the other side offered 25 million, no was the easy answer.

Alfred Engelberg:ÌýWe said, why are we gonna take this? You know, it’s crazy. There’s a reward here we know what it is. We’re gonna get it eventually.

Dan:ÌýAl sits down with a lawyer from the other side, a guy he knows, explains how he sees the math.

And soon the other side comes through with a much bigger offer: 72 million dollars – almost three times as much.Ìý

Alfred Engelberg:ÌýAnd I’m sitting there like, what are you crazy? But then think about it from their point of view.Ìý

Dan:ÌýPaying 72 million dollars is nothing, compared to what Bristol stands to gain if this lawsuit goes away.Ìý

With their monopoly, Bristol Meyer Squibb is making more than 200 million dollars a year on Buspar. And unless somebody else lines up to do what Al Engelberg had done, expect to keep that monopoly for years.

Charging whatever they want. Two dollars a pill, three dollars a pill. Which Al Engelberg says is exactly what happened.

In fact, they kept that monopoly for like five years.Ìý

Alfred Engelberg:ÌýAs it turned out, nobody came behind us. And so, they had that monopoly until 2000. So they got five years of 2 billion, in gross profits.Ìý

Dan: They made out.

Alfred Engelberg:Ìý For the cost of $75 million. And you know, the public got screwed ’cause they are continuing to pay, you know, $2 a pill or $3 a pill for a drug that eventually ends up being available for 20 or 30 cents. Um, so that’s, that’s how it works.

Dan:ÌýThat’s how it works. The branded company and the generic company both make out great. Cheaper generic versions of a drug get delayed.Ìý

That amazing payday for Al Engelberg and his partners at the generic drug company turned into a model a template for the kind of deal that every generic drug company would want in on.

It got a nickname: Pay for delay.

Alfred Engelberg:ÌýThat spread through the industry like wildfire, those numbers, you know, you don’t make those numbers half a cent at a time on, on pills,

Dan:ÌýLawsuits were way more profitable.

But Al Engelberg wasn’t filing them.

A year or so after the Buspar case settled, sparking the Pay for Delay gold rush, he retired. He had plenty of money and nothing to prove.

And in retirement, he started evaluating what he’d accomplished, for better and for worse.

For better, generic drugs had more than doubled their share of the market since Hatch-Waxman took effect.

For worse, he could see two places where — despite all of his Atlantic City training — he had missed a couple of angles in negotiating Hatch-Waxman.Ìý

One was: this whole pay-for-delay scheme. Turned out, in balancing incentives for brands and generic makers, he’d left open this perverse incentive that left the public out.Ìý

And the second was a loopholeÌý that Hatch-Waxman had left open.:Ìý

It created a process where players like Al and his generic partners could challenge patents on drugs like Buspar, that they thought didn’t deserve protected monopolies. It removed some friction for those attacks.Ìý

The drug companies developed a way to add more friction:Ìý stacking extra patents — secondary patents — on every drug.

Developing patent thickets.

Even if a secondary patent is trivialÌý — and lots of them do get tossed out — challenging it means a court fight. And that costs money.

Alfred Engelberg:ÌýIt caused the big drug companies to just get more and more patents. Because why not? You know, there was nothing standing in the way.

Dan:ÌýI mean, nobody knows better than Al Engelberg: Patent examiners don’t exactly stand in the way.Ìý

And those patent thickets and pay for delay, they feed on each other.Ìý

Alfred Engelberg:ÌýThe economics of the business, caused these kinds of settlements to reach epic proportions. So the generic companies would, challenge these secondary patents and, the drug companies would pay them off.

Dan:ÌýIn 1999 he published an article in a scholarly journal arguing that Hatch-Waxman needed a reboot. Even the six-month head start for a successful challenge could probably go.Ìý

And ever since — for more than twenty-five years — he’s poured millions of dollars into efforts to tighten the rules. Funding research. A public-information campaign from Consumer Reports. Even a center for IP law at his alma mater, NYU.

It hasn’t always gone his way.Ìý

Pay for delay has gotten much bigger since Al Engelberg wrote his first article calling for reform: He wrote in 1999 that about two dozen patent challenges had been filed.

Now he estimates that number at twelve thousand.

Alfred Engelberg:ÌýI can’t tell you how many tens of billions of dollars in legal fees that is. It’s one of the fastest growing and and steadiest industries for big law.

Dan:ÌýA Hatch-Waxman litigation forum on LinkedIn has more than fourteen thousand members.

And Hatch-Waxman doesn’t cover many of today’s the top-selling drugs– the biggest moneymakers. They belong to a class called “biologics.”

That includes famously-expensive rheumatoid arthritis drugs like Humira and Enbrel — and insulin.Ìý

Biologics weren’t a category forty years ago when Hatch-Waxman got negotiated. Congress passed a new law to deal with them in 2010 — ?the Biologics Price Competition and Innovation Act.

Al Engelberg is not a fan of that law.

Alfred Engelberg:ÌýWhatever mistakes were made in Hatch Waxman, they were multiplied by 10 and deliberately in the biologics law

Dan:ÌýHe says the all but encourages patent thickets. And doesn’t provide a pathway to challenge them.

He says it reminds him of some of his early days practicing law.

Alfred Engelberg:ÌýBack in the seventies, we used to have small startup clients in the computer field, and they would get letters from IBM. It says, we are ready to inform you that you may be infringing one or more of the following patents. And there was a 10 page list of patents attached.ÌýAnd the startup would come to us and say, you know, what should we do? And we would say, find another line of work, you know, what are you gonna do?

Dan:ÌýBut he has not given up. In 2025, he published a book: Breaking the Medicine Monopolies.

It tells the story of his career — and lays out his prescriptions for fixing the problem.

He doesn’t JUST focus on plugging the holes in Hatch-Waxman and the biologics law.

Alfred Engelberg:ÌýYou know, we don’t actually need a generic drug industry. We need generic drug pricing.Ìý

Dan:ÌýHe’s got proposals for an increased government role in negotiating and regulating prices — and more than that.

He argues that a 1980 law allows the government to commisssion generic versions of drugs that were developed using public research dollars.

He also says the FDA rules that protect secondary patents on drugs — that allow patent thicketing — are based on a completely wrong interpretation of Hatch-Waxman.

And tells us he’s working up a challenge, with help from AI tools like Claude.Ìý

He’s 86 years old. And he doesn’t seem inclined to stop.

Alfred Engelberg:ÌýIt so changed my life and I did so well by it, I thought, how can I not take on this problem? Who’s gonna do it if I don’t do it?

Dan:ÌýHe’s got the time. Money’s no object. And he knows the territory as well as anybody. He helped create it.Ìý

Alfred Engelberg:ÌýSo it’s, it’s my obligation really. It’s that sort of Jewish guilt. What can I tell you? I’m paying back for the bingo game.

Dan:ÌýSo we’ve gone back more than fifty years on the question: Why aren’t there more generic drugs? We’ve learned why we’ve got the ones we have, and what stands in the way of getting more.

And that is just in time. Because this spring the U.S. Supreme Court will hear arguments in a case that could restrict the generic drug pipeline even further. It could have major implications.

And understanding what they are requires all of the 101 we’ve covered here. We’ll have that story for you in a few weeks. Til then, take care of yourself.Ìý

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

This series — An Arm and a Leg 101 — is made possible in part by support from Arnold Ventures.Ìý

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

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Attorney Nicole Wipp and skate-shop owner Noah Hulsman tell An Arm and a Leg host Dan Weissmann how they tried to balance their financial and physical health when they couldn’t find good options.

Wipp and Hulsman first spoke with Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Renuka Rayasam for the series “Priced Out,” which tracks how people are responding to skyrocketing health insurance costs.

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

Dan:ÌýHey there. About a dozen years ago, Nicole Wipp was trying to spend less time running her law firm and more time with her son, who was in preschool. ?It was a work in progress.Ìý

And then she started feeling— a little off. ?Tired. Out of breath. Her doctor thought it was stress.

Nicole didn’t think so, but she soldiered on. And got worse. For months. Until one day— when she told her husband she just couldn’t get off the couch — he was like, you’re going to urgent care. An x-ray showed her whole left lung totally blacked out.?

ÌýNext stop, emergency room.Ìý

Nicole Wipp:ÌýThey put a huge needle and shoved it into my back and drew out two liters. Imagine a whole two-liter of pop – I’m from Michigan, so I say pop – from your body. They draw a whole two-liter of liquid. And I felt so much better immediately. I was like, wow, I can breathe. Like, wow, this is so cool. But, um, it was sort of horrifying.

Dan:ÌýNicole says she eventually got diagnosed with a rare lung condition

Nicole Wipp:ÌýIt’s called lymphangioleiomyomatosis — LAMB for short.

Dan:ÌýBut not before she’d spent a month in hospitals — hospitals, plural — and had multiple expensive surgeries.

Nicole Wipp:ÌýMinimum — my husband and I tried to like tally it all up, like look at all the bills afterward — and it was, minimum, a half a million dollars.Ìý

Dan:ÌýWhich, because her husband’s job at the time provided good health insurance, didn’t break them.

Nicole’s condition hasn’t bothered her for years. But it’s not cured. It’s incurable.

And yet. This year, Nicole and her husband didn’t sign up for health insurance.

For more than 20 million people on Obamacare plans, the price of health insurance changed dramatically this year. Premiums skyrocketed just as subsidies got sharply reduced.Ìý

Some people faced horrifically stark new circumstances:Ìý

People who needed insurance to cover ongoing treatment: for cancer, for diabetes — treatment they literally could not live without — saw premiums jump by thousands of dollars a month, more than they could possibly afford.

And millions more got stuck taking gambles. Making messy, unsatisfying choices.Ìý

Our partners at Ñî¹óåú´«Ã½Ò•îl Health News have been talking with lots of those people.Ìý

They introduced us to Nicole. She and her husband could have paid for health insurance. But when rates went up, they did the math and decided not to. They’re generally healthy, and honestly have more financial cushion than most people.Ìý

If they need medical care — ordinary medical care, anyway— they think they’ll be better off just paying cash.Ìý

But they know they’re gambling: that 2026 won’t be the year Nicole’s condition flares up, or that some other catastrophe hits.

Our pals at Ñî¹óåú´«Ã½Ò•îl Health News also introduced us to this man:

Noah Hulsman:ÌýMy name’s Noah Hulsman. I own and operate Home Skateboard Shop here in Louisville, Kentucky.

Dan:ÌýIt’s Louisville’s only skateboard shop. It’s kind of a family business, kind of a community center, kind of a place Noah’s spent most of his 37 years.Ìý

Noah’s still paying for insurance — paying forÌý protection against catastrophe. But because all he can afford this year is a bare-bones plan, he doesn’t have a way to pay for ordinary medical care. Which he could actually really use.Ìý

Noah Hulsman:ÌýSo I’m kind of in a position right now… I need my left shoulder looked at, but I have an $8,400 deductible. Yeah.

Dan:Ìý We’ll get into that — it sucks. But first: I really want you to hear about this skateboard shop.

Noah Hulsman:ÌýWhen I tell the story, it almost seems like a movie or something. Like, somebody made this up.

Dan:ÌýLet’s go.Ìý

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

Here’s how Noah ended up a skater for life.

Noah Hulsman:ÌýSo my grandmother, she opened up a skateboard shop in 1988 here in Louisville. It was called Skateboards Unlimited. She had a little skate park also behind it called Ottoman Skate Park.

Dan:ÌýNoah’s grandmother was not a skater. She’d been a nurse — but she had five kids, and Noah says she ended up more of a stay-at-home mom.

Noah Hulsman:ÌýAnd then with all the commotion that was always occurring, with all the friends in and outta the house, with having five kids and all these skateboarders that just started popping up, she just decided, you know what? Let’s like have a place for you all to go.

Dan:ÌýShe opened Skateboards Unlimited — and a skate park behind it.

When her youngest son finished high school — and moved to the West Coast as a professional skateboarder — it was the end of an era. And the beginning of another.Ìý

Noah’s grandma closed up Skateboards Unlimited.Ìý

Noah Hulsman:ÌýAnd uh, that’s when one of her employees was like, you know what? We gotta keep having a skate shop.Ìý

Dan:ÌýThey called it Home Skate Shop. Noah became a regular customer, eventually an employee. And — ten years ago, when he was 27, — he took over the business.Ìý

Noah is as invested as anybody could possibly be.

Noah Hulsman:ÌýIt’s everything. It’s my whole life. Yeah.

Dan:ÌýIt’s doing OK. There were a few rocky years early on — Noah says he qualified for Medicaid. But things actually picked up when the pandemic started.

Noah Hulsman:ÌýSkateboarding was one of the only things that you do by yourself. You’re doing it outside. If I would’ve been able to get a hold of more product, we would’ve, we would’ve killed it.

Dan:ÌýNoah got an Obamacare plan, and he even bought a building — he leases out a couple of apartments, runs an air bnb in a third one, and says he breaks even on it, right now..

Noah Hulsman:ÌýThey say, you know, real estate is a long term game.

Dan:ÌýNoah’s a long-term kind of guy.

\He and his girlfriend have been together for 16 years — even while she was away at veterinary school.

Noah Hulsman:ÌýShe just finished up at Auburn this past year and moved back home and yeah, it’s been awesome.

Dan:ÌýNow they live together — with their four cats — in an apartment less than a mile from where his grandma started her skate shop.

But it’s not a cushy living. Noah says he takes odd jobs and gives skateboarding lessons to make ends meet.

Noah Hulsman:ÌýEvery single day is a hustle. There is no day, like you can’t get sick, you can’t be–Ìý no downtime. If you take vacations, you’re still working from your phone, you’re checking in on the shop.

Dan:ÌýNoah says his income — all in — has been holding steady at around $33,000 a year. Last year, with a subsidy, he was able to get a gold plan for about a hundred and five dollars a month.

For 2026 — with premiums jacked up and subsidies cranked down — that gold plan would have cost him an extra $500 a month. That’s $6000 a year. Way more than he could afford.

Instead, he picked a Bronze plan. It leaves him paying pretty much exactly the same every month as he did last year, but it covers so much less.

Noah Hulsman:ÌýI don’t even know why I’m paying that. It’s useless really, unless I get into a car accident and I have $10,000 worth of bills.

Dan:ÌýOr a skateboarding accident. Or a serious illness. Anything.

He’s holding onto the plan as a backstop against a worst-case scenario, against ending up with more debt than he could ever pay back.

But having a backstop is not the same as having access to medical care.

A few months ago, Noah says his left shoulder started bothering him. He says it doesn’t stop him from day-to-day stuff, running the shop. But it does impose limits.Ìý

Noah Hulsman:ÌýIt’s those like quick movements. It’s those like blast-off times like when I’m popping on my skateboard or when I’m like turning a certain like front side and like throwing all my weight that way.Ìý

Dan:ÌýHis bronze plan — with its $8400 deductible — means he can’t afford to get it checked out.

Noah Hulsman:ÌýTo go through, okay first you have to go see primary care, then they gotta do the x-ray. Then once you see the x-ray, oh, we can’t tell anything from the x-ray. Yeah, we know because it’s ligaments and tendons and muscles and things like, I’m not a doctor, but I’ve been through this a few times. So, okay, we’re gonna get you the MRI. All right. Here’s the MRI. None of that’s gonna be covered.

Dan:ÌýIt sounds like thousands of dollars to Noah — to me too, really. And that’s before getting it treated, which could mean surgery.

Noah doesn’t have thousands of dollars lying around. If he did, he would’ve paid up for the gold plan.Ìý

So he’s avoiding tricks that could irritate the shoulder,

Noah Hulsman:Ìý I can still skateboard. I just have to choose what tricks or what obstacles. I don’t have like the freedom that I had when I used to ride my skateboard.

Dan: He’s hoping he can nurse the injury along till next year, when he thinks he could afford better insurance.Ìý

Noah Hulsman:ÌýWhat I’m kind of planning on doing is my, my shop vehicle is about to be paid off next year or like at, at the, I think it’s like middle of next year. And that payment is basically what that gold plan payment is.

Dan:ÌýYeah, yeah,

Noah Hulsman:ÌýThat’s what’s probably gonna happen. That’s my new car payment. New shoulder payment.

Dan:ÌýMan, that super sucks. I mean, grimly hilariousÌý

Noah Hulsman:ÌýYeah. Yeah. I mean, if this, you have to just laugh at how ridiculous the world is these days. There’s, I mean, if you just take it serious, doom and gloom all the time, it’s going to, you’re not gonna make it. You gotta just laugh these days. It’s so ridiculous.

Dan:ÌýIt is. Noah is far from alone. A Gallup poll taken in late 2025 found that more than a quarter of all Americans had postponed surgery or medical treatment because of cost.

Being insured and having access to medical care — for lots of people, they haven’t been the same for a long time.

This year, especially for people using Obamacare, that’s accelerating.Ìý

We don’t know yet how many people made choices like Noah’s, and moved to plans that cover less, in order to have a monthly payment they could kind of afford.

Federal numbers won’t be out for a while. But an analyst named Charles Gaba ran some preliminary numbers from a few states.

He found that the number of people in Silver and Gold and Platinum plans was down significantly. And the number of people in Bronze plans, the cheapest, was up dramatically.

And we do know that at least a million people have dropped Obamacare. Some have dropped insurance altogether. Including, of course, Nicole Wipp.

We’re coming back to her story, just ahead.Ìý

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom reporting on health issues in America. The reporters at Ñî¹óåú´«Ã½Ò•îl Health News do amazing work — win all kinds of awards every year. And in a little while, you’ll meet the KFF reporter who introduced me to Noah Hulsman and Nicole Wipp.

Dan:ÌýBefore Nicole Wipp knew that her Obamacare rates would be going up, she knew she was pissed at what she calls the insurance industrial complex.Ìý

Nicole Wipp:ÌýSo my son. Just for example, we took him— called in advance, ‘do you take our insurance?’ Took him to get basic well child vaccines. Well, next thing I know, I got a bill for $4,000. I called them up and wasÌýlike, what is this?Ìý

Dan:ÌýShe says that was early 2025, and she’s been fighting ever since.Ìý

Nicole Wipp:ÌýThey’ve cut it down to like 1200, but I’m like, no, no, no, no, no. It should be a hundred percent covered under our insurance, So that’s the thing is like, why would I participate in this?

Dan:ÌýAnd at least since her half-a-million-dollar medical adventure Nicole Wipp has been pretty determined to live life on her own terms.

Even before her illness, she had already been trying to spend less time running her law practice and more time with her family.

Then, after the illness, she more than doubled down on that. On her website, she says she went from working 80 hours a week to working just five days a month.

That’s the website for a new business she started after her recovery: a consulting and coaching practice that offers to help people achieve financial success on their own terms.Ìý

Nicole Wipp:ÌýFinancial success for me is very much not just about money, it’s really more about quality of life and having enough money to have that quality of life.

Dan:ÌýSo, for instance, about four years after her illness, Nicole’s family moved from Michigan to Hawaii.

Nicole Wipp:ÌýWe said, we want to live in Hawaii because we wanna have a quality of life. And of course, living in Hawaii is not cheap. It’s one of the most expensive places in the United States to live.

Dan:ÌýBut that’s what they wanted. And they made it work.Ìý

And then their son got into polo. Like, with horses. Which is harder to do in Hawaii— to do seriously, competitively — without a lot of traveling to the mainland. So they moved again, to South Carolina.

Nicole Wipp:ÌýAnd we did, by the way, when we moved back to the mainland, FedExed four horses from Hawaii

Dan:ÌýOh my God.

Nicole Wipp:ÌýI know, and like when you say, all these things, it sounds insane, right? It is insane.Ìý

Dan:ÌýSince then, she says they’ve picked up another four horses.

Nicole Wipp:ÌýNow we have a total of eight, which is a lot, a lot by the way. Um, and so, you know, I say it out loud and I’m like, oh, I’m not proud of this, to be honest with you. But, but we have also though made other choices like we live in a smaller home than we would otherwise, so that we can do that.

Dan:ÌýAnd that home is in a part of South Carolina where houses aren’t super- expensive. So Nicole says the mortgage on their house is less than the $1400 they would’ve been paying if they’d kept their insurance this year.Ìý

The expensive horses, the less-expensive home…

Nicole Wipp:Ìý Like these are choices that we’ve made as a family that I understand very much that most people would never make these choices, but we’re doing it in as responsible of a fashion as we possibly can.

Dan:ÌýA few years ago, her husband changed careers— no more job-based health coverage. They started buying insurance on the Obamacare exchange.

But by mid-2025, it started looking like that insurance could get a lot more expensive. Not because they’d lose a subsidy — they hadn’t qualified for a subsidy to start with.Ìý

But if subsidies went away, she figured rates would go way up.ÌýÌý

Nicole Wipp:ÌýI started bringing it up to my husband. Like, I don’t know what this is gonna look like. I’m very worried about it. And we may be in a situation where we need to make a choiceÌý

Dan:ÌýCould they contemplate doing without insurance?

Nicole Wipp:ÌýAnd so we had probably, you know, 20 conversations, at least, about it.

Dan:ÌýBefore making a decision — even before 2026 rates got posted — Nicole and her husband started taking some steps. She scheduled a colonoscopy, and went to the dermatologist for a skin check. Her husband got some tests too.

If they didn’t have insurance next year, those tests wouldn’t be covered. And if any tests came back with scary results, insurance would be more important.

Obamacare premiums for 2026 got published. Their family’s rate would go up by about 50 percent.Ìý

Nicole Wipp:ÌýOnce the numbers came out, I was like, I just don’t know if this makes sense.?But we were like, okay, we need to gather more information. We need to think about it some more.Ìý

Dan:ÌýTheir tests had come back OK. And they felt fine. Maybe they wouldn’t need any medical care in 2026, or not much. But maybe they would. How might they pay the bills? They kept talking. And they identified some ideas.

For one thing, Nicole found some money socked away in a health savings account from her husband’s old job.Ìý

Nicole Wipp:ÌýIt’s not a lot, but it was like, oh, that’s a nice little cushion. Like we could use that if we needed it.Ìý

Dan:ÌýNicole figured, if they were paying cash, she’d be in a good position to negotiate with providers for discounts.Ìý

Nicole Wipp:ÌýBecause I’m a lawyer and I’ve been around the block on these things, so I had a lot of faith that I could negotiate a bill.

Dan:ÌýAnd she had other ideas for finding deals.Ìý

Nicole Wipp:ÌýI was like, you know, depending on what the situation is, we could fly to another country, receive healthcare quality healthcare. It still would be less. And I am not above doing that.

Dan:ÌýAnd if all of that required more cash than they had lying around, Nicole figured, they still had options.Ìý

Nicole Wipp:ÌýWe have certain assets that in an extreme emergency we could sell – I mean, because it’s not just the horses. We have horse trailers and like, you know, there’s a lot that goes along with all of that that isn’t just the horses by the way.

Dan:ÌýNone of which made the decision easy. Nicole says she and her husband didn’t fully decide until the actual deadline came for signing up. Even then, they knew they were gonna keep their son insured.

Nicole Wipp:ÌýI would be in my opinion, not responsible as a mom, so… because he does play a very dangerous sport.

Dan:ÌýBut for the adults, they weighed the risks, and decided to gamble.

Nicole Wipp:ÌýIf I take that money and invest it instead of putting, I don’t know, am I gonna be out further ahead? I will if I don’t have a massive emergency and a half a million dollar illness. Um, right? And so it’s a gamble, like, right? All of this is a gamble, but it was a gamble that I was like, I just don’t want to participate in this any longer because this is not workable for almost anybody, but it certainly isn’t workable for me anymore mentally or emotionally.

Dan: Not workable for almost anybody.Ìý

[Music transition]

Renu Rayasam:ÌýI mean, I also think about this as a reporter. We have these individual stories. What do they mean? First of all, why is this system like this and what does it mean for everyone?

Dan:ÌýThat’s Renu Rayasam. She’s a senior correspondent with our partners at Ñî¹óåú´«Ã½Ò•îl Health News. She introduced me to Nicole and to Noah. She and her colleagues have been talking with dozens of people about the choices they’ve been forced to make about insurance this year.

?And thinking about what those individual stories mean has led Renu to some big reflections.Ìý

Renu Rayasam:ÌýI think sometimes in the US you take for granted the way things are. Just you don’t, you don’t realize there is another way, you know? There is another way! And um, and that’s where everybody has health insurance and those costs are better spread out.Ìý

Dan:ÌýRenu is speaking in part from experience. She spent a half-dozen years living in Germany. We talked about her experience— and how it affects the way she sees stories like Nicole’s and Noah’s.Ìý

Renu Rayasam:Ìý?Well first of all, it was kind of amazing to like never get a medical bill. Like that was like, like so mind blowing that you just, like, you go to the doctor and you never get a bill.Ìý

Dan:ÌýNot because the government pays for health care. But because the government requires everybody to have health insurance.Ìý

Renu Rayasam:Ìý People pay premiums. ?You have to pay into the system. And it’s not necessarily cheap either.??But then on the back end, you’re never worried about, oh, my shoulders hurt, I have to get this MRI and I’m gonna get a bill.

Dan:Ìý?Most people pay a government-set rate — about 15 percent of their income. Most insurance funds are non-profit. Everything’s highly regulated, and everybody gets the same benefits. Here, things are … more chaotic. Less predictable. People have to make hard choices— and those choices feed back into the chaos.Ìý

Renu Rayasam:ÌýSo if somebody like Nicole opts out of health insurance, they’re not paying into this system and the people who are paying into the system are people who need care. And so that makes health insurance more expensive generally.Ìý

Dan:ÌýBecause insurers set their rates based on how much they expect to pay out. When healthy people bail, the rates go up. And when rates go up, healthy people bail. They reinforce each other. It’s what experts call a death spiral.

As some of those experts told Renu, a version of that happened over the last year. ?It wasn’t a coincidence that insurers jacked up prices when subsidies were on the chopping block.Ìý

Renu Rayasam:ÌýPart of the reason that insurers raised their prices was because they expected people to drop plans and that fewer people would be paying their premiums and be paying into the system.

Dan:ÌýAnd people like Nicole and Noah ended up with lousy choices to make.Ìý

Noah chose to keep paying for insurance as a backstop against absolute financial catastrophe — even though the insurance he can afford doesn’t give him access to medical care he needs.Ìý

Nicole and her husband think they’ve got the resources to pay for ordinary medical care. Even maybe a big medical deal — as long as there was time to hop on a plane and get to a country where they could afford treatment.

But they’re not protected against the worst. Nicole knows bankruptcy is a real possibility.Ìý

Nicole Wipp:ÌýWe don’t have a guarantee. And it still weighs on me every day that I made this choice because it feels fraught. Do I regret it? No, not at the moment. I don’t. Will I regret it? I hope not.

Dan:ÌýHmm.

Nicole Wipp:ÌýI don’t know though.

Dan:ÌýYeah, you’re not like, I did it. I’m free, you know, this is the best. It’s like, no, you’re not free of it.

Nicole Wipp:ÌýNo, I don’t feel free at all.

Dan:ÌýI wish I had a snappier ending to this story. We are more stuck than ever — all of us — making messy choices, hoping for the best. So I’m gonna give Noah the last word here.Ìý

He’s taking his own advice: Taking things as they come, recognizing what’s ridiculous, and aiming to hang in there for the long term.

Noah Hulsman:Ìý?Hopefully we, you know, get enough equity in this building that once it’s time to pass the skateboard shop on, maybe sell the building and hopefully that’s when we get to maybe cash out and go to the beach.Ìý

Dan: Wow.Ìý

Noah Hulsman:Ìý?Maybe. Or maybe I’ll just get to pay off my medical debt that I’ve accrued over however many years at that point.

Dan:ÌýWe’ll be back in a few weeks with a new episode. Till then, take care of yourself.Ìý

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý“.” You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).

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 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.

Credits

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

Dan:ÌýHey there.ÌýLet’s meet somebody.Ìý

Ron Lieber:ÌýI’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:Ìý 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.Ìý

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

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

Dan:ÌýShe 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.Ìý

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:ÌýAnd 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:ÌýSo 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:ÌýAnd 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:ÌýRon says he suspects right away that it’s bad news about the surgery.

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

Dan:ÌýFirst, 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?Ìý

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

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

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

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

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

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

And second: How worried should they be?

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

Dan:ÌýHe’s a professional at beating the system.Ìý

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

Dan:ÌýAnd he’s not in this alone.

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

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

Ron Lieber:ÌýI 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:ÌýOne 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:ÌýWe 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:ÌýHe 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:ÌýShe’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.Ìý

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

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

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

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:ÌýProtestors have targeted United Healthcare, which reportedly denies one of every three claims.Ìý

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

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

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:ÌýPeople 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.Ìý

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

Ron Lieber:ÌýThe 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:ÌýAnd she said something else that gets Ron’s wheels spinning.

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

Ron Lieber:ÌýI’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:ÌýAnd he’s thinking: Ok, what’s my next move?

Ron Lieber:ÌýThere 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:ÌýHow do you not blow your cover?Ìý

Ron Lieber:ÌýExactly. Right.

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

Ron Lieber:ÌýI 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:ÌýAnd there was more relief coming right up.

Ron Lieber:ÌýJodi 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:ÌýWaiting 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.Ìý

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:ÌýAnd 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:ÌýRon 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:ÌýWhy 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.’Ìý

Dan:ÌýThere’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:ÌýThe 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:ÌýThe 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,Ìýwe 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:ÌýAnd 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:ÌýOpt-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.Ìý

Ron Lieber:ÌýSo 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.Ìý

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

Ron Lieber:Ìý 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:ÌýAnd that is coming right up.

This episode of An Arm and a Leg is a co-production between Public Road Productions and Ñî¹óåú´«Ã½Ò•îl Health News. Ñî¹óåú´«Ã½Ò•îl 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:ÌýAnd, 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:ÌýAnd 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.Ìý

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:ÌýThere 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.Ìý

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?Ìý

Dan:ÌýHe 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:ÌýAnd 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:ÌýSomething 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.Ìý

Ron Lieber:ÌýWho 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?Ìý

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

Ron Lieber:ÌýIt 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:ÌýAgain, lots of responses.ÌýUseful responses.

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

Dan:ÌýFor 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.Ìý

Ron Lieber:ÌýThere 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:ÌýOther 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.Ìý

Ron Lieber:ÌýAnd 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:ÌýRon digested all the feedback on the memo he’d published.

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

Dan:ÌýWe’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:ÌýSo 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:Ìý?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.Ìý

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.Ìý

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

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.”ÌýÌý

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.Ìý

Because hearingÌýÌýone part ofÌýhis 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.Ìý

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

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?Ìý

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

And he had a good answer:

Ron Lieber:Ìý?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:ÌýThis 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:Ìý I’m going to.Ìý

Here’s one other thing I’m going to do in the next few weeks:Ìý Have surgery myself. A hernia repair, it’s gonna be fine, I’m in great hands.Ìý 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!Ìý

My colleagues Emily and Claire have been serving up need-to-know information:Ìý Like, when you get your annual checkup… what’s actually covered?Ìý 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.Ìý

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý. You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

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This story can be republished for free (details).

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

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

Credits

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

Dan:ÌýHey there.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan:ÌýAnd it has been wild ever since.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Oh wow.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

That’s coming right up.

This episode of An Arm and a Leg is a co production of Public Road Productions and Ñî¹óåú´«Ã½Ò•îl Health News.Ìý That’s a nonprofit newsroom covering health issues in America.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dollar For’s answer: zero point seven percent.Ìý

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

Dan:ÌýNot all hospitals, as Jared is quick to note.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.Ìý

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl Health News. He’s editorial liaison to this show.

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

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

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

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

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

[Names redacted for web transcript.]

“An Arm and a Leg” is a co-production of Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý. You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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

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

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

Credits

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

Dan:ÌýHey there–

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So, let’s go.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan:ÌýHow long has the organization been around?

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

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

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

Dan:ÌýWell, there might be some countervailing forces.

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

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

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

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

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

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

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

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

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

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

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

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

Dan:ÌýNobody voted against the bill. Not in committee. Not on the Senate floor, not in the House. It was a better return on investment than Ann Woloson had hoped for.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

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

Which definitely sounds like it sucks.

But here’s where things get good and nerdy.

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

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

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

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

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

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

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

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

Which of course has started. Actually, in Maine.Ìý

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

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

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

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

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

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

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

That’s next.Ìý

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom covering health issues in America. These folks are amazing journalists. Their reporting wins all kinds of awards every year. We are honored to work with them.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Which is probably going to sound familiar.

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

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

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

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

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

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

Emily:ÌýNo, I love it. I love it. It’s great.

Dan:ÌýEmily? Really long?

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

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

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

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

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

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

One of its authors is Erin Fuse Brown.Ìý

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

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

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

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

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

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

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

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

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

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

Emily:ÌýAnd here’s the basic structure.

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

Emily:ÌýA management service organization — MSO for short .

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

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

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

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

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

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

Which Erin says is a conflict of interest.?

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

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

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

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

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

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

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

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

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

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

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

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

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

Emily:ÌýOf course there were opponents.

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

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

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

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

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

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

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

Emily:ÌýYep, Optum Oregon showed up.ÌýAnd handed Ben Bowman and his allies a talking point.Ìý

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

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

Emily:ÌýBowman says that lineÌýhelped makeÌýthe stakes really clearÌýwhen he brought his bill back in 2025.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We’ve gotta get around to that.Ìý

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

Emily:Ìý100% and I will add that I also got to talk with people in states like Colorado and California who have been doing incredible work to lower drug prices on things like insulin and the rheumatoid-arthritis drug Enbrel.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And we definitely need your help to make it happen.Ìý

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

Arm and a leg show dot com, slash support.

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

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

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

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

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

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

Till then, take care of yourself.

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý. You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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This story can be republished for free (details).

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

Plus, Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Julie Appleby explains what could happen if Congress changes course and extends the enhanced premium tax credits for Obamacare enrollees that are due to expire at the end of the year. And a listener wonders: Is paying for health insurance even worth it at this point?

Credits

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

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

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

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

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

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

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

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

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

But even if they’re wrong, even if some unexpected deal gets made, expect nightmares. Logistical nightmares. Tech nightmares. Julie Appleby is a reporter with our pals at Ñî¹óåú´«Ã½Ò•îl Health News.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan hosting: Hey Emily.

Emily hosting: Hey Dan.

Dan hosting: So, let’s recap…Ìý

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

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

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

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

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

Elisabeth Benjamin: Ok, so ready?…

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

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

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

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

Emily: Yeah.

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

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

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

Emily: Yeah.Ìý

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

Emily: You wanna share your screen?Ìý

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emily hosting: Mmhm.

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

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

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

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

Devo: All right.

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

Devo: Alright.

Dan:Ìý And be aware that it super sucks.Ìý

Devo: Alright.

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

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

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

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

Dan: You can say them all you wantÌý

Devo: Okay. Fuck.Ìý

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Oh my God. Wow.

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

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

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

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

Dan: For sure. For sure.

Jess: It sucks.

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

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

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

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

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

That’s coming right up.

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News — that’s a nonprofit newsroom covering health issues in America. These folks are incredible journalists — their work wins all kinds of awards, every year. We are honored to work with them.

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

And Devorah and I were processing.

Devo: I mean…Ìý

Dan: It’s a lot.

Devo: That’s a lot of money.Ìý

Dan: It’s a lot of money.Ìý

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

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

Devo: Can I have a different timeline?

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

Devo: Okay.Ìý

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

Dan: …They take it down to about 2300.

Devo: Okay.Ìý

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

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

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

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

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

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

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

Dan: I know you’re serious.Ìý

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

Dan: Yes, that’s right. And this is…Ìý

Devo: that’s insane.Ìý

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

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

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

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

Devo: I kind of am leaning towardsÌý

Dan: Yeah. Keeping what we have.Ìý

Devo: Keeping what we have.

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

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

Dan: Yeah,Ìý

Devo: I don’t like it.Ìý

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

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

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

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

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

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

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

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

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

Emily hosting: Kurt!Ìý

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

Emily hosting: I know. I know you are.

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

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

… I’ll put it in the chat.

Emily: Okay

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

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

Dan: Yeah, yeah. You for sure.Ìý

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

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

Emily: Mm-hmm Mm-hmm .

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

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

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

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

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

Emily: Yeah yeah.

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

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

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

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

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

Emily: Hey.

Dan: Yeah, right. Yeah.

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

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

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

Emily: Hell yeah.

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

Emily: Yeah. Yep. Exactly.

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

Emily: It is, yeah.

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

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

Dan: Oh my God.

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

Dan: Let’s do it.Ìý

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

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

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

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

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

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

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

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

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

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

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

So yeah, we need your help.

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

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

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

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

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

Kimberly, thank YOU so much.

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

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

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

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

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

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl Health News. He’s editorial liaison to this show.

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

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

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

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

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

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

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For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý. You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

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This story can be republished for free (details).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here. Let me introduce you to somebody.

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

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

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

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

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

And look, just to zoom out:Ìý

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

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

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

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

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

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

In 2024 they know of 10 that passed.

In 2025, so far, they have logged 20.

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

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

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

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

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

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

Dan: Like a general…Ìý

Eliot Bostar: General practice pediatrician.

Dan: How old was the patient?

Eliot Bostar: An adult.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So some lessons here:Ìý

One, go big. Why the heck not?Ìý

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

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

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

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

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

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

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

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

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

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

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

That’s next.

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom covering healthcare in America. These folks are amazing journalists. Their reporting wins all kinds of awards every year. We are honored to work with them.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: 45% all lawsuits, like..?

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

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

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

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

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

Dan: Hmm.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: They didn’t get everything they wanted.Ìý

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

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

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

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

Dan: We’ll get to that one.

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

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

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

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

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

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

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

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

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

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

Adam Raymonda is our audio wizard.

Our music is by Dave Weiner and Blue Dot Sessions.Ìý

Claire Davenport is our engagement producer.

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter,Ìý. You can also follow the show onÌý,Ìý,Ìý, andÌý. And if you’ve got stories to tell about the health care system, the producers would love toÌý.

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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

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

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

Dan: Hey there–

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

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

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

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

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

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

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

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

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

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

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

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

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

But they were actually giving out less charity care.ÌýÌý

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Yeah.

Vivian Ho: Yeah. So…

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

Especially this:

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

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

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

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

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

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

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

That’s next.

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. They’re a nonprofit newsroom covering health issues in America. Their reporters do amazing work. They win all kinds of awards every year. We’re honored to work with them.Ìý

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

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

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

Elena Prager: I was like, wow, goldmine.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Oh.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dan: Yeah.

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

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

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

Vivian Ho’s got researchers standing by.

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

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

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

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

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

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

That’s next time on An Arm and a Leg.

Till then, take care of yourself.Ìý

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

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl 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 Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, . You can alsoÌýfollow the show onÌýÌýandÌýthe . And if you’ve got stories to tell about the health care system, the producersÌýwould love to .

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

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

Credits

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

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

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

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

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

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

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

OK, here’s the story — so far:ÌýÌýÌý

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

Thomas Sanford: …where I go out of the classroom and I start spending my days in the hospital interacting with patients and and appreciating that for especially folks in my area — which is one of the poorest parts of Brooklyn– that can be a financial death sentence. It will ruin you in debt that you cannot get out of. And I listened to your episode about Dollar For, the nonprofit that helps people apply for charity care.Ìý

Dan: We’ve talked about Dollar For a lot over the last few years. Their founder, Jared Walker, has helped a lot of people, including me, understand how powerful hospital charity care can be.Ìý

A few months ago, Jared’s small organization hit a big milestone:Ìý

Eliminating more than 100 million dollars in hospital bills, over just a few years.

Jared Walker: And we have been able to do that without charging a single dollar to patients.

Dan: That’s Jared, in a video he posted over the summer to mark the occasion.

Jared Walker: We’re a nonprofit. We help people eliminate hospital bills, mostly by enforcing hospital financial assistance policies,. These programs reduce or eliminate hospital bills for people within certain income requirements. The problem is, is they don’t tell you. So we do.

Dan: Now, working in a hospital himself, Thomas Sanford decided to help spread the word.

He wrote to the folks at Dollar For, and they sent him a PDF for a “touch card” — it’s like the size of a business card.Ìý

It says, “Struggling with hospital bills? Most hospitals offer bill forgiveness programs. On average, a family of four, earning less than 100 thousand dollars a year will qualify. Dollar For can help – for free.”

And then, there’s a web address in big type, and a QR code to scan — and on the back of the card, the whole thing in Spanish.

Thomas Sanford: And I just went and printed out a thousand of them, started handing ’em out to residents and giving them to patients.

Dan: Handing them out to other residents, so they could pass cards to their own patients.Ìý

Thomas says he also left boxes of cards in the break room, so residents could grab as many as they wanted. And then he went to other local hospitals to distribute the cards in bulk.

Thomas Sanford: A lot of little hospitals or community clinics that have like little like business card holders, on the counter in the waiting room, and I just bring a stack and just dump them in.

Dan: And all of this is already extremely cool. And then, Thomas did something else: He wrote to us — to tell us about what he was doing, and to ask for help.

Because over the course of months,as he’d been passing out these cards, Thomas had found: Charity care didn’t necessarily cover everybody’s needs — like paying for prescription drugs.Ìý

Thomas Sanford: And just very frankly, I was busy doing the whole medicine thing, trying to take care of people, and I wish I had the time to sit with them and, you know, search for what would help them specifically, and I just didn’t. So I was looking for, really hoping for, very selfishly, a resource where I could just say, here’s your one-stop shop. It’ll almost certainly cover what you need. I hope this helps.

Dan: He wrote to us, to ask if we knew of anything good. And honestly we didn’t.

So we asked you for help. In our First Aid Kit newsletter, we told Thomas’s story, we added a link to that PDF from Dollar For — because that seemed worth passing around — and we did two more things:

First, we made our own first draft — basically, an annotated list of the resources we would put on a one-page handout.

And second, we asked: Help! What are we missing here? Including: Has anybody actually already made a version of this?

And: You wrote back!Ìý

As it turned out, a couple of you had worked on some great online projects. One was from the nonprofit PIRG — another group I’ve learned a ton from over the years. And the other was actually created by the federal government.Ìý

And, they were great! We wrote about them in First Aid Kit, with links. Other folks had tipped us off to resources that hadn’t been on our original lists — we added those..

And THOMAS took all of that and ran with it. Meaning: He started printing up a rough draft to hand out.

Thomas Sanford: I keep a little stack of them in my backpack, as it’s become somewhat complete and vaguely presentable, and at times I’ve just be like, hold on, leave, come back and be like, here you go.

Dan: And he says: It worked. He told me about this especially dramatic example.

Thomas Sanford: I was in the emergency department and someone come in having a heart attack — very serious. This could kill you. And their only concern when they got there is, what is this going to cost me? And it’s a difficult time to be having that conversation, but being able to say, look, here’s a crummy first draft of something I’ve been working on. I hope this gives you a little relief, but please, right now, let me focus on what’s a little more important, which is keeping you aliveÌý

Dan: Recently Thomas wrote to us AGAIN, to say: Here’s the vaguely-presentable version I’ve been handing out. Can I get more help making it better?

We went back to you — published Thomas’s draft in First Aid Kit, asked if anybody could pitch in, created a sign-up form.

And you’ve been pitching in! Thomas says he’s added more resources, and he’s gotten help making things more presentable.

Thomas Sanford: Just little type things about, you know, me not having to use a period correctly. Big things like maybe you name this document a little more correctly.

Call it help with your medical expenses.

Dan: He’s just shared the most recent version with us, and he says he could still use more help.Ìý

Thomas Sanford: If you know how to copy edit, and you can take my terrible descriptions and make them great. If you know graphic design and can make my, very basic, PDF into something that’s a little more presentable, that would be amazing. Also, if you want to make a version of this, you customize for your own hospitals. instead of a link for dollar four, put in a link to your hospital’s charity care policy.Ìý

Dan: This is actually one of the coolest things. Thomas is using what’s called a “Creative Commons” license. That basically means anybody can take it, make copies of it, make variations on it.Ìý

Thomas Sanford: You can make your own version of it. You don’t need my permission. You can do whatever you want with it. The only thing you have to do is share it under the same license and share it freely

Dan: And give credit to the original creator, so people know where it started. But Thomas wants people to make it their own.

Thomas Sanford: I think that that’s really the ideal: when people start taking it, just make their own version, put it out there and it sort of just evolves on its own, becomes the best thing it can be.

Dan: So, I hope you can see why I’m so excited about this project. I think it’s got incredible potential.Ìý I’m inviting you to pitch in, however you want, and however you can.Ìý

?And at Thomas’s suggestion: We’re posting a PDF of the current version. Print it out, make copies, tell us how you’re using them.Ìý

We’re also posting a google doc that ANYONE can comment on.Ìý

And we’re posting that sign-up form again, so you can volunteer to pitch in. Designers, editors, experts — translators.

And especially: if anyone has a talent for organizing groups of volunteers on a project like this, PLEASE GET IN TOUCH. That would be truly amazing.Ìý

You’ll find these links wherever you’re listeningÌý

And the place where we’re really gonna keep digging in on this project is where it started — in our First Aid Kit newsletter. I’d love for you to sign up. The place for that is www dot arm and a leg show dot com, slash, first aid kit.

That’s arm and a leg show dot com, slash, first aid kit.

This has been a little mini-episode of An Arm and a Leg– a show about why health care costs so freaking much and what we can maybe do about it:Ìý Together– right?

We’ll be back with a full-length episode soon. Till then, take care of yourself.

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

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

An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl 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.

ÌýZach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl Health News. He’s editorial liaison to this show.

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

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

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

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

“An Arm and a Leg” is a co-production of Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

For more from the team at “An Arm and a Leg,” subscribe to its weekly newsletter, . You can alsoÌýfollow the show onÌýÌýandÌýthe . And if you’ve got stories to tell about the health care system, the producersÌýwould love to .

To hear all Ñî¹óåú´«Ã½Ò•îl Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on , , , or wherever you listen to podcasts.

Ñî¹óåú´«Ã½Ò•îl 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 .

USE OUR CONTENT

This story can be republished for free (details).

Her search is off to a rocky start. Pisacreta gives listeners a sobering look at how the high price of health insurance plans could change her life and those of millions of others looking for Affordable Care Act plans, as premiums, on average, are by more than they have in recent years.

Joined by “An Arm and a Leg” host Dan Weissmann and Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Julie Appleby, Pisacreta examines how recent budget cuts by the Trump administration for navigators — the individuals, families, and businesses sign up for ACA plans — could make it harder to find the right plan and to pinpoint what people can expect in November when open enrollment kicks off.Ìý

Credits

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

Dan: Hey there–

Over the summer, our pals at Ñî¹óåú´«Ã½Ò•îl Health News published a story with the headline: “Insurers and customers brace for double whammy to Obamacare premiums.”

Basically– whammy number one — insurers are planning to raise premiums for 2026 —

And whammy number two: federal subsidies for Obamacare policies are scheduled to get a lot less generous.Ìý

Together, these whammies mean millions of people will be looking at paying a LOT more every month — like hundreds of dollars more.Ìý

Folks are going to need as much advance warning as possible, to figure out how to prepare for a hit like that.

Meaning: This is our kind of story.Ìý

And this one hits a little close to home. Because one of those folks is An Arm and a Leg’s senior producer, Emily Pisacreta.

Emily: Yeah, it’s a wild time. I’ve never had to do this before. Cuz I’ve always had health insurance through work. I’ve totally shaped my life around that because I have diabetes, and without health insurance, I can’t afford what I need.

Dan: But that health insurance has never come from An Arm and a Leg. When Emily started working here as an intern, she was the first person besides me to work more than a few hours a week. We didn’t have an employee health plan because we didn’t have employees.

And we’re still so tiny, so tiny. Apart from summer interns, there’s still only ever been one other person working more than a few hours a week besides the two of us. I’m still the only full-time person, and we still don’t have an employee health plan.

Emily: And until recently, that worked for me– I had another part-time job, and it had health benefits.

Except my contract with that job just ended.Ìý

So for the first time, like more than 20 million other people, I’m looking at open enrollment. And I gotta say, it’s one hell of a year to do that.Ìý

Dan: You’re a double-whammy case study.Ìý

And to get a broader perspective, the two of us talked with Julie Appleby, the reporter who wrote that “double-whammy” story, and since then you’ve continued to do more homework.Ìý

Emily: It’s been pretty intense!ÌýÌý

Dan: For real. And I’m a little bit of a case study too:

Suddenly I’m finding out what our country’s “system” — where health insurance gets tied to jobs — looks like … from the employer side. It’s a whole new adventure.Ìý

We don’t know exactly what we’re going to do. Honestly, I don’t think anybody does.

But we’ve learned a ton. About what we’re up against — along with millions of other people — and our options.

And by tackling this right now — six weeks before open enrollment starts — I hope we can help a lot of other people start planning early with solid information. Let’s go.

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

So, we started by checking in with the person whose reporting first got us looking at this story.

Julie Appleby: It’s recording. It looks like it says 10, 11,

Dan in interview: perfect.

Julie Appleby: I have notes and I’ll try not to rattle the papers.Ìý

Emily in interview: I mean, if we have a reporter on tape rattling papers, I feel like that’s probably okay.

Julie Appleby: Okay. That’s a plan, man.

Emily in interview: Yeah. Why don’t we start out, could you just like, tell us your name and what you do and where you work?

Julie Appleby: So this is Julie Appleby. I’m senior correspondent at Ñî¹óåú´«Ã½Ò•îl Health News.

Emily in interview: What sort of stuff do you cover?

Julie Appleby:Ìý I cover healthcare policy, but that’s a broad term. So everything from cost to, the Affordable Care Act, to what’s going on with Medicare, all kinds of different things involving health care programs and insurance.

Emily in interview: So we were really excited to talk with you, because we wanted to cover, you know, all the changes to the marketplace plans, that you’ve been writing about. And, it just so happens that I need to enroll in a marketplace plan.

Julie Appleby: So let’s give you kind of the rundown. There’s like, there’s kind of like two things going on here. One of them is that just premiums are going up as they do every year. Although this year it’s bigger than it’s been since 2018. So the median increase nationwide, and this is according to some data research by KFF, is about 18%. So that’s a big jump, right?Ìý

Emily in interview: Yeah. Yeah. In your reporting you called it a double whammy. Rates are going up, enhanced subsidies are probably going away.Ìý

Julie Appleby: Right. That’s the second half of the double whammy.

Dan: OK, breaking in here– gonna do this a couple of times for Obamacare vocabulary. Emily just mentioned an important term, went by kinda fast: enhanced subsidies. Obamacare has always included subsidies for most people — that’s part of the “Affordable” part of Affordable Care Act. But for lots of people, Obamacare policies still were… pretty expensive!

So, in 2021 — like, as part of a COVID recovery package — Congress added extra subsidies for Obamacare policies: Enhanced subsidies.Ìý

Julie Appleby: Basically, they made the coverage more generous on both ends of the income spectrum. In fact, I think I was looking at some statistics this morning and something like, 80% of people who have coverage right now have a plan that’s $10 a month or less.

Dan: These are folks with lower incomes — where paying sixty or eighty dollars a month is a big bite. With “enhanced” subsidies, that became ten dollars — or even zero.

But people with higher incomes also got help. Before the enhanced subsidies, people with incomes above a certain level didn’t get ANY subsidy. People called it an “income cliff.”

For the last four years these enhanced subsidies, kind of erased that cliff. If your income was higher, you just paid a percentage of your income. Enhanced subsidies picked up the rest.

But the enhanced subsidies weren’t permanent. They’ll expire at the end of this year, unless Congress extends them. Otherwise…Ìý

Julie Appleby: people who make more than the four times the federal poverty level will not qualify for any help with their premiums under the Affordable Care Act. There will be that cliff.

Emily in interview: Right, right.Ìý

Dan: And it turns out Emily is basically standing on that cliff. She shows Julie the numbers.

Emily: We found this calculator from KFF that attempts to show the changes in premiums if the subsidies expire. And maybe I’ll just share my screen and we can look at – we can look at what I’m looking at.

Okay, you guys see KFF? Maybe just reload and I can enter some Emily figures in here. So, they ask you about where you live and your yearly household income.Ìý

Dan in interview: what’s the amount that you’ve entered as income?

Emily in interview: I have entered $63,000. And it says, without enhanced subsidies, you will likely lose financial help. Because my income is 418% of the federal poverty level.

Dan: Oy. a little more Obamacare vocabulary. First: Federal poverty level. Four times that level is where you fall off the income cliff, no subsidies. 400 percent. And the calculator – which we should say, is a year out-of-date, so the numbers aren’t precise, but they give us an idea– that calculator says Emily’s at 418.

And next:  Obamacare plans come in different “levels,” like Olympic medals: Bronze, Silver, Gold… Bronze plans are the cheapest, and cover the least.Ìý

If Emily got a subsidy, the calculator says a silver plan would be like 400-and some dollars a month, but it says Emily wouldn’t GET a subsidy, so…Ìý

Emily in interview: It would be about $880 a month for a silver plan, or $675 a month for a bronze plan. So for me, that is stressful to read.Ìý

Julie Appleby: That’s a lot of money. 880 bucks a month. So you’re in the situation where you don’t get any, subsidies because your income is over that amount. But I played around with one of these calculators too when I wrote a story recently. And I also plugged in somebody, let’s say who’s earnings are kind of at the lower end of the income scale, say just over 150% of the federal poverty level. So they’re still gonna pay more. They’re, it’s gonna go from paying sort of a national average of about $2 a month to 72 bucks a month, or $864 a year. And remember, this is somebody who’s making 23,000 a year. So $864 is a lot of money.Ìý

Dan in interview: Emily, can you put that calculator back up on the screen for us?

Emily in interview: Sure can.

Dan in interview: The scary calculator. I mean, what would happen if your income were just a little bit lower? If you just shave $3,000 from your income, what does it lookÌý

Emily in interview: So maybe like 60?Ìý

Julie Appleby: I bet you could even shave a little bit less. Why didn’t you make it 62?

Ìý(Sfx: Buzzer)Ìý

Dan: How about 61? What does 61 do for us?

Emily in interview: Can I get a 61Ìý

(SFX: Buzzer)Ìý

ÌýDan: how about $60,500?

Ìý(SFX: Buzzer)Ìý

Dan in interview: I feel like this is like an auction reverse.

Julie Appleby: in reverse.

Emily in interview: I know this is like the auction from hell

Dan in interview: Yeah, we’re, we’re lowering your income. So let’s keep going. $60,200,

Ìý(SFX: Ding!)Ìý

Dan in interview: That is it. Holy crap it’s a giant cliff. It’s a $5,000 cliff

Dan: Breaking in one last time:Ìý Five thousand dollars is how much money Emily might save on Obamacare premiums if her income stays below that 400 percent line.Ìý Put another way: It’s how much more she’d have to pay if she steps over that cliff.

Dan in interview: Julie, what does that look like to you, seeing that?

Julie Appleby: I think this also, this illustrates a lot of things. I mean, people are gonna have to keep in mind that cliff for next year if these tax credits aren’t extended. This is a projection, this is what you think you’re going to earn next year. So that’s one thing that to keep in mind, okay? And something could happen. Emily could, I don’t know, maybe she wins the lottery or she goes to the casino and wins a bunch of money and that puts her over.Ìý

Emily in interview: Or offers me, you know, a freelance job that’s really interesting. It doesn’t pay that much, but just puts me over, you know?Ìý

Dan in interview: You have to say, I’m sorry, that freelance job is gonna cost me more than $5,000 to accept.

Dan: So, Emily: listening back to that conversation now. What are you feeling?

Emily: I mean, I was trying to stay calm but internally I was freaking out. As Gen Z likes to say, I was crashing out.

Dan: It was really emotional. We both needed time to cool off, just to put this story together.

Emily: Yeah, this situation is stressful. I don’t know for sure how much money I’m even going to make next year. And it feels kind of weird to put all this out here. I don’t know how any of this sounds to other people. Because maybe it sounds like 400% of the federal level is a lot of money. And in some parts of the country it definitely is. But I live in New York City. So my income doesn’t go that far. And that $880 bucks a month we were talking about? That’s actually a big hit.Ìý

Dan: Yeah and — not to pile on, but: the data behind the calculator where we got that number, 880 — that’s last year’s data.Ìý So it doesn’t include the big premium increases that Julie was writing about. The actual amount you’dÌý be paying every month would be bigger. And you looked up the deductible: more than four thousand dollars.Ìý

Emily: Right, which I won’t have lying around at the beginning of next year either. Yeah so honestly, all of it still makes me want to scream.Ìý

Dan: Yeah, and you’re a case study for a LOT of people. Julie read us a really sobering number, where one consulting group estimated that with this double-whammy Obamacare enrollment could drop by like half or more.Ìý

And, in fact, one of the reasons insurers say they’re raising prices this year is– without the enhanced subsidies, they figure a lot of healthy people will just opt out.Ìý

Emily:  I can see why people don’t sign up. I mean,Ìý I don’t have that choice. But in order to get a subsidy, I’d have to lower my income, and to a very specific number – which is less than I live on now. And watch it to make sure I don’t take in a penny more.Ìý

Dan: While still paying hundreds of dollars a month for Obamacare – even with a subsidy.

Emily: And look. This is a thing a lot of people do. All the time. –intentionally limit their income to qualify for assistance.. To keep Medicaid, people skip out on jobs, careers, marriage.Ìý

 So my situation is NOT unique. It’s definitely not the worst.

Dan: You’re our in-house case study. You can’t stand in for everybody.

I mean, just to add one more wrinkle: If you didn’t live in a super-expensive city, your premiums would actually be lower..

I used that calculator to look up what you’d pay for a silver plan in … Chicago, like where I live? Way, way cheaper. Like, unsubsidized? A lot less than a New York plan *with* a subsidy. I’m just saying.

Emily: That’s… wild. No shade on Chicago But I don’t think I’m ready to make a long distanceÌý move for health insurance yet.

Dan: I’m just saying…Ìý

Emily: But while we’ve been looking ahead to 2026 insurance, I’ve actually had a more-immediate decision to make.

Dan: Right.

Emily: LIke I said before, I had insurance through my old employer. But that’s ending. While we were doing this story, I had to figure out health insurance for the last three months of 2025.

Dan: You ended up getting some help from a real expert.

Emily: I sure did.

Dan: And: I called up An Arm and a Leg’s insurance broker.

Because like we said: If Emily’s a case study, so am I. We’re so small, and I’m the only one here who’s needed health insurance from this tiny little enterprise. Now, things are a little different.

What we’ve learned, and what’s next. That’s just ahead.

This episode of An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a nonprofit newsroom covering health issues in America. Their journalists — like Julie Appleby — do amazing work. We’re honored to be their colleagues.

Emily: Julie Appleby left me with a little advice: Connect with an ACA navigator.

Dan: Navigators: These are folks who can guide you through the process of signing up for Obamacare. They’re not brokers, they don’t make a commission. They’re paid by the government.Ìý

Emily: But they’re not government employees — local organizations work on government-funded contracts.

Dan: Which makes sense– Obamacare plans themselves are basically local: The menu of plans to pick from, they don’t just vary from state to state: They can be different from one county to another.

Emily: And I wanted a little perspective on how the whole navigator program works.

Dan: And it turns out: We know someone at the organization that coordinates all the navigators in New York state.

Elisabeth Benjamin: My name is Elizabeth Benjamin. I’m Vice President for Health Initiatives at the Community Service Society of New York.

Dan: We’ve spoken with Elisabeth before — a bunch of times — about her work pushing hospitals in NY to quit suing people over medical debt.

And yes, it turns out her shop also runs the network of navigators throughout New York.

Emily: But when we talked, it turned out, her connection to the navigator program is a little different than I’d expected.

Elisabeth Benjamin: I don’t, you know, run it day to day, but I, myself do help people individually enroll. Because it’s really important to understand what people are experiencing, what their concerns are. I have like a small group of people that I help every year, Lots of friends, children.

Emily in interview: Oh, that’s awesome. Okay. Yeah, I bet you’re like a great like auntie to have..

Elisabeth Benjamin: You know, people that turn 26 and the parents are like, I know, please, will you help me?

Emily: She was like: Look, everybody needs help.

Elisabeth Benjamin: The bottom line is, you know, it isn’t for the faint of heart. It is hard to work through these websites. I mean, they are as user friendly as possible, but there’s like little kind of little moguls that you have to kind of ski over and it’s easy to kind of miss a mogul and faceplant, and we don’t want that to happen.

Emily: And when I told her about how my story fits into this episode, she was immediately like.

Elisabeth Benjamin: Oh, well, I can help you.

Emily: Not with my whole 2026 dilemma: there’s just no information about 2026 plans out there yet. But for my immediate question — what do I do about the rest of 2025 – she was like, I’m pretty free tomorrow.

Elisabeth Benjamin: You can tape your enrollment.

Emily in interview: Oh my gosh, that would be amazing.

Dan: Seriously amazing. I mean, it sounded like good tape, which we always like.Ìý

But also — we talked that day, you and me: You were really weighing some big decisions.Ìý

Emily: I mean one was: Do I sign up for Obamacare for the rest of the year, or do I stay on my old employer’s plan?

Because a law called Cobra means they have to allow me to buy in — but I’d have to pay the whole monthly premium, which was SUPER high. More than a thousand dollars.

So Obamacare was looking good. Those extra subsidies are still in place through the end of the year.

Dan: There was a downside.

Emily: Yeah — starting a brand-new plan would mean starting with a brand new deductible– money I’d have to pay out of pocket before the new insurance kicked in for most things.

Dan: Those can be like thousands of dollars.Ìý

Emily: Yeah, but then there was an amazing surprise: In New York, where I live, a new state law means that all Obamacare plans include insulin with no copay. Even if you haven’t paid out and hit your deductible. That’s a deal I’ve *never* gotten from any insurance, ever.

AND this deal included other diabetes supplies — like my continuous glucose monitor. That stuff can be hugely expensive.

So my thinking was like: I’ll grab the cheapest Obamacare plan– and get all my diabetes supplies — and I’ll try not to go to the doctor for the rest of the year.Ìý

Elisabeth Benjamin: Okay, so ready?

Emily in interview: I’m ready.

Emily: The next morning, I showed up at Elisabeth Benjamin’s apartment.

Elisabeth Benjamin: All right. So Emily, here you are, you’re on my dashboard. Oh, wait, here I can make this easier for you. Let’s do the big screen. Okay.Ìý

Emily: Elisabeth started walking me through the application.  Name, date of birth, address… pretty routine to start.Ìý

Elisabeth Benjamin: That’s your phone number…

Emily: And at this stage I’m wondering if I should’ve just done it all myself and left poor Elisabeth alone.

But after a while — once we started actually looking at plans, I was like: Oh wow. Elisabeth was able to like really zip through things. It was a whole vibe.

Elisabeth Benjamin: Hold on one second. That’s not, that’s not important I wanna see if this is in network…

Emily: And she spotted things I would have totally missed.

Elisabeth Benjamin: So this is kind of an interesting plan. ’cause you would be able to go to a doctor or a specialist before the deductible.

Dan: Wait, you could do a doctor visit before you spent that deductible? That’s a thing?

Emily: Yeah, in that one plan, I guess? But even Elisabeth had to really dig to figure that out.Ìý

Elisabeth Benjamin: Like see, it’s sort of a little frustrating because you wouldn’t, you couldn’t really tell that from this. This is why it’s helpful to have a navigator

Emily: I mean, super-helpful: With Elisabeth’s help, I got a planÌý

Elisabeth Benjamin: and you’re done.Ìý

Emily: where OK, I can’t actually SEE a doctor before the deductible. Not in person. But I CAN do telehealth. So if god forbid I get some kind of weird infection, I could get a prescription. Oh, and my actual doctor, like my endocrinologist, is covered. And the deductible is much, much lower than the other plans I’d been looking at. I mean, it’s still scary as hell, but HALF as scary-as-hell?

Dan: And the only catch is: You have to do this all over again in November or December. Except then — unless Congress extends the extra subsidies — you may be looking at much higher monthly payments.

Emily: Right. Actually, let’s come back to me in a minute. Because the good news in my case: At least I’ll be able to get Elisabeth’s help again. Like, she offered to, which was so nice. But also: even if she’s super-busy, I’ll be able to talk to another navigator. Because I live in New York.

Dan: Yeah. This is one of the things we learned from Elisabeth. It goes back one of the reasons we wanted to talk with her in the first place. Because there’s another big change with Obamacare this year: the federal government is cutting funding for navigators by like 90 percent. We wanted to hear from Elisabeth — how is that gonna affect her group’s work.

Emily: And — this was a surprise: She said it won’t affect her work at all– because New York navigators are funded by the state government. Turns out the same thing is true for about half the states. But I talked with Elisabeth’s counterpart in a state where that is not the case.Ìý

Nicholas Riggs: We are not gonna be able to reach the number of people we did before. That’s just reality. You can’t do more with less. People will lose their coverage because of this.

Emily: That’s Nicholas Riggs. He runs the NC Navigator Consortium.

Nicholas Riggs: We cover all 100 counties. We’re the only navigator entity in North Carolina.

Emily: He says a big piece of their work is actually outreach– finding people who may not know they can get this kind of help.

Nicholas Riggs: You know, there’s no list of the uninsured.

Emily: And they don’t just help people pick Obamacare plans– they help people sign up for Medicaid. A 90 percent budget cut hits all of that. He says they’re looking for more volunteer navigators, but it won’t be the same as having experienced staff.Ìý

Nicholas Riggs: What you’re losing is institutional knowledge. Volunteer navigators are great. But sometimes it takes a few years to really get a handle on some more complex cases.

Dan: I mean, Emily — you experienced first hand how big a deal it was to hae, like,Ìý a real expert walk you through this process.

Emily: Elisabeth spent almost an hour with me!

Dan: A lot of people won’t have access to that kind of help. It’s one more crummy thing we’re trying to help people plan for. You found a map that shows which states fund their own navigators. We’ll post a link — so people can see what the deal is in their state.

And Emily, let’s come back to you for a minute: You’re lucky to have access to the world’s greatest navigator, but unless Congress extends the enhanced subsidies, that next conversation with her is gonna be a lot tougher.

Emily: I mean, unless I get another job with health insurance first.Ìý

Dan: So, about that: While you were having your first conversation with Elisabeth, I was talking with An Arm and a Leg’s health insurance broker, Kurt Kaufman.

Because I was like: What can I do to make it possible for Emily to stick around?

I asked Kurt, could we set things up for Emily to buy into An Arm and a Leg’s plan? Like, at all?

Our insurance is from Blue Cross Blue Shield of Illinois. Could it cover Emily in New York? He was like

Kurt K: Yeah, that’s fine.

Dan: Then she,

Kurt K: a hundred percent.

Dan: She could be insured on our Illinois based plan,Ìý

even though she’s in New York.. Is that right?

Kurt K: All day long.

Dan: All day long,

Kurt K: yep.,Ìý

Oh, yeah.

Dan: So I was like: Um, how much would it COST?

He said, based on your age — insurance gets more expensive as you get older — like, five, six hundred.

Emily: That’s a LOT less than what the scary calculator said I’d pay for a Silver plan with no subsidies. That was showing like nine hundred dollars.

Dan: Yeah. I mean: These are 2025 numbers, just like everything else we’ve been looking at. Everything in 2026 is gonna be higher. But it seems like An Arm and a Leg gets a better deal than you’d get with Obamacare. However, there’s a but. You’d need to be full-time.

Emily: Aha!

Dan: Yeah. I mean we’ve got you at 20 hours a week.

Emily: Yeah.

Dan: I was like Oh my god. I’d have to DOUBLE that? But Kurt was like: Actually, no. The way insurance looks at it, if you were working an average of 30 hours a week, then you could qualify.

Kurt K: She could be meeting that definition of quote unquote full-time employee.

Dan:  Which, you know, isn’t in my budget for next year– and I’m still working to make sure some other parts of our scrappy little budget get funded– but it’s not DOUBLE. I’m starting to think about it– like, a stretch goal. I mean, I’d LOVE to have more of your time. I dunno.

Emily: I mean I like the idea a lot! But there are just a lot of unknowns, right?

Dan: Yeah, here’s where we’ve landed: You’ve got health insurance lined up for the rest of 2025. And after that, there’s so much we don’t know. Will I find more money? Will you take another job?Ìý

And: Will Congress extend the enhanced subsidies? When we first started working on this story, over the summer, experts were like, “That’s not gonna happen.”

But in the last few weeks, SOME Republicans have been proposing it. We definitely don’t know — and it’s nothing we can count on.

It’s all, honestly, a little scary.

Emily: Honestly, more than a little.

Dan: BUT: We know more than we did. We’ve started really confronting the scary numbers and the unknowns. You’ve taken a practice run at picking insurance.

Emily: That was actually kind of a big thing.

Dan: It was, right?Ìý And: I’ve started thinking about stretch goals.

We’re more prepared.

And — here was the point of doing this whole case study– I HOPE we’ve just helped a lot of other people get more prepared, to start planning.Ìý

We’ll keep you posted on how things go for us. Some updates will show up in our First Aid Kit newsletter.Ìý

If you’re not getting First Aid Kit, go check it out.Ìý

Emily: While we were reporting this story, we published a guide there: Get ready, emotionally and financially, for 2026 health insurance.

Dan:Ìý It has links to resources we talked about here, and we’ll have more in this week’s First Aid Kit.Ìý

What you wanna do is go tor at Arm and a Leg show dot com, slash, first aid kit.

You’ll find the whole archive there — including notes about honestly, some extremely exciting projects that Arm and a Leg listeners are doing — and how you can pitch in.Ìý

We’ll be back with another podcast episode in a few weeks. Till then, take care of yourself.

Emily: This episode of An Arm and a Leg was produced by me, Emily PisacretaÌý

Dan: and me, Dan Weissmann.Ìý

Emily: With help from Janmaris Perez and Lauren Gould.

Dan: And edited by Ellen Weiss.

Dan: Adam Raymonda is our audio wizard. Claire Davenport is our engagement producer.

Dan: Our music is by Dave Weiner and Blue Dot Sessions.

Dan: Bea Bosco is our consulting director of operations.

Big thanks to Lynne Johnson, who just wrapped up her run as our operations manager. Lynne, your work has done SO much to make our work more sustainable. I can’t thank you enough.

Dan: An Arm and a Leg is produced in partnership with Ñî¹óåú´«Ã½Ò•îl Health News. That’s a national newsroom producing in-depth journalism about health issues in America — and a core program at KFF: an independent source of health policy research, polling, and journalism.

Dan: Zach Dyer is senior audio producer at Ñî¹óåú´«Ã½Ò•îl Health News. He’s the editorial liaison to this show.

Dan: An Arm and a Leg is Distributed by KUOW — Seattle’s NPR station.

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

Dan: They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.Dan: Finally, thank you to everybody who supports this show financially. You can join in any time at Arm and a Leg show, dot com, slash: support.

“An Arm and a Leg” is a co-production of Ñî¹óåú´«Ã½Ò•îl Health News and Public Road Productions.

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

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Ñî¹óåú´«Ã½Ò•îl 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 .

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